WHO's quality of maternal and newborn care framework: is harmonisation of tools best?
Authors: Aduragbemi Banke-Thomas, Charles Anawo Ameh
Journal: The Lancet Global Health (2019)

Vanessa Brizuela and colleagues (May, 2019)1Brizuela V Leslie HH Sharma J Langer A Tunçalp Ö Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools.Lancet Glob Health. 2019; 7: e642-e732Summary Full Text Full Text PDF Scopus (49) Google Scholar identified five globally applied large-scale survey tools that have been used to measure quality of care in maternal and newborn health. The tools were benchmarked against the WHO framework according to their capacity for assessing quality of care in this area.2WHOStandards for improving quality of maternal and newborn care in health facilities. World Health Organization, Geneva2016Google Scholar Of the five surveys identified, those with the highest capacity for quality of maternal and newborn care assessment were the Service Provision Assessment (which covered 62% of quality measures) and the Averting Maternal Death and Disability (AMDD) Needs Assessment of Emergency Obstetric Care toolkit (which covered 57% of quality measures). This finding is important and robustly highlights the insufficiency of the existing tools as quality of care assessment tools. In our 2016 systematic review of the application of the AMDD Needs Assessment of Emergency Obstetric Care,3Banke-Thomas A Wright K Sonoiki O et al.Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines.Glob Health Action. 2016; 9: 31880Crossref PubMed Scopus (21) Google Scholar we reported the experiences of researchers using this tool in low-income and middle-income countries (LMICs). Three key points came from our review. First, wide consensus existed around the need to refine indicators used for quality of care assessments. Second, a need existed to take a holistic approach to quality of care assessments that leverages quantitative and qualitative research methods. Finally, a need existed to integrate these assessments into routine health information management systems. To focus attention on retrofitting existing survey tools into the WHO framework is entirely reasonable since this approach will not incur any additional design costs. However, this strategy does not guarantee the holistic assessment that is crucially needed to improve service delivery. The alternative is to focus on designing a new quality of care framework that responds to our most important questions. In several LMICs where attempts have been made to assess quality of care in maternal and newborn health using the WHO proposed indicators, researchers needed to revise the indicators to operationalise them.4Madaj B Smith H Mathai M Roos N van den Broek N Developing global indicators for quality of maternal and newborn care: a feasibility assessment.Bull World Health Organ. 2017; 95 (52i): 445Crossref PubMed Scopus (32) Google Scholar The definition of quality by the women receiving care is different from that of WHO experts.5Bohren MA Titiloye MA Kyaddondo D et al.Defining quality of care during childbirth from the perspectives of Nigerian and Ugandan women: a qualitative study.Int J Gynecol Obstet. 2017; 139: 4-16Crossref PubMed Scopus (27) Google Scholar Attempts to capture these beneficiary-specific interpretations of quality are likely contained within the measures of the framework; however, focus on these quantitative metrics might obscure the perceived experiences of care. Indeed, cultural nuances of quality of care exist, which are best captured qualitatively. We agree that “more measurement for the sake of measurement” is not the right approach for the future.1Brizuela V Leslie HH Sharma J Langer A Tunçalp Ö Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools.Lancet Glob Health. 2019; 7: e642-e732Summary Full Text Full Text PDF Scopus (49) Google Scholar However, we believe that the right measurement for the exact purpose of measuring quality of care is essential. The existing survey tools do not help in achieving that goal—maternal and newborn quality of care tools need to assess the capacity of health systems as well as the experiences of women. We declare no competing interests. Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment toolsExisting facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research. Full-Text PDF Open Access