Master of Health Promotion
Department of Public Health Sciences.
MATERNAL MORTALITY AND QUALITY OF MATERNITY CARE
IMPLICATIONS FOR PAKISTAN.
M. TAUQEER MUSTAFA CHOUDHRY
THESIS FOR DEGREE OF MASTER IN HEALTH PROMOTION.
SUPERVISOR: PROF. BO JAN ANDERS HAGLUND.
ASSISTANT SUPERVISOR: THERESE WIRBACK.
EXAMINER: GLORIA MACASSA
OPPONENT: JESSICA RÖÖK
Report series of Master theses in Public Health
These reports come from the Board of Education in Public Health Sciences at Karolinska
The master education of Public Health at KI is a collaborative work of mainly three
departments: Department of Public Health Sciences, The Department of Biosciences at
Novum , Division of Preventive Nutrition, and The Institute of Environmental
These reports are presented as PDF files on the WebPages of Master of Public Health
Education at Karolinska Institutet
Professor and Programme Director
This study is a literature review, to look at the relationship between quality of maternity care and
maternal mortality. The aim of the study was to find out different aspects, perspectives and
necessities of a quality maternity care department and then to analyze the interventions
implemented in different countries to improve quality of maternity care. Finally how has this
improvement in quality affected maternal mortality, and which of these interventions could prove
to be effective in Pakistan.
The main sources of information were online journals, through Pub Med and Medline.
Additionally, WHO publications, books from KI library and some websites were also consulted.
Quality of maternity care was found to be defined and assessed in three different aspects: structure,
process and outcome. Then subcomponents of these three major aspects like physical structure,
facilities, equipment, organizational form, Administrative structure, staff structure/qualifications,
diagnosis, treatment, surgery, consultation/referral, coordination & continuity, health outcomes,
mortality, complications, satisfaction etc. were found and finally necessities under each
subcomponent were explored in detail.
Then a number of studies carried out in different countries were analyzed for the strategies and
interventions used to improve the quality of maternal care. Criterion-based clinical audit, quality of
care, performance and quality improvement tool, facility based maternal death review, better
management, multi-strategy approach, confidential enquiries into maternal deaths and near-miss
case review were the approaches used in these studies for quality improvement.
Then evidence was sought for a relationship between improved quality care and maternal
mortality. As measurement of MMR is fraught to problems and underestimates, some process
indicators like services utilization, met-needs, providers behavior etc. were used alternatively. It
was evident from the results that improvement in quality of maternity care happened to decrease
maternal mortality in all of the cases reviewed. It occurred either directly by the provision of better
services to the complications brought to the facility, or by changing community behavior towards
seeking maternity care , when required.
Improvement of quality at maternity care services is an effective strategy to reduce maternal
mortality in all types of setting.
Furthermore, criterion-based clinical audit was proposed to improve the quality of maternal health
services in Pakistan. However a pilot study is needed to assess the feasibility of tool in Pakistani
Keywords: Maternal Mortality, Quality of care, Maternity Care Services, Quality improvement,
( 10 699 words)
Keywords: ......................................................................................................................................... 3
Background ...................................................................................................................................... 6
Health care system in Pakistan....................................................................................................... 9
Quality of health care................................................................................................................... 10
Models of quality care: ................................................................................................................ 10
Definitions of quality care: .......................................................................................................... 12
Quality of maternity care and its assessment............................................................................... 14
Main Objective ............................................................................................................................... 17
Specific objectives ....................................................................................................................... 17
Materials and Methods.................................................................................................................. 17
Results ............................................................................................................................................. 19
Major quality aspects of maternity care:...................................................................................... 19
Strategies and tools used for quality improvement:..................................................................... 22
Quality of care and maternal mortality: ....................................................................................... 25
Conclusion ...................................................................................................................................... 32
Further Studies............................................................................................................................... 32
Figure 1: Proportion of maternal deaths by country 2002-2003........................................................................................7
Figure 2: Percentage distribution of Maternal Deaths by Cause. ......................................................................................8
Figure 3: Donabedian’s Model of quality. ......................................................................................................................11
Figure 4: Bruce’s Quality of service Model. ...................................................................................................................12
MATERNAL DEATH: Death of a woman while pregnant or within 42 days of termination of
pregnancy irrespective of its duration and site, from any cause related to or aggravated by the
pregnancy or its mismanagement, but not from accidental causes.1
MATERNAL MORTALITY RATIO: Number of maternal deaths per 100,000 live births, due to
complications of, or medical conditions aggravated by pregnancy, childbirth, or postnatal period
up to six weeks after delivery.
MATERNITY CARE SERVICE: Routine Obstetric care, including ante partum care, vaginal
delivery (with or without episiotomy/ caesarean delivery) and postpartum care.
QUALITY: Quality is the ongoing process of building and sustaining relationships by assessing,
anticipating, and fulfilling stated and implied needs2.
QUALITY OF MATERNITY CARE SERVICES: Quality of maternity care services means 1)
providing a minimum level of care to all pregnant women and their babies, 2) a higher level of care
to those who need it, 3) obtaining the best possible medical outcome, 4) providing care that
satisfies women and their families and care-providers, 5) maintaining sound managerial and
financial performance and developing existing services in order to raise the standards of care
provided to all women3.
Pregnancy is not a disease and pregnancy related mortality is almost always preventable. Yet more
than half a million women die annually worldwide, due to pregnancy related complications.3About
90-95% of these come from developing countries. Maternal Mortality Ratio (MMR) in developing
countries ranges from 300 to 1000 in contrast with 2.9 in the industrialized world. This is the only
Public Health Statistic with such a huge difference. In Pakistan alone, an estimated 30,000
maternal deaths occur each year, due to pregnancy related complications4.
There are a number of causes behind this problem, major being illiteracy, lack of health education,
lack of Trained Birth Attendants (TBAs), lack of transport facilities and lack of Health Care
Services. Major Clinical causes include Haemorrhage, Hypertensive disorders/Eclampsia, and
Puerperal sepsis. Literature review has shown that a number of deaths occur even after reaching
and seeking maternity care services either at Primary; Secondary and Tertiary level. This study is
an attempt to show the relationship between maternal mortality and quality of maternity care
services. What different interventions have been utilized in different countries of the world to
improve quality of maternity care, and how this quality improvement has affected maternal
mortality. And finally, which of these interventions could prove to be effective and suitable for
In September 2000, the largest-ever gathering of Heads of State ushered in the new millennium by
adopting the UN Millennium Declaration. The declaration, endorsed by 189 countries, was then
translated into a roadmap setting out goals to be reached by 2015. Three out of eight goals, eight of
the 16 targets and 18 of the 48 indicators relate directly to health. Reduction of maternal mortality
is one of the key goals of millennium declaration. Target is to reduce MMR by three quarters
between the years 1990 and 2015 and the indicators include maternal mortality ratio and
proportion of deliveries with a skilled health care provider5. Reduction of maternal mortality has
been endorsed as a key development target by countries and is also included in consensus
documents emanating from international conferences, including the World Summit for Children in
1990, the International Conference on Population and Development in 1994, the Fourth World
Conference on Women in 1995, the Millennium Summit in 2000 and the United Nations General
Assembly Special Session on Children in 2002.
Around 53 000 women of childbearing age die every year in the Eastern Mediterranean Region as
a result of pregnancy-related complications. Over 95% of the burden of maternal death in the
Region is shared by seven countries, namely Afghanistan, Iraq, Morocco, Pakistan, Somalia,
Sudan and Yemen. Community awareness about life-saving practices in pregnancy childbirth and
home care for children, literacy and female education, fertility and family formation patterns, and
quality of health care delivery systems, are the main factors that contribute to the high maternal
and child mortality in the region. Provision of primary health care and effective referral services to
mothers and their children, particularly where they are most needed, is a prerequisite to reduction
of morbidity and mortality among these vulnerable groups of the population. Lack of quality
services, lack of essential supplies and trained personnel, lack of access to quality care, lack of
facilities for emergency transport, and lack of or poor referral services, are all crucial steps on the
road to death due to poor infrastructure6.
Figure 1: Proportion of maternal deaths by country 2002-2003.
Source: Demographic and health indicators for countries of the Eastern Mediterranean, 2002/2003
As is obvious from the figure above, Pakistan contributes second biggest proportion towards
maternal mortality in the region, after Afghanistan. There are a number of causes behind this
problem, major being illiteracy, lack of health education, lack of Trained Birth Attendants (TBAs),
lack of health care services and insufficient access to health care services. In developing countries,
inaccessibility of health services comprises physical as well as economic and sociocultural
distance from the health facilities. Due to some cultural and religious restrictions, women face
difficulties in approaching healthcare services. This is because women are not allowed to consult
male health care providers, especially for maternity related problems. But consulting female
attendants is not restricted by either religion or cultural and at least one female is appointed at each
PHF officially but the problem is that they are not available during the duty hours. And this is what
determines the quality of a PHF.
Another important obstacle in seeking adequate medical care during obstetric emergencies is the
lack of information about the existence and the location of the referral hospital. Sundari38
examined a number of hospital-based studies on the determinants of maternal mortality in
developing countries. The ``patient factors'' identified by these studies included, among others,
lack of early and/or adequate prenatal care and delay in arriving in a hospital. Sundari argued that
the reasons behind such behaviour on the part of women and their families may be lack of
information, economic factors, cultural barriers (e.g., possibility of being attended by a male
doctor) and lack of transport. In the Pakistani scenario, cultural barriers and lack of exposure of
women to modern health services is an important reason for such behaviour35. This is particularly
true in the rural areas, where government health facilities are under-staffed and ill-equipped to
provide obstetric care. Even where the peripheral health facilities do not provide ``routine'' prenatal
care, pregnant women may visit them for other reasons and be exposed to the health system.
However, there is a direct relation between the quality and organization of health services and their
utilization by women35.Literature review has shown that a number of maternal deaths occur in
Pakistan, even after reaching and seeking maternity care services either at primary; secondary and
tertiary level. Keeping all these reasons in view, quality of maternity care has been decided to be
the main focus of this literature review.
Provision of quality health care and effective referral services to mothers and their children,
particularly where they are most needed, is a prerequisite to reduction of morbidity and mortality
among these vulnerable groups of the population. Despite significant advances in medical
technology, maternal mortality remains high in Pakistan. It is estimated that about 30,000 Pakistani
women die each year of maternal causes. The maternal mortality ratio (MMR), reported in various
studies, range between 300 and 700 per 100,000 live births, average being 340/100000 live births
as reported by WHO. Number of studies have been brought about to find out the clinical causes of
maternal mortality. The results found are almost always the same. Postpartum haemorrhage,
eclampsia, puerperal sepsis and obstructed labor are proved to be the leading causes of maternal
deaths. Women giving first birth or those having five or more children, those under 18 or over 34
years of age, and those having a history of previous fetal loss are considered at a higher risk of
Figure 2: Percentage distribution of Maternal Deaths by Cause35.
Where PPH stand for “Post Partum Haemorrhage” and APH stands for “Ante Partum
Most maternal deaths are preventable if the complications are diagnosed and managed effectively
and in time. The classical three delays include delay in decision to seek help, delay in getting
transport, and delay in providing effective treatment7. Maternal mortality ratios in Pakistan are still
higher than in many parts of the world, and maternal mortality is largely due to conditions which
require basic hospital services, such as surgery for complications of pregnancy, control of
infections, transfusion, intravenous fluids, oxygen, and intensive antibiotics. Most of these can be
made available in very simple and unsophisticated hospital facilities. It has wrongly been assumed
that the cost of such facilities would be high, and the cost effectiveness much less than that of
preventive, educational, and home care programs8.
Health care system in Pakistan
The government health services in all the four provinces of Pakistan are almost similar in structure
and functioning. The health services infrastructure is not developed, particularly in the rural areas.
Only the large government hospitals, located in major cities, provide adequate obstetric care. The
public sector comprises a network of almost 10,000 health facilities ranging from basic health units
to tertiary referral hospitals. The MCH organizational setup at all levels is weak in terms of
technical capacity and resource availability. For instance, the MCH provincial directorate in the
Punjab, a province of 80 million people, has the director as its only professional staff9.
The health delivery system of the country is stratified and in practice has many deficiencies. The
government health system in a typical district comprises peripheral health facilities (PHFs) and the
district hospital. The peripheral health facilities (PHFs) which include Basic Health Units (BHUs)
and Rural Health Centres (RHCs), lack emphasis on safe motherhood, and are therefore under-
utilized. The average number of outpatient visits by adult women to any government health facility
was 0.8 per woman in the NWFP and just 0.2 in Balochistan Province. (Rates computed from
annual statistical reports of the respective provincial health departments.)
The range and quality of the services expected to be provided at a PHF depend largely upon its
staffing pattern. Facilities having a doctor and/or lady health visitor (LHV) provide prenatal care,
basic lab tests used in pregnancy and diagnosis and referral of obstetric complications.
The PHFs having one or more doctors are relatively better equipped and better utilized. Therefore,
the average number of doctors per PHF is a good indicator of the state of development of
peripheral health services in a district. The PHFs, however, do not have facilities for caesarean
section or blood transfusion. Even though a majority of deliveries are conducted by traditional
birth attendants, the LHV is usually called upon in cases of obstetric complications. The latter is
trained to stabilize the woman's condition before referring her to a secondary care hospital. The
PHFs having both a doctor and LHV are better equipped to provide obstetric first-aid and referral
services. However, the PHFs are not capable of providing the full range of essential obstetric care
(EOC), and women in need of such care are referred to a secondary care facility.
The primary care facility is a Basic Health Unit (BHU) with one visiting doctor and three to four
paramedics for a population of 10 to 20,000 persons. The second tier facility, a Rural Health
Centre (RHC), is a small peripheral hospital with a clinic, small wards for some 20 patients, an
operating room, and a delivery room. The allocated staff consists of three medical officers (one
female) and a dental surgeon besides supporting paramedical staff. Nurse midwives called Lady
Health Visitors (LHV) provide maternity care. Residential accommodation is provided on the
premises for most of the staff members. Each RHC caters for a population of 100,000 to 150,000.
Shortage of staff and structural neglect are seen in most RHCs.
Each administrative district has two or three general hospitals called District/Tehsil Headquarter
Hospitals (DHQ/ THQ Hospital) (for two and a half million people), many of these hospitals are
without sufficient specialists to provide the required emergency cover.
All the major cities have teaching hospitals called Tertiary referral hospital, providing a high
standard of tertiary care but of limited accessibility.
Quality of health care
Quality is difficult to define, it is an abstract term, and it requires continuous and dynamic
adaptation of products and services to fulfil or exceed the requirements or expectations of all
parties in the organization and the community as a whole.
Models of quality care:
Available literature on medical and health care research includes various formulations for defining
and capturing the essence of ‘quality’. Among the earliest and most prominent are Donabedian’s10
explorations of a definition and of the process involved in the provision of quality care. He
suggests three different definitions of quality based upon the notion of the benefits versus the harm
of care. The absolutist definition of quality considers the possibility of benefit and harm to health
as valued by practitioner, with no intention to monetary cost. The individualized definition of
quality takes into account the patients’ expectations of benefit/harm and other undesired
consequences (e.g. monetary cost to client). Finally the social definition includes the cost of care
and the benefit/harm and distribution of health care as valued by the population in general. He sees
the balance of these benefits and harms as the essential care of quality.
His pioneering work helped to systematize thinking on the multi-layered aspects of ‘quality’ in
health services. The concept of quality, as defined by Donabedian, is a ‘property’ or characteristic
of medical care. This characteristic can rang from one end of the spectrum to the other (e.g. low to
high quality care) and can manifest itself through various elements or “attributes”. The first
category of attributes includes the technical aspects of care and the human context in which it is
How medical science is applied technically to cure medical problems and to promote human health
falls under the technical domain. To complement the technical application of that science (cure)
comes the equally important human setting (care) in which that science is applied. The “human
setting” pertains to the nature of the patient-provider relationship i.e. whether the patient finds the
provider understanding, courteous, informative, and respectful for privacy. If the patient does
perceive the provider as described above, and the provider is technically competent, the
interpersonal aspects of care will blend with the technical ones to increase the probability of a
positive outcome for patients’ health.
The second category of attributes, according to Donabedian10, goes beyond the technical
interpersonal frame and includes accessibility and continuity. Accessibility refers to the structure
and location of care. It assumes clear and well-defined 'points of entry' (e.g. emergency services)
and whenever possible round the clock services. It also assumes that services can be provided at a
reachable distance and affordable cost. Continuity implies a coherent pattern of services between
and within various health delivery systems.
DONABEDIAN MODEL OF QUALITY
STRUCTURE PROCESS OUTCOMES
Figure 3: Donabedian’s Model of quality.
• Physical structure, facilities, equipment
• Organizational form
• Administrative structure
• Staff structure/qualifications
• Fiscal health
• Coordination & continuity
• Health outcomes
Another significant contribution to understanding the definition of quality, particularly in terms of
family planning services, comes from Bruce11. Her broad definition includes the ways in which
individual users are treated by the system. Bruce has identified a framework which encompasses
six fundamental elements crucial to the quality of family planning services if clients' demands and
expectations are to be fully met. These elements include
• Method choice;
• Provision of information to clients;
• Technical competence of providers;
• Interpersonal relations between clients and providers;
• Mechanisms for follow-up and continuity; and
• An appropriate array of services.
This model, developed by Bruce, has spurred interest in the different elements of quality in
reproductive health-care services.
Figure 4: Bruce’s Quality of service Model.
Definitions of quality care:
There are certain other definitions and concepts of quality in health care, presented by different
scientists and researchers. A few of these are presented below.
Wyszewianski, Thomas and Friedman’s12 definition includes accuracy of diagnosis and the
appropriateness and efficacy of treatment rendered.
Vuori13 advances the notion of optimal quality (objectives achieved at least cost) versus logical
quality (efficiency with which information is used in making decisions). He declares that a health
care system should function at the optimal qualitative level so as to assure the most purposeful
allocation of the scarce resources without wasting them unnecessarily.
Steffen 14 defines quality as the capability of an object to achieve a goal. He differentiates between
two senses of quality, the metaphysical sense and the referential sense. The metaphysical sense of
quality comprises those properties of care independent of how they are perceived, that is those
aspects of an organization and its services that are believed to contribute to quality without regard
to preferences or values of the patient. The preferential sense of quality implies that there are
differing preferences and values in regard to what adequately fulfils a patient’s needs and
expectations. He believes that to successfully evaluate the quality of care, a formal assessment of a
patient’s value must be included.
O’Leary suggests that quality varies depending upon the particular constituencies assessing it: the
provider, the patient, or the purchaser. Providers may define quality as technological
sophistications or therapeutic efficacy, while the patients are likely to define quality by amenities
(e.g. edible food, clean linen) and professional competency. Purchasers, on the other hand are
likely to use terms such as length of stay, cost effectiveness or appropriateness.
Institute of Medicine defines quality of care as “Degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent with current
Applying a systems perspective more explicitly, the IOM recently has proposed six dimensions for
quality improvement in the health care delivery system:
Safety of patients,
Effectiveness of services,
Timeliness of care,
Efficiency of resource use, and
Equity of care across gender, ethnicity, geographic location, and socioeconomic levels.
Chassin and Galvin16 have defined poor quality of care as the under use of effective services, the
overuse of services when the potential for harm exceeds the potential benefit, or the misuse of
services resulting in preventable complications.
And finally, The National Association of quality Assurance professionals17 defines quality as
“levels of excellence produced and documented in the process of patient care, based on the best
knowledge available and achievable at a particular facility”. This definition is most appropriate for
the purpose of this study.
Quality of maternity care and its assessment.
The growing interest in the quality of reproductive health services over the last decade has
emanated from a concern with the high levels of maternal mortality and morbidity in developing
countries. Health professionals and organizations working in the developing world are now
actively seeking more effective ways to prevent maternal deaths and improve women’s health care.
Quality care is provided by a complex blend of multidisciplinary, technological and human
resources. In order to serve the public better, quality assurance activities must promote active
collaboration between the staff and the management. Thus quality control should not be
constructed as an extra burden incorporated in, or added to, a process. It should be the concern of
all personnel, since the production of high quality services enhances the reputation of organization.
Quality assessment and improvement activities are as relevant to the public health sector and
community-based health care organizations as they are to the rest of the health care industry. We
distinguish first between quality assessment and quality improvement.
Quality assessment means “the process of measuring quality of care, including development of
quality measures, implementation of quality measurement activities, and monitoring of quality
information over time to detect trends or to identify high-performance or low-performance”.
Measures of quality are multidimensional and can focus on the structure, process, and outcomes of
care. They can be based on administrative, clinical, or patient-reported data. Quality assessment
also includes the process of providing information on quality to stakeholders, including providers,
consumers, payers, policy makers, and the general public18.
Quality improvement means “the ongoing, systematic process of using quality measurements to
identify problems and to implement strategies to improve the quality of care, usually within
specific organizational entities, such as a group practice, a health plan, a hospital, a public health
department clinic, or a community-based clinic”. The objective is to identify the causes of
variation in the processes and outcomes of care and to strive continuously for higher levels of
Despite the lack of a generally accepted definition of quality health care, numerous tools
purporting to measure quality are being developed and disseminated. Traditionally, quality of care
has been assessed in three general domains: structure, process, and outcome. Structure assessment
concerns the characteristics of the care environment, including material resources (i.e., facilities
and equipment), personnel (e.g., number, credentials, and qualifications), and organizational
characteristics (e.g., methods of reimbursement and peer review). Process assessment concerns the
characteristics of the care provided, including appropriateness, adequacy, technical competence,
coordination, and continuity. Outcome assessment concerns the results of care on the health status
of patients, including changes in patient knowledge and behaviour, patient satisfaction with health
and medical care, biologic changes in disease, complications of treatments, morbidity, and
Many clinicians consider process to be the most direct and valid measure of quality: i.e., the right
things done right at the right time.
A number of tools for the quality assessment of maternity care were found in the literature, but the
one which seems to be applicable to the Pakistani context is the one developed by researchers
working in Nepal19. This is because both Pakistan and Nepal are located in the same geographical
region and many of their financial and social indicators resemble.
It identifies ten essential components of quality maternal care. It further divides each component
into sub-components and presents every necessity in yes/no format. Applying the tool to any EOC
immediately gives an idea of the quality of care at the centre.
Aim of this study is to find out the relationship between quality of maternity care
services and maternal mortality, and how can maternal mortality be reduced by improving the
quality of maternal care in Pakistan.
Following questions will be the main focus of the study.
1- What are the major quality factors of maternity care services?
2- To analyse the examples of interventions from different countries, aimed at improving
quality of maternity care.
3- How does quality of maternity care services affect maternal mortality?
4- Which of these interventions could be implicated in Pakistan?
Materials and Methods
This study was a review of secondary literature. A combination of search techniques was
employed to find the relevant data. Major source of information and data were online journals.
Different scientific engines were searched for related articles, using different search words and
their combinations. The search engines used were
● Pub Med
And the phrases used for searching were, “Maternal mortality”, “Maternal mortality in Pakistan”,
“causes of maternal mortality in Pakistan”, “Pregnancy complications in Pakistan”, “Maternity
care services”, “Quality of health care services”, “Quality of maternity care”, “Quality of maternity
care in Pakistan”, “Quality of maternity care and maternal mortality”, “Quality assessment of
health care”, “Quality improvement of maternity care”.
These phrases were used individually and in combinations and different number of articles were
found. Number of articles obtained against each search phrase, is given in the appendix at page 33.
While searching at Google, number of web links were found which contained information related
to the topic. Websites of the following agencies were found to be helpful.
World Health Organization
Agricultural Development Bank
United Nations Fund for Population Development
Searches through the Library Catalogue of KI were made, using phrases like “Maternal Mortality”,
“Causes of Maternal Mortality”, “Maternal Mortality in Developing countries”, “Maternity care
service”; etc, and a few relevant books were found.
Criteria for inclusion of article:
To be included in the review, every article was matched with the criteria given below, and had to
fulfil all of the requirements.
● written in English
● published between 1990 and 2005
● contained the search phrase in title or abstract
● addressed the concept under study
● full text was available
Criteria for exclusion of articles:
The articles which met any of the following criteria were not included in the review.
● Published in languages other than English
● Published before 1990
● Addressed concepts other than maternal mortality, alone or in combination with it
● For which, full text was not available
Each article was analysed conceptually to be included and quoted in the study. Only abstract was
read initially to be included in the review and the whole article was read later. It was quoted in the
study only if it addressed any of the three concepts: quality of maternity care, quality assessment or
improvement and, its relation with maternal mortality.
Major quality aspects of maternity care:
World Health organization (WHO) has recommended some guiding principles20 for a good quality,
effective maternity care system. The basic level of care: primary healthcare level, offers antenatal
care, normal delivery and case referral services. The next tier, the first referral or secondary level
of care, concentrates on looking after case referrals, handles complicated pregnancies and delivers
and takes care of puerperal complications. A small minority, in need of highly specialized care and
others requiring intensive care are managed in tertiary care establishments. Additional
responsibilities at tertiary level include the organization of national blood transfusion services and
manpower training and development. It is obvious that the whole system of effective maternity
care, capable of reducing maternal mortality, has to be built around antenatal care and first-referral
level of care.
Improving the quality of maternal health services requires identifying the basic ‘ingredients’ of
quality health care. In order to make improvements one must determine what constitutes quality
and how it could be measured.
Quality cannot be defined only in clinical and technical terms21.The WHO definition of
reproductive health extends beyond the physical aspects of health to include mental and social
well-being. A quality service attempts to capture all aspects of the definition. This means that
reproductive health service programs must take into account the social context in which women
live. Especially relevant are women's position in the hierarchy of family relationships, their role in
the family, their workload, their contribution to decision-making, and their ability to pay for
services, all of which affect women’s potential to seek care and to comply with the health care
provided. Addressing the socio-cultural determinants of women’s health thus becomes a necessary
part of any quality health service. Studying the components of quality must be sensitive to the
social context, such as the woman-provider relationship and information exchange, can increase
our understanding of the health services factors influencing health-seeking behaviour, and can
provide insight into the more successful preventive and curative approaches to reproductive health.
This understanding can help the health service manager formulate interventions to make their
health facilities more socially acceptable and accessible to women users.
Assessing quality in reproductive health services means, measuring the gap between the quality of
care as perceived by the providers and as perceived by the women users22. For instance, quality
care to some providers may mean impersonal ‘efficient’ care, which reduces mortality and
morbidity. Less attention is given to women’s perception and experience of illness such as daily
discomforts which are not identified as major problems. It is often precisely those daily
discomforts which influence her health-seeking behaviour. Thus a quality service ought to give
special emphasis to women’s experiences, expectations, and level of satisfaction with the service,
to complement the views of the providers of care.
According to Bergström, good quality maternal care should fulfil the following criteria21.
• Be based on technical competence of healthcare providers with clear guidelines for
• Involve mother in decision making and see her as a partner in health care
• Strive for continuity of care and follow up
• Be available as close as possible to where the mother lives and be at the lowest level
facility that can provide the services safely and effectively
• Be equipped with essential supplies
• Provide counseling and information for mothers regarding their health and health needs
• Be responsive to cultural and social norms and thereby be acceptable to potential users
regarding preferences for privacy and confidentiality
• Give comprehensive care and linkage to other reproductive health services
• Give social and economic support to health care providers to enable them to provide an
• Be staffed by workers providing respectful and nonjudgmental care, responsive to women’s
In addition, he suggested that it was increasingly important to recognize that quality of maternity
care is not a luxury; rather it is an expression of making services cost-efficient by meeting
women’s health needs in an appropriate way. Additionally, much empirical evidence indicates that
under use of existing services, which is tangible problem in many settings in low-income
countries, is directly related to substandard quality of maternity care.
When we apply Donabedian’s10 framework of quality to the maternity care, it would include the
1. The Concept of ‘Structure’: is considered to encompass the stable features of the providers of
maternal care, the tools and resources at their disposal, and the physical and organizational settings
in which they work. Thus, structure includes the human, physical and financial resources that are
used to provide maternal health care
2. The Concept of ‘Process’: is defined as the set of activities that take place between the provider
and woman. It refers to the actual transaction in which the provider of care makes use of the
available structural elements, described above, to manage the technical and personal aspects of
3. The Concept of ‘Outcome’: includes two elements: the direct impact of treatment on the current
or future health of a woman or her newborn, and the indirect impact on her satisfaction with the
services offered and her health-seeking behaviour.
Al-Qutob22 has proposed a framework for the quality of reproductive health care. It comprises the
1- Management: refers to the set of all activities within the health care facilities through which the
available human, physical, and financial resources are utilized efficiently to produce a given
planned output. Subcomponents include,
2- Woman-provider Relationship: describes an interpersonal link between the provider and the
woman. This link is supposed to be established and maintained by a “considerate, courteous, and
understanding” provider who possesses good listening skills and cares for the woman in a
respectful way and in a private environment. Subcomponents include,
3- Provider Competence: refers to the qualifications and experiences of the providers as well as to
the ways in which they use their technical knowledge and skill to provide women with the optimal
promotional, preventive and curative care. Subcomponents include,
- Qualification of staff and prerequisite training in maternity care
- High risk screening
- Management of complicated pregnancies
4-Information Exchange: describes the flow of health information between the provider and the
woman recipient of care. This component is intertwined closely with the component of technical
competence and the woman-provider relationship. Subcomponents include,
- Discussion of pregnancy related information
5-Continuity: refers to a set of mechanisms that strengthen the progress of care including referrals
and promoting regular utilization of services.
These components provide an idea of different aspects of quality, to be considered while delivering
maternity care services.
Strategies and tools used for quality improvement:
Number of strategies have been developed, implemented and evaluated, in order of improving the
quality of maternity care services, in different countries. Here are some of the examples.
● Criterion-based Clinical audit tool was used to measure and improve the quality of four
district hospitals, two in each Ghana and Jamaica. The audit cycle consisted of five steps:
establish criteria for good quality care, measure current practice, feedback findings and set
targets, take actions to change practice and re-evaluate practice. The aspects improved
significantly were clinical monitoring, drug use, and record keeping. Conclusively, the Clinical
Audit Tool is feasible and acceptable method for quality assurance and appears to have
improved the management of life threatening obstetric complications23.
● Another study describes a Quality of Care (QOC) approach integrated into the efforts of His
Majesty’s Government of Nepal (HMGN) and the Nepal Safer Motherhood Project (NSMP) to
improve access to and the quality of emergency obstetric care (EmOC) in rural districts. The Nepal
District EmOC Model, the rationale for a QOC approach within that model and the process of
developing a QOC approach over a 5-year period (1997–2003) are presented. The underlying
principle of NSMP’s QOC approach is that improved QOC contributes to enhanced patient care
and improved maternal outcomes. The positive relationship between QOC and service utilization
has been proven for family planning and evidence that sub-standard obstetric care contributes to
maternal mortality also underlies the QOC approach. The 3general steps in the approach are to (1)
set local standards for quality of EMOC services; (2) take actions to achieve the agreed-upon
standards and (3) monitor changes over time. Following structure and process indicators were
shown to be improve after application of QOC approach.
Availability of all necessary infection prevention materials, Provision of 24 hour blood supply
service, Provision of drugs for obstetric emergencies, availability of nurses, availability of
midwifery and EmOC services, improved training approach, integration of reproductive health
services, client–provider interaction, and continuous monitoring of quality improvement.
• A Quality Improvement tool named as “Performance and Quality Improvement (PQI)”
has been developed and implemented jointly by John Hopkins University Centre for
Communication Programs, the centre for Development and Population Activities, and the
Program for Appropriate Technology in Health (JHPIEGO), in five developing countries:
Burkina Faso, Honduras, Indonesia, Tanzania, and Guatemala. The PQI process has proven
to be an effective technique to guide key stakeholders as they systematically improve
components of skilled attendance. The process ensures that staff and community members
look at all elements that contribute to the quality of maternal and newborn healthcare
services and behaviors and select interventions that target the needs of their facilities and
communities. Interventions focus on improving clinical and behavioral aspects of skilled
attendance as well as factors that staff and community perceive to be crucial to enhanced
performance and quality of care. This approach results in efficient, cost-effective
programming because the PQI process allows stakeholders to identify only interventions
that are necessary to improve quality, thus eliminating unnecessary activities and expenses.
For instance, in the Koupéla district of Burkina Faso, the Maternal and Neonatal (MNH)
Program, in collaboration with UNICEF and Plan International, is developing a model
system to increase the use of skilled providers in 13 health centres. Healthcare facilities
have noted significant improvements in quality as a result of the interventions they
identified and implemented through the PQI process. Between April and December 2001
the Koupéla medical centre averted 60 emergency evacuations by handling the
complications (including 27 caesarean sections and 13 deliveries by vacuum extraction) at
the centre. By handling the complications on-site, the Koupéla medical centre was able to
reduce the amount of time it took for women to get the emergency care they needed—an
important factor in saving women’s and newborns’ lives.
The PQI process consists of five steps: defining desired performance, describing actual
performance, finding root causes, selecting and implementing intervention, and monitoring
and evaluating performance.24
• Malaysia has a unique, multi strategy approach which targets specific problems and
addresses them through incremental and systematic improvements in health service and
hospital and community systems. While the efforts focussed on increasing access to basic
maternity care before, now they emphasise to improve the quality of available services
through better management.
Different strategies used to improve the quality of maternity care services are the
National Maternal and Child Health Committee defines standards for clinical care and
referral through the development of manuals and protocols for different cadres of health
providers, in collaboration with a range of stakeholders. Standards and protocols are
continuously revised and updated to reflect the changing realities. In 1984, national
guidelines for antenatal care were formulated and management protocols were developed
for major causes of maternal mortality. These guidelines were amended in 1996 to include
obstetric indicators that reflect quality of care.
The Quality Assurance Program was introduced in 1986 as a continuous assessment system
for quality of care. Indicators for antenatal and Obstetric Quality of care were used to
correct the weaknesses in the health system and improve substandard care.
Since early 1990s, maternal mortality reductions strategies have been identified through a
District Team Problem-Solving Approach, where districts identify deficiencies in care,
determine strategies/solutions and design interventions to address these difficulties through
development of a district plan of action25.
• Under FIGO save the mothers initiative, a program was implemented in 1999-2000 in a
semi urban and rural setting within the district of Kasur, Pakistan, some 30 KM from
Lahore, the provincial capital, to improve the quality of maternity care services through
better management, using the available resources. Not much of new resources were
utilized and the existing facilities were managed to increase quality and adequacy of the
facilities in the project area26.
• A number of other examples and evidences have been found where Criterion-based
Clinical Audit proved to be effective in increasing the quality of maternity care services.
One such study is the Pilot Project run between August and December 2001 jointly by the
department of Obstetrics and Gynaecology and the Regional Centre for Quality of Health
Care at Makerere University Medical School. Strategies included didactic teaching about
criteria based audit followed by practical work in own units, with ongoing support and
follow-up workshops. Improvements were seen in many standards of care. Staff showed
universal enthusiasm for the training. Many staff produced simple, cost-free improvements
in their standard of care. Because the method is simple and can be used to provide
improvements even without new funding, it has the potential to produce sustainable and
cost-effective changes in standard of health care27.
• A facility-based maternal deaths review was carried out in three districts of Nepal during
1996 and 1997. This was part of a study which included community-level verbal autopsies of
maternal deaths, as well as case reviews of maternal deaths occurring at the hospitals and of
cases of maternal morbidity in hospital inpatients.
The review was conducted in four hospitals of the three selected districts. Obstetric and
gynaecology physicians and nurses in the maternity wards of the hospitals were trained in
the process. The review was begun within 24 hours of the occurrence of a maternal death.
The physician initiated the review and the doctor and/or the nurse completed a review
form. The review process was based entirely on the no name—no blame principle, with a
primary aim to determine whether the maternal death was due to substandard care or to
other factors. The selection of cause of death was made according to the guidelines in ICD-
10 (WHO 1993). A questionnaire was used to review each maternal death, with
information collected from the maternity and laboratory registers as well as from
interviews with all staff members who were involved in providing care, including ward
boys and hospital peons. After each finding, interventions were proposed and implemented
to correct the deficiency and finally the quality of care at the department was substantially
● Another method used at the facilities to improve the quality is, confidential enquiries into
maternal deaths. Confidential enquiries tell the story of “HOW and WHY” individual
woman died, and trace their path through the health and community services. Confidential
enquiries are essentially observational studies, using qualitative and quantitative analysis,
which take account of the medical, and sometimes, non medical factors that led to a
woman’s death. They provide data on individual cases, which when aggregated together
can show trends or common factors for which remedial action may be possible. The longest
running example of a confidential enquiry into maternal deaths (CEMD) is that of the
United Kingdom29. During the 1920s, at a time when other health indicators such as infant
mortality were improving, health care professionals and women’s advocacy groups became
concerned about the apparent lack of similar improvement in levels of maternal mortality.
Consequently, in 1928, local health professionals started a system of case review audits.
Although not national in scope; these maternal death audits included a detailed review of
adverse events. Over time, as commitment improved, these small-scale reviews or local
facility audits evolved, by 1935, to wider area health authority-based systems of
confidential enquiries, the recommendations of which played a major part in improving the
quality of maternity care and reducing the maternal mortality rate over the next two
● Near-miss case Review technique was used in a feasibility study in Benin, Ghana, Ivory
cost and Morocco. This collaborative research project was aimed at developing and
implementing a strategy to improve obstetric care in referral hospitals by using a systematic
review of near misses as a mechanism for the evaluation and improvement of the quality of
obstetric care. The study took place in 12 referral hospitals in four African countries. The
strategy of the case reviews involved: establishing a near-miss enquiry committee to
facilitate the development, application and dissemination of the findings from the near-miss
enquiries, establishing hospital teams to conduct near-miss case reviews in their facilities,
identifying valid and reliable criteria for the definition and identification of near-miss
events, conducting in-depth enquiries in a subset of cases of near miss to document the
nature of substandard care, to make recommendations concerning the improvement of
clinical care and organizational procedures, and to implement the changes, conducting a
quantitative assessment of all reviewed near misses to document the magnitude and causes
of near-miss morbidity in the hospitals30.
Quality of care and maternal mortality:
These are some examples of the interventions used in different countries to improve the quality of
maternity care services. But how does improvement in quality of care, affect Maternal Mortality
Since measuring maternal mortality ratios is fraught with problems and underestimates, therefore,
process and outcome indicators such as the use of antenatal and obstetric services, the behaviour of
providers, client satisfaction with antenatal and delivery care, and changes in client knowledge and
behaviour resulting from an intervention have been proposed for monitoring the availability and
use of obstetrics services31. Moreover, the recognition that some women need specialist obstetric
care to prevent maternal death has led to the search for indicators measuring the met need for
emergency obstetric care.
Available evidence suggests that a substantial proportion of maternal and perinatal deaths are
attributable to poor technical quality of care32. An analysis of some of the studies that show a
relationship between maternal mortality and quality of maternity care is presented below. Again
due to difficulty of measuring the effects directly on MMR, almost all of the studies have used
process and outcome indicators to measure the success of interventions.
● A study was conducted in Jamaica, during the years 1991-1995, to determine whether
improvements in primary and secondary care service could prevent antenatal eclampsia. One
intervention (St. Catherine) and two control (St. Ann, Manchester) parishes were chosen. The
health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions
for referring patients to a high risk antenatal clinic or to hospital. Guidelines were provided to
high risk clinics and the antenatal ward for appropriate treatment of hypertension and pre-
eclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored
before and during the intervention and was compared with the control parishes. Each eclampsia
case was investigated to find out inadequacies in the system. The eclampsia incidence dropped
dramatically (25% of that at the start) as the care improved, while there was no change in the
control. Conclusion is that reorganization and improvement in the quality of maternal care can
have major public health benefits and cost savings33.
● A district-based audit of maternal and perinatal mortality began during 1994 in three provinces
of South Kalimantan, Indonesia. Both medical and non-medical factors were documented and
an effort was made to progress from merely assessing substandard care to recommending
improvements in access to care and the quality of care. Extensive discussions of cases of
maternal death were held during regular meetings with providers, policy-makers and
community members. The sources of information included verbal autopsies with family
members and medical records. Between 1995 and 1999 the audit reviewed 130 maternal deaths.
The leading causes of death were haemorrhage (41%) and hypertensive diseases (32%). Delays
in decision-making and poor quality of care in health facilities were seen as contributory factors
in 77% and 60% of the deaths, respectively. Equipment shortage 13.3%, Drug shortage 6.7%,
Delay in meeting health provider 36.7%, Inadequate care 26.7%, and care not in accordance
with protocols 23.3%.The distance between a patient's home and a health provider or facility
did not appear to have a significant influence, nor did transport problems. The audit led to
changes in the quality of obstetric care in the district34.
● A study was carried out during the years 1999-2003 for developing a locally-appropriate quality
of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. It
describes the context of maternal health issues in Nepal, the rationale for developing a quality
of care approach within a model to improve EmOC, and outline the outcomes and catalytic
effects of the process. The program developed and implemented a quality of care approach at
three district hospitals in Nepal. This resulted in improvements in the structure, process and
outcomes of EmOC in these institutions. The process also resulted in improved understanding
of quality of care approaches on both local and national levels and the creation of a Nepalese
quality of care evaluation framework for maternity services.
To evaluate outcomes process data was used (e.g. EmOC utilization data) which is usually more
sensitive than outcome data to changes in quality. Outcomes (such as number of deaths) may
also be affected by non-facility QOC factors. All 3 sites increased the met-need for EmOC and
caesarean sections. Although progress was slow (approx. 2–3% increase in met-need a year)
and the gap between met-need and unmet need remains unacceptably high, the flow of patients
and hospital workload was significantly increased. In short, this program, using QOC approach
was successful in increasing the use of EmOC19.
● A pilot study in Punjab, Pakistan was one of the five paired demonstration projects sponsored
by FIGO in the “Save the Mothers” maternal mortality project. The goal of the project was to
bring and improve basic and comprehensive emergency obstetric care (EmOC) in a semi urban
and rural area some 30 km from Lahore. The aim was to achieve this by using the existing
facilities within the rural health system without the deployment of extra specialist staff other
than as initial facilitators. This report shows trebling of some performance indicators and an
improvement in met need. Proportion of births at health care facilities, within the project area
increased from 442 to 1694, Proportion of complications treated from 379 to 1091 and
proportion of caesarean section from 62 to 310 in periods Jan-Jun2000 and July2001-June2002.
There is coincidentally a similar increase in the uptake of general medical services. It was
concluded that reducing maternal mortality requires building local capacity for EmOC; the
essential components being the premises, trained personnel, equipment, and availability of
drugs and blood. Availability and provision of EmOC coupled with changes in the attitude of
the population resulted in marked improvement of process indicators26.
● Safe motherhood programmes assume that maternal health services can reduce maternal
mortality- a serious problem in developing countries. The assumption that services make a
difference is supported by historical data on the timing of maternal mortality declines, which
suggest that such declines have not coincided with socioeconomic gains but with improvements
in specific services. Data supporting the effect of services is also now coming from case
control and experimental studies. For instance, Midhet et al35 linked lower maternal mortality in
rural Pakistan to health facility staffing and the availability of essential obstetric care, and
Frankenberg and Thomas linked the addition of village midwives in Indonesia, if not to
maternal mortality, at least to an important protective factor, i.e. increase in body mass among
women of reproductive age36.
● To help strengthen the components of the skilled attendance system, the Maternal and Neonatal
Health Program used performance and quality improvement (PQI), a technique for achieving
desired performance at service delivery sites and within communities. The MNH Program has
used PQI to help health facilities and their beneficiaries take a comprehensive look at their
skilled attendance system and identify, implement, and monitor a range of targeted
interventions aimed at improving maternal and newborn healthcare services. The PQI process
has proven to be an effective technique to guide key stakeholders as they systematically
improve components of skilled attendance. The process ensures that staff and community
members look at all elements that contribute to the quality of maternal and newborn healthcare
services and behaviours and select interventions that target the needs of their facilities and
communities. Interventions focus on improving clinical and behavioral aspects of skilled
attendance as well as factors that staff and community perceive to be crucial to enhanced
performance and quality of care. PQI empowers individuals and communities to seek
knowledge and services, thus increasing informed demand for high-quality services. In addition,
PQI can be a catalyst for collective action aimed at bringing about policy change and improving
the quality of healthcare.
In its programs in Guatemala and Burkina Faso, the MNH Program has demonstrated how
using the PQI process can improve informed demand and collective action for safe motherhood
within communities. Both programs have used PQI problem-solving techniques as part of
community and social mobilization campaigns and have found them remarkably motivating,
both to individuals and to community groups24.
● A case-control study of preventable and non-preventable perinatal deaths taking place between
1988 and 1991 at The National Institute of Perinatology in Mexico City suggested that the
overall perinatal mortality rate of 24.8 per 1000 births could have been reduced by 35% with
better quality care, and that 88% of preventable deaths involved provider responsibility37.
● A review of evidence concerning maternal deaths attributable to service-related factors at
various levels of the referral system suggests that a substantial percentage of maternal deaths in
more than thirteen countries are due to inadequate supplies and equipment or poor client
● A qualitative study interviewing members of 164 households where a maternal death occurred
in Mexico, found that quality of care in health services was a significant factor in a woman in
labor delaying seeking medical care. Relatives reported that the decision to not to seek medical
care when danger signs appear is an outright negative opinion that the woman and her partner
has of modern health services, which derives from previous interactions with health providers.
Another frequent problem at health services is lack of medical supervision which translated into
inadequate follow-up of patients39.
● A review of 12 maternal deaths in Haiti, through interviews with families and friends suggested
that a lack of confidence in available medical options were decisive factors in delaying or not
● A survey was conducted of 19,545 pregnant women in West Africa who were followed through
the second trimester and puerperium, and the 66 resulting maternal deaths were analyzed.
Twenty women died outside health facilities. The analysis confirmed that most of the maternal
deaths might have been avoided had access to quality care been available. Lack of attention to
women in labor at health care facilities was also responsible for a great proportion of deaths41.
● A study in which pregnant women were interviewed in India found that respondents identified
the poor quality of service offered at government institutions to be a motivating factor for
delivering at home42.
● In Romania, the maternal mortality ration reached nearly 180 per 100,000 in 1980s. In Mexico
city, where most of women give birth in large public hospitals, the MMR in 1988 was 114.
Eight hundred and fifteen of these deaths during 1988.89 occurred in four hospitals and 85
percent of the deaths with clinical records were preventable. Quality of care in hospital is
● Satisfaction with prenatal care was associated with positive perceptions of staff, long visits with
doctors, ease in contacting the doctor, and shorter waiting time. A study conducted in Cebu,
Philippines showed that improved quality, as measured by the availability of services and
supplies, provider training, facility size, degree of crowding, price, and distance, increased the
probability that poor women used formal services44.
Safe motherhood goes beyond individual women, but it also has a communal and public health
goal. The survival and well-being of mothers and children is central to family and community life
and social flourishing. Reducing maternal mortality is an attainable goal for countries around the
world. Statistics show that among the women who die of pregnancy related causes, 25% of the
women die during pregnancy, 16% die during delivery and 61% die after delivery, with most of
these deaths occurring within one week45. Hence in total, about 75 % of all maternal deaths are
those, associated directly or indirectly with some sort of health care facility. Delivery and the week
immediately after, is the most critical stage for every pregnancy, and this is the stage where quality
of care available does matter. Since measuring maternal mortality ratios is fraught with problems
and underestimates, therefore, process and outcome indicators such as the use of antenatal and
obstetric services, the behaviour of providers, client satisfaction with antenatal and delivery care,
and changes in client knowledge and behaviour resulting from an intervention have been proposed
for monitoring the availability and use of obstetrics services
It is obvious from the results shown above, that quality of maternity care has a direct impact on
maternal mortality. Quality of any health care facility has three major aspects: structure, process
and outcome. As is shown in the studies quoted above, the most common practice is to first assess,
which of these three aspects has deficiencies and problems. Number of such assessment and
improvement tools and techniques have been and are being used. Choice of the method depends on
a number of factors, including availability of resources, set-up of the organization, social and
cultural set-up etc.
Improvement in the quality of maternity care services affects the maternal mortality ratio, in two
1- First through better management and services provision directly to the complications
brought to the facility
2- And secondly indirectly by changing behaviors of the community towards consulting the
facility, when in need of it.
Substantial evidence exists, and some of which has been quoted above which shows that quality of
care is one of the major factors in women’s behaviour towards seeking maternity care. PQI
experiences in Guatemala and Burkina Faso have proved that improvement in the quality of care
has changed the social behaviour to a great extent.
None of the tools used in the above studies could generally be declared to be the best for all types
of circumstances and settings. While deciding about which technique to be used for a specific
facility, following points should be considered by the facilitators.
- What is the objective of the study?
- How will cases be identified?
- Where and by whom will cases be examined?
- How many cases are expected and what is the workload likely to be?
- What resources are available?
- Who can act on the results?
- What or who is the driver for change?
- Who are the key stakeholders?
While analyzing the above results with respect to different interventions, which have been
implemented to improve the quality, following interventions can be identified.
- Better management of resources
- Better management of manpower
- Improved referral system
- Training and refresher courses for personnel
- Making the most of available facilities
- Better care to the women, which included Courtesy, Understanding, Communication,
Consideration, Privacy, and Respect
- Health promotion and education activities during prenatal care
- Involving women in decision making
- Continuity of care
And then how can these results and findings be applied to Pakistan?
The concept of avoidability, “a maternal death is considered avoidable whenever there is a
departure from the generally accepted standards of satisfactory care”, has wider implication under
the improvised conditions in developing countries. Medical history shows that maternal mortality
decline is more associated with the impact of medical technology than other health indices46. The
aim of medical interventions is to reduce the potential risks of adverse reproductive outcome. A
program of maternal health care should be considered from a cost-benefit point of view, taking
into account local disease patterns and limited resources.
There is a direct relation between the quality and organization of health services and their
utilization by women35in Pakistan. This is particularly true for peripheral health services. In an
evaluation of rural basic health services in Pakistan, it was found that, of those women who did
visit a PHF for prenatal care, about one third did not receive tetanus immunization, and only about
56% got their blood pressure checked. Rural women in Pakistan are obliged to see only a female
health care provider, particularly for obstetric care. However, about 40% of all Peripheral Health
Facilities (PHFs) in the rural areas of Pakistan do not have a Lady Health Visitor (LHV) appointed.
The same study assessed the association between the district level indicators of health services on
the individual risk of maternal mortality. The results of the study suggest that a significant
reduction in maternal mortality might be achieved by better staffing of the peripheral health
facilities and, to a lesser extent, by improving the population's access to EOC. It showed that the
effects of known risk factors of maternal mortality are modified by staffing patterns of peripheral
health facilities and by accessibility of EOC.
A further impediment to care-seeking is women’s perception that they will be treated poorly at the
government BHUs and RHCs, where dismissive and rude providers are the norm. Typically,
providers are condescending and abrupt with clients; visibly poor clients receive the worst
treatment. Providers often interrupt and make treatment suggestions based on little or no real
communication with the client. Moreover, the recommendations may be inappropriate to the
woman’s situation. In short, the clients perceive many providers as rude and incompetent, while
providers may view clients as an unpleasant nuisance. The only thing about which they seem to
agree is that the provider holds the power to shape the interaction.
So these are the two major problems owing to the poor quality of service at PHFs. As has been
mentioned earlier, that staffing is the major indicator of quality at PHFs. Hence, in order to
improve quality at these facilities, staffing has to be improved first of all. This is the absence of
staff which is also behind poor referral system and hence is responsible for a great number of
maternal deaths. In addition to staffing, basic necessities like drugs and normal delivery equipment
should be provided with. And the staff should undergo proper training, and should be involved, in
Health promotion and health education facilities. How to deal with the patients should specifically
be stressed in these training sessions. Much would be gained by simply improving staff attitude.
The first referral or secondary level care is the other aspect, which is most important to provide
good quality services. This is because all the complications are here to be referred to and dealt
with. Much stress has been laid on improving primary care in the past, and less has been done with
respect to secondary care.
Considering all of the tools, techniques and interventions used in different studies mentioned
above, Criterion-based Clinical Audit tool seems to be most appropriate for quality improvement
at secondary and tertiary level care in Pakistan.
Clinical audit is “a quality improvement process that seeks to improve patient care and outcomes
by the systematic review of care against explicit criteria and the implementation of change.
Aspects of the processes and outcomes of care are selected and systematically evaluated against
explicit criteria. Where indicated, changes are implemented at an individual, team or service level
and further monitoring is used to confirm improvements in health care delivery.”
In this context, the word “clinical” applies to the work of doctors, midwives, nurses and other
health professionals. Although a clinical audit tends to be used to investigate the structure and
process of care, it can also be used to look at health outcomes.
Many people who have been involved in the process of audit believe that it has considerable
potential to influence the quality of patient care. This is certainly so in the United Kingdom, where
the government and leaders of health professions have taken numerous steps to promote this
approach. Clinical audit of selected topics was initiated by the UK government in 1989 as part of
health service reforms and is now a key part of overall efforts to promote the provision of services
that are clinically effective.
Characteristics of Clinical Audit, which make it suitable to be applied to secondary and tertiary
level care in Pakistan context, are
- The participatory element of clinical audit provides an effective mechanism for bringing
about improvements in care.
- It is an excellent educational tool and, when properly carried out, is nonpunitive.
- It provides direct feedback to facility staff on practice and performance, and the participatory
process enables them to help identify realistic means for improvement.
- It can be initiated locally and results in the production of locally relevant and immediately
- It can be less expensive than other forms of audit, as nonmedical personnel are capable of
doing the necessary data extraction.
- It provides a structured framework for gathering information and involves less subjective
assessment of case management than in facility-based deaths reviews or confidential enquiries,
- The audit process can help to highlight deficiencies, in both recording in-patient records and
And finally, the method used for literature search and review worked. Enough and relevant
material was available which efficiently provided the information required.
Quality of maternity care has a direct effect on maternal mortality ratio. A number of tools and
interventions have been used and proven to be effective in improving the quality of maternity care,
but the choice of one to be applied to any specific setting and context depends on a number of
conditions which should be considered by the managers before making any decision. Criterion
based Clinical Audit seems to be the best strategy for quality improvement in a developing country
A pilot study to investigate the feasibility of Clinical Audit for health care system of Pakistan is
needed. A representative sample of twelve hospitals: eight District Headquarters Hospitals
(DHQs), two from each of the four provinces, and one tertiary care teaching hospital from each
province can be chosen as study setting for this project. A retrospective study should be carried out
first, taking a pre decided number of maternal deaths, or some specific time period, and then some
interventions should be proposed for quality improvement of the setting, based on this
retrospective study. Finally a prospective study can be carried out to measure the effect of these
interventions to all the three aspects, structure, process, and outcome. If successful, the process can
be incorporated into the policy of National Health Care system.
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FOUND REPEATED SELECTED
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Maternal mortality in Pakistan Medline/Ovid 5 0 4
causes of maternal mortality in Pakistan Medline/Ovid 4 1 2
Pregnancy complications in Pakistan Medline/Ovid 1 0 1
Maternity care services Medline/Ovid 24 0 3
Quality of health care services Medline/Ovid 131 0 6
Quality of maternity care Medline/Ovid 28 2 4
Quality of maternity care in Pakistan Medline/Ovid 0 0 0
Quality of maternity care and maternal Medline/Ovid 2 0 2
Quality assessment of health care Medline/Ovid 10 1 5
Quality improvement of maternity care Medline/Ovid 1 0 1
Quality of maternity care, maternal mortality, WHO 2 0 2
Quality of maternity care, maternal mortality, ADB 1 0 1
Quality of maternity care, maternal mortality, Population 2 0 2
Quality of maternity care, maternal mortality, Worldbank 1 0 1
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