Quality of Care for Maternal and Child Health: An Interview With Dr. Zulfi Bhutta

The maternal health community has made great strides towards improving the health of women and newborns around the world, but as global efforts have scaled up interventions quickly, the Maternal Health Task Force (MHTF) has often paused to consider the quality of this work.

To evaluate this, Ana Langer and Anne Austin from the MHTF joined experts from around the world to create the Quality of Care in Maternal and Child Health supplement, published by the Reproductive Health Journal in September, 2014.

Three of the five articles in the supplement have been highly accessed, which demonstrates high interest in quality of care in the community and untapped momentum that may be used to fill the identified research gaps.

We talked to Dr. Zulfi Bhutta, lead researcher for the series, and asked him a few questions about the research process and how we as the maternal health community should move forward with the results.

Q: What prompted the research team to take on the systematic reviews that make up the series?

Despite recent progress, about 273,500 women died of maternal causes in 2010.  Furthermore, the share of neonatal deaths among all under-five children increased from about 36% in 1990 to 44% in 2012. These deaths have occurred disproportionately in low-income countries or among the disadvantaged in high- and middle-income countries. It is particularly acute where access to and utilization of skilled services for childbirth and newborn care is lowest.

Evidence shows that poor quality of care for these women and newborns is a major factor for their elevated morbidity and mortality rates. Understanding underlying factors that impact the quality of maternal and newborn health (MNH) services and assessing the effectiveness of interventions at various health care delivery levels is crucial.

The collection assesses and summarizes findings from systematic reviews on the impact of various approaches to quality of care improvements. The focus was two-fold: identify the evidence base and information gaps and assess approaches that enable health providers to adopt and implement patient-centered, evidence-based interventions that improve quality of care during childbirth and immediately after.

Q: What gap does this series fill?

This series systematically reviews the evidence of interventions aimed at improving care at the community, district and facility level. It also highlights knowledge gaps, especially in low- and middle-income countries (LMICs). The gaps point to priority research questions to pursue to improve quality of care in these settings.

The findings can help governments, stakeholders and donors to form policies and develop health care models applicable to various levels of healthcare. This could enable community- and facility-based health care providers and district-level program managers to implement patient-centered, evidence-based interventions, which will improve childbirth and postpartum quality of care delivery.

Q: Which result stood out most?

At the community level, packaged care involving home visitation, outreach services, community mobilization, referrals, women’s support groups and community health worker and traditional birth attendants training showed improvements in MNH outcomes.

Mid-level health worker (MLHW) based care not only demonstrated outcomes comparable to routine non-MLHW care delivery but also showed better results for some outcomes. At the district level, user-directed financial strategies—especially conditional cash transfers and voucher schemes—increased MNH service utilization. District level supervision also found positively influenced provider’s practice, knowledge and awareness. At the facility level, in-service training, standardized or individualized social support programs and continuity of specialized midwifery care throughout pregnancy, labor and the postnatal period have the potential to improve perinatal, maternal, and labor specific indicators.

The findings demonstrate that community-based improvement interventions have been widely assessed for MNH outcome effectiveness in LMICs. However, many district- and facility-level interventions have been evaluated mainly in high-income country settings. Given the differences in low-, middle-, and high-income county healthcare infrastructure and systems, findings across countries in district- and facility-based care are not generalizable. There is also an information gap on the effectiveness of these interventions on different subgroups that may represent within-country disparities. Few of the studies provided evidence on sustainability and scale up.  Generating evidence on the sustainability of proven interventions—including implementation feasibility and scale up in various settings in countries with constrained resources and weak health systems—is needed.

Q: What is the series’ biggest take-away?

In addition to the effectiveness of specific quality improvement interventions on MNH, as I mentioned above, there is a dearth of evidence on district- and facility-level interventions, particularly those specific to quality of maternal health and MNH outcomes. Further evidence is needed to evaluate the best combination of strategies.

Q: Given the research gaps you’ve identified, what are the priority areas for future research?

Future research in LMICs should focus on factors affecting interventions’ sustainability and cost-effectiveness when scaled up. District- and facility-level interventions—including social support, specialized midwifery teams and staff skills mix—have proven to improve MNH outcomes in high-income countries; we need further research on implementation feasibility in low-resource settings. We also need qualitative data describing the individual components of interventions for reproducibility, which would make the interventions invaluable for scale up and sustainability in low-resource settings. Strengthening health information systems, one of the strategies that evaluate interventions’ effectiveness over a time period, should be established in LMICs. Further evidence is now needed to evaluate the best possible combination of strategies and healthcare models to suit specific groups.