How Good Are Our Current Measures for Maternal Health Care Quality?

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By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

The public health community has emphasized the importance of quality of maternal health care, noting that increasing access to care alone is not sufficient for improving maternal health outcomes. Many of the maternal health quality of care indicators currently used around the world have not yet been validated, which means that we may not be measuring what really matters. Researchers have demonstrated a lack of correlation between quality measures and maternal mortality. The challenge is how to capture the quality of maternal health care in diverse settings across the globe: What factors are important, and how can those factors be measured accurately? In an effort to answer that question, the Maternal Health Task Force (MHTF) partnered with colleagues at the Population Council to evaluate current measures of maternal health care quality.

A research team led by Ann Blanc examined the validity of common quality measures—particularly the skilled birth attendant (SBA) indicator—in Kenya and Mexico. The researchers compared women’s self-reports with those of trained, third party observers for numerous indicators including the health care provider’s skill level and actions, finding that the women’s and observers’ reports were incongruent for many of these indicators. For example, in Kenya, 78.9% of the women surveyed reported that the baby was placed immediately skin-to-skin after delivery, but only 16.3% of the third party observers reported that skin-to-skin contact was performed. Similarly, while 59.1% of the women surveyed reported receiving a uterotonic after delivering the placenta, only 2.4% of the observers reported that a uterotonic was administered. Reports were inconsistent in Mexico as well: 94.1% of the women surveyed reported receiving a uterotonic immediately after delivering the placenta, but only 20% of third party observers reported that a uterotonic was administered.

Overall, the validity of the quality indicators was mixed in both Kenya and Mexico. In Kenya, the most accurate indicators assessed whether the main provider during delivery was a nurse/midwife, whether a support companion was present at birth, whether a cesarean section was performed and whether the infant had a low birth weight. In Mexico, the most accurate indicators measured if a urine sample screen was taken, if an injection or IV medication was administered during labor, if an episiotomy was performed, if excessive bleeding occurred and if blood products were given. The results of these studies point to a number of important considerations and implications:

  1. The way questions are worded to women is extremely important for eliciting accurate self-reports. For example, fewer women in Kenya may have answered “yes” to the skin-to-skin indicator if the term “skin-to-skin” was explained thoroughly.
  2. While there was some overlap, many of the indicators worked better in Kenya compared to Mexico and vice versa, illustrating the importance of adapting quality measures to local contexts.
  3. Women in both settings had more difficulty answering questions related to the timing and sequence of events. Indicators that do not rely heavily on timing may be more accurate.
  4. In Kenya, an indicator measuring whether the main provider during delivery (but not during labor) was a nurse/midwife was accurate, but the same indicator was less accurate in Mexico. This finding suggests that some SBA indicators may be more accurate than others, and some may work in particular settings but not others.

Additional efforts are warranted to continue evaluating current measures and develop better ways of measuring the quality of maternal health care around the globe. Ensuring that we are truly capturing what we want to measure is a prerequisite for identifying gaps and improving the care that mothers and newborns receive.

Learn more about the MHTF’s role in validating the skilled birth attendant indicator.

Read perspectives on the SBA indicator and proposed alternatives.

Explore the MHTF-PLOS Collection highlighting quality of maternal health care.

Check out the newest guidelines from the World Health Organization for measuring quality of maternal health care.

Are you working on measuring or improving the quality of maternal health care? We want to hear from you!