Access to high quality health care is not only an inherent human right but also a critical component underpinning positive maternal health outcomes. This was indicated clearly by the World Health Organization (WHO) Multicountry Survey on Maternal and Newborn Health, which found that while a base of essential interventions is necessary to manage severe complications, above this minimum level of equipment and trained staff, more technological infrastructure is not associated with better maternal health outcomes.
The BetterBirth study, a more recent large-scale randomized controlled trial, looked specifically at the technical processes that make up management of pregnancies, including handwashing and use of gloves, early referral for at-risk women and magnesium for hypertension. The trial was conducted over one year in 60 hospitals in Uttar Pradesh, India to support medical staff in adhering to the WHO Safe Childbirth Checklist. The BetterBirth trial results showed that the coaching-based program was associated with significantly higher adherence to essential birth practices, but this led to no significant improvement in maternal mortality, the primary outcome indicator of the study.
In 1966, Avedis Donabedian proposed a simple framework for understanding health care quality, dividing the observable components into structure, process and outcomes. The implication is that structure plus process must equal outcomes. The evidence from the WHO Multicountry Survey and the BetterBirth Study suggests that improvements in structure or technical process alone will not lead to improvements in outcomes. Two recent publications lay the groundwork for studying a third key component of maternal health: patients themselves. WHO and the Institute of Medicine explicitly address the importance of “patient centered care” in current guidance, and this concept is increasingly being changed to “person-centered care” (PCC) so as to include those who are not ill—women attending an antenatal care session, for example. PCC incorporates the human-rights dimensions of respectful maternity care and adds domains of knowledge exchange and experience of care (privacy, predictability of costs, cleanliness, etc.) that, when combined with patient-provider interaction, make up the key non-clinical aspects of care. PCC provides a framework for examining maternal health that starts from the perspective of the person receiving care.
Based on existing analytic models of patient experience, quality of care, health seeking-behavior and other areas of health, researchers have developed a new model of the key domains of PCC for reproductive health.
After conducting qualitative data collection, expert reviews, cognitive interviews, iterative testing and revisions, surveys and psychometric analysis, researchers have translated this framework into a validated scale for measuring person-centered maternity care (PCMC). The PCMC scale is a standardized tool that researchers, program managers from government or health facilities and health providers themselves can use to measure the whole patient experience. The scale, which has been adapted for different contexts, consists of 30 questions in the Kenya-specific scale and 27 in the India-specific iteration. A shorter multi-setting version has been developed with only 12 questions.
The PCMC scale has been applied in studies and interventions in Kenya, India and Ghana thus far. With it, researchers are now able to identify and better address the aspects of care that matter most to ensure positive patient experiences. The scale can also identify where these areas of care fall short and inform what practices must change to improve the quality of care as a whole. Both the framework and the scale are important as pragmatic, actionable steps to understanding patient care during childbirth. The improvements being made to infrastructure and medical processes need to be matched by improvements in the respect, empowerment, support and overall women-centered experiences that are at the center of every birth.
Donabedian proposed that structure plus process drives outcomes. The experiences of BetterBirth and the WHO Multicountry Survey on Maternal and Newborn Health may seem to have challenged this assumption, at least for hospital-based maternity care and in the geographies they examined. But perhaps it was because a key aspect of process was missing from this work. Donabedian identified process to include technical as well as human components, noting that “the interpersonal process is the vehicle by which technical care is implemented and on which its success depends.” PCMC brings these interpersonal processes to the forefront of maternal health care.
Perfect information is not necessary for improvement, although searching for good information when there are unknowns will lead to a better understanding of the complexities of health care and through that to improvements. The recent advances in person-centered care for maternal health, and the development of models and tools to understand patient experiences more accurately, come at a time when WHO’s initiative on Quality, Equity and Dignity is bringing new attention to the same issues. The growing attention to this issue will help us understand both how to improve person-centered Care and how doing so might change both experiences and outcomes for women.
Read the full paper and access the validated scale for measuring person-centered maternity care: Development of a tool to measure person-centered maternity care in developing settings: Validation in a rural and urban Kenyan population
Learn more about measuring women’s childbirth experiences.