In this package, we will take a health systems oriented perspective on quality MNH services. This is consistent with the World Health Organization (WHO) approach and the dimensions of quality model. The WHO justifies its rationale with a quotation from the Institute of Medicine report:
The implication is that technology, knowledge and resources alone will not lead to improved quality of services or care. Issues such as fragmented health care delivery systems and differing expectations between service providers, service users and policy makers are recognised as barriers to sustained improvements; even where investment is relatively high.
The health systems approach is intended to support national and regional decision makers and managers determine which quality strategies and strategic initiatives will have the greatest impact. This may involve addressing dimensions of quality, such as equity and accessibility, which are systems dependent.
In keeping with the systems oriented perspective of this resource, our focus is on the quality of services rather than care, which generally refers to the specific care provided to an individual by a service provider. The resource also focuses on strategic quality improvement strategies (discussed further in Section C), rather than specific interventions.
From coverage to quality
We have seen progress in the coverage of some critical services globally. Overall, in low and middle income countries an increase in the proportion of pregnant women attending at least four antenatal care visits has occurred, from approximately 37% in 1990 to about 52% in 2012. The proportion of births attended by skilled health personnel increased from 59% to 68% between 1990 and 2009 (WHO 2014).
Such indicators suggest that women are coming to the services currently being offered, yet the reductions we see in maternal and neonatal health burden are insufficient. See Section A for the data on comparative trends. One plausible argument for why that is happening is that coverage is not translated into expected health gains because the quality of services received by women is inadequate.
Another reason for coverage not producing results is that coverage is inequitable. In low income countries, only 38% of pregnant women attended antenatal care four times or more during the period 2006-2013, compared to 56% of pregnant women in all low and middle income countries. In the WHO African Region, fewer than 50% of births are attended by skilled health personnel and these are also the countries where the greatest number of maternal deaths occurred in 2010. This data hints that the services we offer are not being used by those most in need and that we may not be offering services in a way that is acceptable to the most disadvantaged and vulnerable. See Section A for data on inequities in access of services by wealth and by geography.
Both lines of reasoning imply that a focus on equitable, quality services may well make the difference to accelerated efforts to reduce maternal and newborn deaths and ill health.
The services offered
We know that women and their babies in many low and middle income settings are receiving services below minimum expected standards. This is evident in the many reports and published papers on availability of essential supplies, assessments of signal functions for emergency obstetric and newborn care and audits of performance.
Midwives and other health personnel do their best to improve services, but they do not necessarily work in an environment that is conductive to quality improvement. Health system bottlenecks – including leadership, financing mechanisms and information systems – are failing the health workforce (Dickson et al 2014, UNFPA 2014). This aggravates and reinforces poor attitudes and behaviours of health workers leading to abuse and disrespect of pregnant women when they come into contact with the health service.
Acceptable, quality services for women
Improvements in quality services can be achieved through a range of quality improvement interventions. Educational, organisational, financial, regulatory and legislative approaches and combinations of these have been implemented. Models using health system perspectives, human rights approaches or the management of organisational structure and culture can be used to frame the different approaches. The purpose therefore of programmatic intervention will be to ensure that inputs (in the form of financial, human and knowledge resources) are sufficient, the process of implementing the interventions are clear, the outputs of actions and interventions well defined and that the outcome of an improved service can be measured, so that health impact can be demonstrated.
- Dickson, K.E., (2014) Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries
- World Health Organization (WHO), The Global Health Observatory Data repository
- United Nations Population Fund (UNFPA), (2014) State of the World’s Midwifery 2014
- Institute of Medicine , (2001) Crossing the quality Chasm. A new health system for the 21st century.