Translating international guidelines for use in routine maternal and neonatal healthcare quality measurement

Abstract

Background: Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low-and middle-income countries. Recent guidance from WHO and others has produced a large number of indicators to choose from to track quality. Objective: To explore how to translate complex global maternal and neonatal health standards into actionable application at the facility level. Methods: We applied a two-step process as an example of how the 352 indicators in WHO's 2016 Standards for Improving Quality of Maternal and Newborn Care in Health Facilities might be reduced to only those with the strongest evidence base, associated with outcomes, and actionable by facility managers. We applied Hill criteria and assessed whether indicators were within the control of facility managers. We next conducted a rapid review of supporting literature and applied GRADE analysis, retaining those with scores of 'moderate' or 'high'. To understand the utility and barriers to measuring this limited set of indicators in practice, we undertook a case study of hypothetical measurement application in two districts in Bangladesh, interviewing 25 clinicians, managers, and other stakeholders. Results: From the initial 352 indicators, 56 were retained. The 56 indicators were used as a base for interviews. Respondents emphasized the practical challenges to the use of complex guides and the need for parsimonious and actionable sets of quality indicators. Conclusions: This work offers one way to move towards a reduced quality indicator set, beginning from current WHO guidance. Despite study limitations, this work provides evidence of the need for reduced and evidence-based sets of quality indicators if guides are to be used to improve quality in practice. We hope that future research will build on and refine our efforts. Measuring quality effectively so that evidence guides and improves practice is the first step to assuring safe maternal and neonatal care.

Towards a harmonised framework for developing quality of care indicators for global health: a scoping review of existing conceptual and methodological practices

“…Despite extensive experience and rigour in the development of paediatric QoC indicators for use at micro and meso levels in HICs for quality improvement and accountability, there was limited translation of these practices to the development of global MNCH metrics 32 49 50. The rapid proliferation of global MNH indicators, with definitional variations, few shared indicators, low scientific soundness, focus on facility inputs and processes rather than outcomes or impacts, and limited feasibility and usability in LMICs has been widely reported 5–8 51 52. A review provided guidance on assessing the validity of MNH indicators, but no guidance was found on reliability, feasibility and usability assessment in different settings 45…”

“… 5 Many MNH QoC metrics were not based on clear concepts of causality and were insufficiently supported by research evidence. 6 Of more than 1400 indicators of the MNH care continuum, only 6.7% met all requirements for scientific soundness by providing a full description and empirically testing validity, reliability and feasibility. 7 MNH standards and indicators of coverage and quality performed poorly in validity, feasibility and usability assessments in low/middle-income countries (LMICs).…”

“… 7 MNH standards and indicators of coverage and quality performed poorly in validity, feasibility and usability assessments in low/middle-income countries (LMICs). 6–8 …”

“…Several MNH measurement initiatives emerging from the Millennium Development Goals and the Sustainable Development Goals have generated a substantial volume of indicators, many of which partially overlapped and lacked adequate documentation or guidance 5. Many MNH QoC metrics were not based on clear concepts of causality and were insufficiently supported by research evidence 6. Of more than 1400 indicators of the MNH care continuum, only 6.7% met all requirements for scientific soundness by providing a full description and empirically testing validity, reliability and feasibility 7.…”

Ecological situation: the role of education and spirituality in improving health of population

“…In general, infant mortality in the regions of the country is declining every year, but in some areas, such as Tashkent, Khorezm, Andijan, and the Republic of Karakalpakstan, it is particularly high. This is since the city of Tashkent and Andijan is the largest industrial and transport center of the country, and some of the above regions are located in the Aral Sea region, ie in the region with a negative nosoecological situation (Chang et al, 2020;Zhu et al, 2013).…”