Measuring maternal health care: Using mixed methods

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Measuring maternal health careUsing mixed
methods
Julia Hussein
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CONCEPTUAL FRAMEWORK FOR QUALITY OF CARE
DEMAND FACTORS
SUPPLY FACTORS
Information, counselling
Support to health providers
Technical competence
Client involvement in decision making
Promotion, protection of health
Referral
Supplies, equipment
Continuity of care
Client-provider interaction
Quality of care
Accessible, available and comprehensive care
Acceptable services
Maternal/perinatal morbidity/ mortality and/or
economic, social
Adapted WHO Mother-baby Package
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MEASUREMENT APPROACHES

• Examples
• Criterion based clinical audit www.abdn.ac.uk/immp
  act
• Audit, confidential enquiries Beyond the
  numbers www.who.int
• Unmet obstetric need www.uonn.org
• Emergency obstetric care (case fatality rates)
  www.amdd.hs.columbia.edu
• Provider knowledge, competence, performance,
  enabling environment www.qaproject.org
• Training, quality, general maternal and neonatal
  health indicators www.jhpiego.org
• Supplies, equipment www.measuredhs.com/aboutsurvey
  s/
• ..and many others

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SKILLED ATTENDANCE INDEX
Aggregate measure of clinical indices of
care, expressed as a of the maximum
n416
The methodology is available in the SAFE Strategy
Development Tool on www.abdn.ac.uk/dugaldbairdcent
re/safe/resources.hti
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SKILLED ATTENDANCE INDEXMETHOD
Establish key criteria
Develop case extraction form, code
Review delivery records of normal and
complicated deliveries
Calculate a summary measure of the percentages of
criteria met in each delivery record
Single composite index of quality of care
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THE CASE EXTRACTION FORM
56 questions (criteria) for all deliveries 38
additional questions for complicated deliveries
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LESSONS LEARNT

• Book no lie
• Quality of care outside facilities limited
  record keeping in domiciliary deliveries
• For taking action on clinical quality,
  disaggregation of index may be more useful (ie
  obtain information on individual criteria)
• How to account for over-medicalisation?

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CONFIDENTIAL ENQUIRIES IN DEVELOPING COUNTRIES

• Recommended by WHO - Beyond the numbers
• Taken up in some developing countries but
  limited
• Why limited uptake?
• Poor quality documentation
• Lack of time/interest/accountability
• Poor organisational capacity of health system
• Heavy clinical workload
• Litigation, futility, fear of exposure?

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FINDINGS FACILITY BASED CARE

• Substandard care
• Caesarean sections conducted in haste
• Inappropriate and ineffective drugs
• Doctor rarely present when woman in critical
  condition
• Acute resuscitation efforts were poor
• Few partographs
• Completed audit forms seldom found

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Decision making for Caesarean Section4/8 done in
haste without properly weighing up the risks and
without stabilizing the patient before operating.
One Caesarean was
unnecessary. In others, the operation appeared to
have contributed to the death (confidential
enquiry report Ghana July 2006)
The decision for operative intervention was
hastythe patient was not adequately assessed
and prepared for anaesthesia and surgerythis
contributed to the death (panel assessment
407101)
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ADAPTING CONFIDENTIAL ENQUIRIES

• Favourable factors in health facilities
• Referral
• Drugs and supplies
• Team communication

• Adaptation
• Building on strengths
• Negative focus only can be discouraging
• Alleviate anxiety and defensiveness
• Prevents sense of being overwhelmed

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FINDINGS MIDWIVES IN THE COMMUNITY

• Availability
• Midwife available, but not usually the assigned
  midwife
• Acceptability
• Preference for traditional attendants
• Role
• Referral
• Administrative/organisational access (health
  insurance, transport etc)

• Clinical skills
• Diagnostic skills sufficient to identify urgent
  referral needs
• Incorrect manoeuvres, lack of confidence in
  obstetric first aid
• Health system
• Blood not available at primary and secondary
  level
• Delays at primary health facilities

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Midwives role in referralThe midwife diagnosed
correctly and made a quick decision to
refershe could convince people that the
patient needed to be referred although the
traditional birth attendant said it was not
time (panel assessment, case 3i)Midwive
s make decisions rapidly and appropriately.but
could be diverted from medical care to
administratively arranging the referral.In one
case of near miss, the midwife insisted the
patient be admitted when the hospital tried to
refuse because they were too busy (confidential
enquiry report Indonesia August 2006)
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ADAPTING CONFIDENTIAL ENQUIRIES

• Investigating community care
• Hospital records not available
• Interviews with providers and lay community
  members
• Explores events before arrival at hospital

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CASE ASSESSMENT FORM

• Personal/family/community
• Health system (transport, availability
  facilities, personnel)
• Medical care (antenatal,intrapartum,emergency,post
  natal)
• Availability of information

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ADAPTING CONFIDENTIAL ENQUIRIES

• Participatory in nature
• Interpretation done by peer practitioners
• Sample of 20 cases in each country
• Range of different complications and deaths

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CONCLUSION

• Measurement of maternal health care complex
• No single, ideal means to measure care
• Mixed methods required
• qualitative and quantitative
• Pluralistic range of perspectives, sources
  methods

• More documentation of how methods for measurement
  work through various forms of adaptation
• Tools for measurement, as well as change