Measuring what matters for maternal and newborn health
Authors: Nadia Diamond-Smith, Patience Afulani
Journal: The Lancet Global Health (2019)

Quality of care for maternal and newborn health has gained increased attention over the past 5–10 years, with many calls to action and recommendations to improve it.1Koblinsky M Moyer CA Calvert C et al.Quality maternity care for every woman, everywhere: a call to action.Lancet. 2016; 388: 2307-2320Summary Full Text Full Text PDF PubMed Scopus (230) Google Scholar, 2WHOStandards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization.http://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/Date: 2016Date accessed: March 14, 2019Google Scholar Measures are needed to ascertain whether these recommendations are being implemented and to drive future improvements. But quality of care for maternal and newborn health is complex to measure. In The Lancet Global Health, Vanessa Brizuela and colleagues3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar contribute to this area by connecting ever-changing quality recommendations to the practical needs of measurement. They assess how multinational facility assessment tools for quality of maternal and newborn health services compare to the most recent WHO recommendations and quality standards for maternal and newborn health. Given the 352 quality measures in the WHO recommendations, this comparison is no small feat. Using narrow criteria (which is reasonable given the vast number of surveys out there), Brizuela and colleagues3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar focused on five commonly used surveys. They then matched each question in the tools to each of the measures in the WHO quality standards to assess whether it captured information relevant to at least one subcomponent of that specific WHO standard. Because the selection of tools was based on a purposive sample, the number of other tools that might have been missed is unclear. The criteria also leave some unfortunate gaps. For example, the exclusion of surveys used in research and those that have not been used on a national scale in multiple contexts means that available tools that could be used to strengthen the multicountry tools are not represented. Overall, these surveys differed in the proportion of WHO measures they covered, with the Service Provision Assessment covering the most measures (62%) and the Service Delivery Indicator Survey the least measures (12%).3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar Physical resources for care and referral indictors are the most represented in selected surveys. These items are, unsurprisingly, the most commonly measured given the preponderance of emphasis on technical and supply-side quality in the past in funding, research, and publications. As the authors note,3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar these measures might not necessarily reflect the care provided because general availability might not mean availability when needed and appropriate use as indicated. These measures are also likely to be over-represented because they are much easier to measure (eg, is oxytocin available?) than more complex concepts, such as respect or dignity. Measures of patients' experience and health information systems are least represented in the tools reviewed, which is probably a reflection of the gap in measurement of these domains because these are constructs that are much harder to measure than input and process indicators. However, some tools do address these areas, but they did not meet the inclusion criteria to be included in the present study. For example, only in the past 2–3 years have scales been validated to measure women's experiences. These include the Respectful Maternity Scale,4Sheferaw ED Mengesha TZ Wase SB Development of a tool to measure women's perception of respectful maternity care in public health facilities.BMC Pregnancy Childbirth. 2016; 16: 67Crossref PubMed Scopus (60) Google Scholar the person-centred maternity care scale,5Afulani PA Diamond-Smith N Golub G Sudhinaraset M Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population.Reprod Health. 2017; 14: 118Crossref PubMed Scopus (73) Google Scholar, 6Afulani PA Diamond-Smith N Phillips B Singhal S Sudhinaraset M Validation of the person-centered maternity care scale in India.Reprod Health. 2018; 15: 147Crossref PubMed Scopus (39) Google Scholar and the WHO mistreatment survey and observation tool kits,7Bohren MA Vogel JP Fawole B et al.Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey.BMC Med Res Methodol. 2018; 18: 132Crossref PubMed Scopus (40) Google Scholar which were all published between 2016 and 2018. Future studies that assess how these tools adequately capture the WHO quality statements related to women's experiences and that examine research tools for measuring actionable health information systems will help provide recommendations for which of these newly developed tools should be incorporated into the existing multicountry surveys. As Brizuela and colleagues point out,3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar the measures included in their analysis were not necessarily developed to measure quality, potentially contributing to their shortcomings. This limitation brings up an important question about how we should measure quality of maternal and newborn health, considering other potential outcomes of interest and other health system priorities. Comprehensive standards and measures of quality of maternal and newborn health care are important. However, development of tools to capture these measures, which can realistically be deployed in an efficient, affordable, and achievable way, is also important. The multicountry facility assessment tools, although not comprehensive enough for the WHO quality standards, are still too long to be used in a routine and actionable manner. Many health facilities, especially in resource-poor settings, are already struggling with an array of challenges, including retaining providers, overcrowding, supply-chain gaps, and outdated facilities and technology. Thus, doing thorough, lengthy, repeated surveys based on these tools is not feasible. A larger conversation is needed to ensure that multiple key domains of quality are measured, while making sure that these measures are feasible and actionable. Guidance on which of the quality measures under each quality statement are key to achieving the quality statement will be helpful to develop shorter actionable measures. The authors mention3Brizuela 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; (published online March 18. http://dx.doi.org/10.1016/S2214-109X(19)30033-6.)Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar that such efforts are underway by the Quality, Equity, Dignity Network, and we are excited to see these recommendations and those from other groups focusing on this goal. Overall, a conversation on the big picture about the direction of measurement of quality of maternal and newborn health care, both scientifically and practically, is needed. 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