Health outcomes (also known as impact) focus on the ultimate result of the care provided. Data sources for measuring health outcomes include many of the sources used to measure the dimensions of quality and improvements in quality. These include vital registration systems, special surveys and routine health information systems, including audit.
In Maternal and Newborn Health (MNH) outcomes are usually measured as maternal or perinatal mortality, morbidity or in terms of lives saved. Section A provides more information on the main indicators used, data sources and additional value that trend analysis of these indicators provides, for example in identifying inequalities of access to services which may be the result of several factors, including the quality of services provided.
Another example of a measure of mortality which is often used in quality assessment is the case fatality rate (CFR). The case fatality rate is defined as the proportion of deaths caused by a specific condition or disease, to the overall number of cases of that condition. See box below:
Expressing CFR in MNH
Numbers of women who were admitted to a health facility and who died as a result of an obstetric complication
Numbers of women admitted to the health facility with obstetric complications (such as post partum haemorrhage or pre-eclampsia)
CFR is often used as a proxy indicator to show the quality of care provided in a health facility and high rates are sometimes exclusively interpreted as the ultimate consequence poor care. However, case fatality rates should be interpreted with caution as they do not reflect the care received by those who survive and also does not reflect ‘near misses’.
In addition CFR rates may be very high for example, in a referral centre which receives cases in critical condition and at a late stage; the rate may reflect the lack of opportunity to intervene rather than poor quality services. Such contextual issues should be taken into account when interpreting indicators in general.
Indicators of quality for mothers
Global indicators of quality in MNH have been identified by the World Health Organization (WHO) and recently highlighted in the initiative to accelerate newborn health, the Every Newborn Action Plan.
These indicators are useful as they focus on the level of relevant services provided rather than on the number of facilities with the ability to provide them as per the United Nations process indicators and signal functions.
Many can also be measured using routine health information systems and are not reliant on separate assessments and surveys. The balance between using readily available data and that which requires special surveys (which can be infrequent, sometimes irrelevant in a shorter programme and expensive to commission) is a consideration to take into account in capturing quality.
Nineteen global indicators of quality have been proposed by WHO. Six indicators relate to the obstetric care provided to the mother
. These include:
- Proportion of women who had blood pressure measured at the last antenatal visit.
- Proportion of women with severe pre-eclampsia and eclampsia treated with magnesium sulphate injection.
- Proportion of women receiving oxytocin immediately after birth of the baby.
- Proportion of women with prolonged labour.
- Intra-partum stillbirth rate.
- Proportion of women with severe systemic infection/sepsis in the postpartum period, including readmissions
Indicators of quality for newborns
Five indicators pertain to the wellbeing of the newborn
1) Proportion of health facilities with maternity services that have a functional bag and mask in the delivery area.
2) Proportion of newborn who received all four elements of essential newborn care i.e.
- Immediate and thorough drying
- Immediate skin to skin contact
- Delayed cord clamping
- Initiation of breastfeeding within the first hour
3) Proportion of health facilities where kangaroo mother care (KMC) is operational, by level of facility.
4) Facility neonatal mortality rate disaggregated by birth weight.
5) Proportion of health facilities offering maternity services that have Baby Friendly Hospital Initiative (BFHI) (See Section B) certification and recertification not older than two years.
There are four other indicators which relate to the wellbeing of children; antibiotics for pneumonia, referral, malnutrition and hospitalisation of children under the age of five.
Cross-cutting indicators of quality
Four others indicators are cross cutting across maternal, newborn and child health. These include:
- Proportion of health facilities that had a stock of essential life saving medicines (e.g. oxytocin, magnesium sulphate, dexamethasone, vaccines, oral rehydration salt (ORS), zinc, oral amoxicillin, injectable gentamicin and malaria rapid diagnostic tests (MRDT), antimalarial and anti-retroviral therapy (ART) where appropriate)) in a specified period of time.
- Proportion of maternal, perinatal and child deaths occurring in the facility that were audited/reviewed.
- Proportion of health facilities with availability of soap, running water or alcohol based rub available in labour, neonatal and paediatric wards.
- Proportion of health facilities with safe, uninterrupted oxygen supply in the labour, neonatal and paediatric wards.
- Number of community health workers providing new-born care in the community.
- Number of midwives in the population.
Most of these indicators also address the structural dimension of quality.
Other global indicators of quality
Other global indicators have been put forward in the ‘Every Newborn Action Plan
’. These are:
- Number of births attended by a doctor or nurse or midwife.
- Number of births attended by a doctor or nurse or midwife and where the mother had a birth companion of choice.
- Number of babies receiving care within two days of birth.
- Number of babies exclusively breastfed in the first 30 days of life.
- Number of babies not showing any signs of life at birth and no signs of maceration.
- Numbers of babies born before 34 weeks (ultrasound confirmed) whose mothers received antenatal corticosteroids.
- Percentage of children <1 year with a birth certificate.
- Number of babies with birth weight recorded within 24 hours of birth.
- Number of neonatal deaths by categories of birth weights.
- Number of perinatal deaths reviewed.
- Number of neonatal deaths reviewed.
- Number of facilities in the population where trained staff are available to perform new-born resuscitation 24/7
You will notice that the emphasis of these indicators is on the process and outcome dimensions of quality, so moving towards the attainment of results. The lists of indicators provided here are still under development. The question of inconsistencies have been raised and efforts are being put into place to avoid confusion.
The purpose of having global indicators is to allow comparisons across countries and to measure the relative performance of countries in improving MNH care. However, another way of assessing performance is to measure performance against norms or standards. We will turn our attention to this in the next section.
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