DOI: 10.1111/1471-0528.12819
Review article
www.bjog.org
Quality of maternal and neonatal care in Central Asia and Europe—lessons learnt A Bacci European School for Maternal, Newborn, Child and Adolescent Health, Trieste, Italy Correspondence: A Bacci, European School for Maternal, Newborn, Child and Adolescent Health, via Ludovico Ariosto 2, 34135 Trieste, Italy. Email [email protected] Accepted 28 February 2014.
In the World Health Organization (WHO) European region despite official high coverage of essential interventions for maternal and neonatal care, there are still significant gaps in the delivery of effective interventions. Since 2001, WHO designed and implemented the Making Pregnancy Safer programme, which includes hands-on training courses in effective perinatal care for maternity teams, development of clinical guidelines, maternal mortality and morbidity case reviews, and assessments of quality
of care. This has contributed to enhancing capacity at country level to improve organisation and provision of care. This paper describes the programme’s components, challenges, achievements and results. Keywords Assessment of quality of care, beyond the numbers, clinical guidelines, effective perinatal care, maternal mortality, morbidity case reviews, quality of care.
Please cite this paper as: Bacci A. Quality of maternal and neonatal care in Central Asia and Europe—lessons learnt. BJOG 2014; 121 (Suppl. 4): 11–14.
Introduction In the World Health Organization (WHO) European Region, which includes countries in Central Asia, official statistics for the former Soviet Republics report high coverage (up to 90–99%) for key interventions, such as skilled attendance at birth, antenatal care and breastfeeding.1 However, outcome indicators still show high maternal and perinatal mortality figures, with significant differences between official statistics and United Nations estimates,2,3 indicating that under-reporting is common. Part of the under-reporting is historically a result of international definitions not being used when calculating the indicators for both coverage (such as, for example, those for exclusive breastfeeding), and outcomes (perinatal mortality, maternal mortality). The mismatch between very high coverage with, for example, institutional delivery care (with the exception of Tajikistan) and unsatisfactory outcomes, clearly points to the existence of unaddressed issues in the quality of care compared with countries with a similar health system context in other regions of the world. The challenges that had to be addressed to improve quality of care were many. Concepts of evidence-based care had to be introduced in a professional environment that was (and still is, in some places) quite isolated from a scientific point of view (due to language and political
ª 2014 Royal College of Obstetricians and Gynaecologists
issues), and not used to applying and implementing updated (or newer) approaches to healthcare delivery. In the period when countries were under Soviet administration, all guidelines for healthcare provision and organisation were developed at central level, and disseminated as ‘mandatory instructions’ (prikaz). The result was that common recommended or mandatory practices (e.g. applying an ice pack on the mother’s abdomen after birth for prevention of haemorrhage) were used in all facilities across more than 20 countries.
Description of the programme In 2001, the WHO Regional Office for Europe developed a strategy for Making Pregnancy Safer (MPS),4 based on the principles described in Box 1. Box 1. Principles of care in the Making Pregnancy Safer
strategy4 Based on scientific evidence and cost-effective Family centred, respecting confidentiality, privacy, culture, belief and emotional needs of women, families and communities Ensure involvement of women in decision-making for options of care Ensure a continuum of care from community to the highest level of care Address wider health system functioning.
11
Bacci
The MPS strategy includes several components that aim to address and improve the quality of care. The first component to be introduced was an interactive, hands-on training package in effective perinatal care (EPC), developed by the WHO Regional Office for Europe,5 which is aimed at improving practices of maternity teams during childbirth. The master training courses are facilitated by a team of international consultants (midwife, obstetrician– gynaecologist and neonatologist), with the objective of improving the knowledge, skills, practice and attitude of healthcare professionals involved in perinatal care. This training involves local teams in the development of action plans for implementation after the training, and ensures a supervisory follow-up visit after 6 months, with reinforcement on relevant areas of care. EPC training courses and training of trainers proved effective in changing practice, and created a basis from which to build national capacity to further disseminate the principles and content of perinatal care, with strong support from development partners, which has been maintained to date in countries in Central Asia, the Caucasus, Balkans, Russian Federation, Moldova and Ukraine.6 The second MPS component included technical support for the development of national clinical guidelines regarding normal birth and common obstetric and neonatal complications. This was a key step leading to the revision of outdated ministerial orders, and contributed to the removal of ineffective or even dangerous practices. An example of this was the practice of ‘overdiagnosis’ resulting in as many as 90% of pregnant women being defined as ‘at risk’, which resulted in normal pregnant women and babies receiving a number of potentially harmful medicines, and even hospitalisation. This process took several years and made it clear that showing good examples of clinical guidelines from other countries or international organisations alone was not sufficient to convince national professionals. The interventions started with the organisation of courses in Russian on evidence-based practice, with key references translated. The second step was to build capacity and ownership among national professionals, in order for them to develop or adapt international guidelines themselves. Translation into Russian of key documents (e.g. Royal College Obstetricians and Gynaecologists Green Top Guidelines, WHO Integrated Management of Pregnancy and Childbirth)7,8 positively impacted this process, which once it started to roll out, created positive ‘competition’ among participating countries.9,10 A third component of the MPS strategy was the introduction in 2004 of maternal mortality and morbidity case reviews, based on the WHO manual Beyond the Numbers (BTN).11 The process of introduction included two regional workshops, involving Ministries of Health and development partners from 14 countries in the WHO European region, fol-
12
lowed by a series of national workshops on BTN, to discuss concepts and methods with key professionals, which were then followed by BTN technical workshops to build capacity to set up the audit systems, develop forms, collect information, run meetings and interview women and families. The approaches outlined in BTN differ from the existing traditional ministerial investigations in that they are based on a key set of updated national clinical guidelines on main obstetric complications (rather than on opinions), on professional (rather than administrative) review, and, most importantly, they imply no blame, no punishment, no identification of guilty professionals, but aim at improving the process of care. International experts were involved during the introduction, piloting and review of the new approach in all countries. Results, challenges and achievements were reviewed in a regional workshop held in Uzbekistan in 2011. In addition, WHO encouraged the documentation of results by the involved professionals, beyond the reports of activities, and a series of articles were published in both bulletins such as WHO Entre Nous, and in international peer-reviewed journals.12,13 In 2009, the WHO Regional Office for Europe developed the tool for assessment of quality of hospital care for mothers and newborn babies as a fourth component of the MPS strategy.14 In 2013, this was complemented by the tool for assessment of antenatal and postpartum care for mothers and babies.15 These tools are intended to guide a problem-based, action-oriented, detailed assessment of all the major areas and factors that may have an impact on quality of care, including infrastructure, supplies, organisation of services and case management, focusing on the areas that have been shown to have the greatest impact on maternal and newborn mortality and serious morbidity, as well as on maternal and neonatal wellbeing. The primary aim of the WHO quality of care assessment tools is to aid Ministries of Health, key partners and stakeholders, to carry out an evaluation of care provided at facility level in a systematic and participatory way (involving international and national experts), to identify key areas of pregnancy, childbirth and newborn care that need to be improved. The tools are designed also to ‘give voice’ to the users, and allow health managers and professionals to take into account their views in identifying and addressing deficiencies in quality of care. Since the commitment of hospital managers and health professionals at facility level is a critical determinant of change, the inclusion in the assessment process of a framework for the development of an action plan, with identification of tasks and responsibilities of the various staff members and departments, proved to be an important element. The findings were also used to promote action at health system level, since the commitment of Ministries of Health to support the process is necessary to achieve
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of maternal and neonatal care—Central Asia
results. The revision of legislation and financial mechanisms are a crucial step to facilitate the introduction of evidence-based practices, eliminate perverse financial mechanisms and wrong practices, and develop and implement mechanisms for rewarding good practices. Although the tools can be used in a single facility for internal audit purposes, the assessment of a representative sample (to be determined depending on the country’s size, structure and distribution of health services) of services providing pregnancy, childbirth and postpartum care provides results that can be generalised to the whole health network.16 The assessment process itself, the assessment findings and the relevant action plans should be seen as components of a quality improvement cycle. By suggesting specific indicators and a scoring system to monitor quality of care, the tool can be used within performance-based and/or accreditation schemes. Quality assessments were carried out from 2009 to 2013, in at least 15 countries in the European region, and also in countries in other regions. As planning for consistent re-evaluation is a key for stimulating improvement, in some countries a second quality of care assessment was carried out, after interventions (EPC training, guidelines development, BTN) to evaluate changes and this showed very encouraging results.17
practice as well as on-the-job introduction of WHO guidelines on maternal and newborn care. The MPS programme contributed to building capacity and leadership at country and facility level, and facilitated exchange and dissemination of best practices across health facilities and countries.
Weaknesses The implementation of facility-based action plans and of action at a health systems level are strongly dependent on local and national leadership. Health professionals still fear punishment, as identified during BTN follow-up activities and staff interviews within the quality of care assessments. This prevents them from providing information, so the new approach to audit (confidentiality, no blame, no punishment, interviews, etc.) was not easy to implement. Migration and turnover of health professionals trained in EPC and BTN methodologies makes sustainability difficult in some cases. All MPS components need the involvement of academics and updating of contents and training methods in schools of medicine and midwifery: this process is still incomplete.
Challenges Strengths The EPC training ensures improvement of clinical practices around childbirth and optimises communication and collaboration between obstetric and neonatal teams. Similarly, the BTN approach improved emergency obstetric care, strengthened the use of updated clinical guidelines, ensured better team work around childbirth and enhanced the role of midwives. Quality of care assessments promote better awareness about gaps and the effect of limiting health system factors on quality of care at both health facility and health system levels; they are also useful to introduce the concepts of peer review, participatory assessment and supportive supervision. Both BTN and quality assessments include views of women and families about the quality of care provided to them and their babies, and what happened in near-miss cases; this was clearly a novel approach for most healthcare professionals. Incorporating the views of mothers on several aspects of care is an important way to promote mother-friendly and family-friendly attitudes among staff, involvement of mothers and families in the decision-making process, as well as creating awareness among mothers about their own health and rights. All MPS components facilitated the introduction of supportive supervision and peer-to-peer review concepts and
ª 2014 Royal College of Obstetricians and Gynaecologists
Challenges in implementation include several issues: the initial one is to plan the introduction of MPS components in accordance with specific national situations and achievements (for example achieving a critical mass of professionals implementing EPC as a basis of introduction of BTN). Standards, training and assessment tools are essential, but on their own they are not sufficient to promote a sustained effort towards quality improvement; a third crucial component is the existence of driving forces capable of stimulating change. Continuity of commitment by Ministries of Health and top-level managers, linked to national strategies and plans, is a key requisite to ensure stable improvement and medium-term as well as long-term results. Another key factor is the commitment of healthcare professionals to quality improvement, but this is dependent on the role of professional associations, which are still often weak in most countries and need to be further strengthened and empowered. Challenges in improving quality of maternal and neonatal care include ensuring continuous technical overview, and sustained and coordinated support by the United Nations and other development partners, keeping in consideration the fact that improving the quality of perinatal care is not a short-term engagement, it is crucial to maintain a continuous dialogue among key stakeholders, and
13
Bacci
continue planning, implementation and monitoring over a period of several years.
Conclusions Making Pregnancy Safer is an example of successful implementation of a series of coordinated synergistic activities that involved national key stakeholders in the process of improving quality and organisation of care for mothers and newborn babies. The timing, sequence and interplay of different strategic components and interventions is important when planning such a programme. No tool per se or on its own makes the difference. The most important issue is the way any new tool, concept or practice is endorsed by national driving forces and the way it is used. Providing other key health system interventions (e.g. improving infrastructure, and ensuring essential medicines and equipment, appropriate human resources, and basic benefit packages are in place) will optimise results. Using benchmarking among countries (‘if the neighbouring country has developed clinical guidelines and introduced BTN, we should do even better’ a Ministry of Health representative) encouraged by WHO, proved to be an effective strategy, which in some cases created a ‘snowball effect’ of good practices. Finally, the synergistic role of international organisations is pivotal for strengthening progress in this area in the European Region.
Disclosure of interest None.
Details of ethics approval None.
Funding None.
Acknowledgements We thank Giorgio Tamburlini for writing and editorial assistance and Gunta Lazdane and Ida Stromgren for significant support in the planning and implementation of the Making Pregnancy Safer programme. &
References 1 WHO Health For All Database. [www.euro.who.int/en/data-andevidence/databases/european-health-for-all-database-hfa-db]. Accessed 4 December 2013. 2 Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank estimates. Geneva: World Health Organization; 2012.
14
3 World Health Organization. Neonatal and Perinatal mortality: Country, Regional and Global Estimates. Geneva: WHO; 2006 [http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf]. Accessed 4 December 2013. 4 WHO European Strategic Approach for Making Pregnancy Safer. [www.euro.who.int/en/health-topics/Life-stages/maternal-and-new born-health/policy-and-tools/european-strategic-approach-for-makingpregnancy-safer]. Accessed 4 December 2013. 5 Effective Perinatal Care training package, WHO Regional Office for Europe. [www.euro.who.int/en/health-topics/Life-stages/maternal-andnewborn-health/policy-and-tools/effective-perinatal-care-trainingpackage-epc]. Accessed 4 December 2013. 6 Berglund A, Lefevre-Cholay E, Bacci A, Blyumina A, Lindmark G. Successful implementation of evidence-based routines in Ukrainian maternities. Acta Obstet Gynecol Scand 2010;89:230–7. 7 Royal College of Obstetricians and Gynaecologists. Guidelines translated into Russian. [http://www.rcog.org.uk/womens-health/ guidelines/search-guideline/guidelines-translated-russian]. Accessed 29 March 2014. 8 WHO Integrated management of pregnancy and childbirth (IMPAC). Russian version. [http://www.euro.who.int/en/health-topics/Lifestages/maternal-and-newborn-health/policy-and-tools/integratedmanagement-of-pregnancy-and-childbirth-impac]. Accessed 24 March 2014. 9 Bacci A, Wyn Huis D, Baltag V, Lazarus JV. Introducing evidence based medicine and guidelines for maternal and newborn health in the Republic of Moldova. Cent Eur J Public Health 2005;13:200–1. 10 Borchert M, Bacci A, Baltag V, Hodorogea S, Drife J. Improving maternal and perinatal health care in the Central Asian Republics. Int J Gynaecol Obstet 2010;110:97–100. 11 WHO, Department of Reproductive Health and Research. Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer. Geneva: World Health Organization; 2004. 12 Bacci A, Lewis G, Baltag V, Betran AP. The introduction of Confidential Enquiries into Maternal Deaths and Near-Miss Case Reviews in the WHO European Region. Reprod Health Matters 2007;15:145–52. 13 Baltag V, Filippi V, Bacci A. Putting theory into practice: the introduction of obstetric near-miss case reviews in the Republic of Moldova. Int J Quality Health Care 2012;24:1–7. 14 Making Pregnancy Safer: Assessment tool for the quality of hospital care for mothers and newborn babies. [www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/ 2009/making-pregnancy-safer-assessment-tool-for-the-quality-ofhospital-care-for-mothers-and-newborn-babies]. Accessed 4 December 2013. 15 Assessment tool for the quality of outpatient antepartum and postpartum care for women and newborns. [www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/ 2013/assessment-tool-for-the-quality-of-outpatient-antepartum-andpostpartum-care-for-women-and-newborns]. Accessed 4 December 2013. 16 Tamburlini G, Siupsinskas G, Bacci A. Quality of maternal and neonatal care in Albania,Turkmenistan and Kazakhstan: a systematic, standard-based, participatory assessment. PLoS ONE 2011;6:e28763. 17 Tamburlini G, Yadgarova K, Kamilov A, Bacci A, for the The Maternal and Neonatal Care Quality Improvement Working Group. Improving the quality of maternal and neonatal care: the role of standard based participatory assessments. PLoS ONE 2013;8: e78282.
ª 2014 Royal College of Obstetricians and Gynaecologists
Review article
www.bjog.org
Quality of maternal and neonatal care in Central Asia and Europe—lessons learnt A Bacci European School for Maternal, Newborn, Child and Adolescent Health, Trieste, Italy Correspondence: A Bacci, European School for Maternal, Newborn, Child and Adolescent Health, via Ludovico Ariosto 2, 34135 Trieste, Italy. Email [email protected] Accepted 28 February 2014.
In the World Health Organization (WHO) European region despite official high coverage of essential interventions for maternal and neonatal care, there are still significant gaps in the delivery of effective interventions. Since 2001, WHO designed and implemented the Making Pregnancy Safer programme, which includes hands-on training courses in effective perinatal care for maternity teams, development of clinical guidelines, maternal mortality and morbidity case reviews, and assessments of quality
of care. This has contributed to enhancing capacity at country level to improve organisation and provision of care. This paper describes the programme’s components, challenges, achievements and results. Keywords Assessment of quality of care, beyond the numbers, clinical guidelines, effective perinatal care, maternal mortality, morbidity case reviews, quality of care.
Please cite this paper as: Bacci A. Quality of maternal and neonatal care in Central Asia and Europe—lessons learnt. BJOG 2014; 121 (Suppl. 4): 11–14.
Introduction In the World Health Organization (WHO) European Region, which includes countries in Central Asia, official statistics for the former Soviet Republics report high coverage (up to 90–99%) for key interventions, such as skilled attendance at birth, antenatal care and breastfeeding.1 However, outcome indicators still show high maternal and perinatal mortality figures, with significant differences between official statistics and United Nations estimates,2,3 indicating that under-reporting is common. Part of the under-reporting is historically a result of international definitions not being used when calculating the indicators for both coverage (such as, for example, those for exclusive breastfeeding), and outcomes (perinatal mortality, maternal mortality). The mismatch between very high coverage with, for example, institutional delivery care (with the exception of Tajikistan) and unsatisfactory outcomes, clearly points to the existence of unaddressed issues in the quality of care compared with countries with a similar health system context in other regions of the world. The challenges that had to be addressed to improve quality of care were many. Concepts of evidence-based care had to be introduced in a professional environment that was (and still is, in some places) quite isolated from a scientific point of view (due to language and political
ª 2014 Royal College of Obstetricians and Gynaecologists
issues), and not used to applying and implementing updated (or newer) approaches to healthcare delivery. In the period when countries were under Soviet administration, all guidelines for healthcare provision and organisation were developed at central level, and disseminated as ‘mandatory instructions’ (prikaz). The result was that common recommended or mandatory practices (e.g. applying an ice pack on the mother’s abdomen after birth for prevention of haemorrhage) were used in all facilities across more than 20 countries.
Description of the programme In 2001, the WHO Regional Office for Europe developed a strategy for Making Pregnancy Safer (MPS),4 based on the principles described in Box 1. Box 1. Principles of care in the Making Pregnancy Safer
strategy4 Based on scientific evidence and cost-effective Family centred, respecting confidentiality, privacy, culture, belief and emotional needs of women, families and communities Ensure involvement of women in decision-making for options of care Ensure a continuum of care from community to the highest level of care Address wider health system functioning.
11
Bacci
The MPS strategy includes several components that aim to address and improve the quality of care. The first component to be introduced was an interactive, hands-on training package in effective perinatal care (EPC), developed by the WHO Regional Office for Europe,5 which is aimed at improving practices of maternity teams during childbirth. The master training courses are facilitated by a team of international consultants (midwife, obstetrician– gynaecologist and neonatologist), with the objective of improving the knowledge, skills, practice and attitude of healthcare professionals involved in perinatal care. This training involves local teams in the development of action plans for implementation after the training, and ensures a supervisory follow-up visit after 6 months, with reinforcement on relevant areas of care. EPC training courses and training of trainers proved effective in changing practice, and created a basis from which to build national capacity to further disseminate the principles and content of perinatal care, with strong support from development partners, which has been maintained to date in countries in Central Asia, the Caucasus, Balkans, Russian Federation, Moldova and Ukraine.6 The second MPS component included technical support for the development of national clinical guidelines regarding normal birth and common obstetric and neonatal complications. This was a key step leading to the revision of outdated ministerial orders, and contributed to the removal of ineffective or even dangerous practices. An example of this was the practice of ‘overdiagnosis’ resulting in as many as 90% of pregnant women being defined as ‘at risk’, which resulted in normal pregnant women and babies receiving a number of potentially harmful medicines, and even hospitalisation. This process took several years and made it clear that showing good examples of clinical guidelines from other countries or international organisations alone was not sufficient to convince national professionals. The interventions started with the organisation of courses in Russian on evidence-based practice, with key references translated. The second step was to build capacity and ownership among national professionals, in order for them to develop or adapt international guidelines themselves. Translation into Russian of key documents (e.g. Royal College Obstetricians and Gynaecologists Green Top Guidelines, WHO Integrated Management of Pregnancy and Childbirth)7,8 positively impacted this process, which once it started to roll out, created positive ‘competition’ among participating countries.9,10 A third component of the MPS strategy was the introduction in 2004 of maternal mortality and morbidity case reviews, based on the WHO manual Beyond the Numbers (BTN).11 The process of introduction included two regional workshops, involving Ministries of Health and development partners from 14 countries in the WHO European region, fol-
12
lowed by a series of national workshops on BTN, to discuss concepts and methods with key professionals, which were then followed by BTN technical workshops to build capacity to set up the audit systems, develop forms, collect information, run meetings and interview women and families. The approaches outlined in BTN differ from the existing traditional ministerial investigations in that they are based on a key set of updated national clinical guidelines on main obstetric complications (rather than on opinions), on professional (rather than administrative) review, and, most importantly, they imply no blame, no punishment, no identification of guilty professionals, but aim at improving the process of care. International experts were involved during the introduction, piloting and review of the new approach in all countries. Results, challenges and achievements were reviewed in a regional workshop held in Uzbekistan in 2011. In addition, WHO encouraged the documentation of results by the involved professionals, beyond the reports of activities, and a series of articles were published in both bulletins such as WHO Entre Nous, and in international peer-reviewed journals.12,13 In 2009, the WHO Regional Office for Europe developed the tool for assessment of quality of hospital care for mothers and newborn babies as a fourth component of the MPS strategy.14 In 2013, this was complemented by the tool for assessment of antenatal and postpartum care for mothers and babies.15 These tools are intended to guide a problem-based, action-oriented, detailed assessment of all the major areas and factors that may have an impact on quality of care, including infrastructure, supplies, organisation of services and case management, focusing on the areas that have been shown to have the greatest impact on maternal and newborn mortality and serious morbidity, as well as on maternal and neonatal wellbeing. The primary aim of the WHO quality of care assessment tools is to aid Ministries of Health, key partners and stakeholders, to carry out an evaluation of care provided at facility level in a systematic and participatory way (involving international and national experts), to identify key areas of pregnancy, childbirth and newborn care that need to be improved. The tools are designed also to ‘give voice’ to the users, and allow health managers and professionals to take into account their views in identifying and addressing deficiencies in quality of care. Since the commitment of hospital managers and health professionals at facility level is a critical determinant of change, the inclusion in the assessment process of a framework for the development of an action plan, with identification of tasks and responsibilities of the various staff members and departments, proved to be an important element. The findings were also used to promote action at health system level, since the commitment of Ministries of Health to support the process is necessary to achieve
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of maternal and neonatal care—Central Asia
results. The revision of legislation and financial mechanisms are a crucial step to facilitate the introduction of evidence-based practices, eliminate perverse financial mechanisms and wrong practices, and develop and implement mechanisms for rewarding good practices. Although the tools can be used in a single facility for internal audit purposes, the assessment of a representative sample (to be determined depending on the country’s size, structure and distribution of health services) of services providing pregnancy, childbirth and postpartum care provides results that can be generalised to the whole health network.16 The assessment process itself, the assessment findings and the relevant action plans should be seen as components of a quality improvement cycle. By suggesting specific indicators and a scoring system to monitor quality of care, the tool can be used within performance-based and/or accreditation schemes. Quality assessments were carried out from 2009 to 2013, in at least 15 countries in the European region, and also in countries in other regions. As planning for consistent re-evaluation is a key for stimulating improvement, in some countries a second quality of care assessment was carried out, after interventions (EPC training, guidelines development, BTN) to evaluate changes and this showed very encouraging results.17
practice as well as on-the-job introduction of WHO guidelines on maternal and newborn care. The MPS programme contributed to building capacity and leadership at country and facility level, and facilitated exchange and dissemination of best practices across health facilities and countries.
Weaknesses The implementation of facility-based action plans and of action at a health systems level are strongly dependent on local and national leadership. Health professionals still fear punishment, as identified during BTN follow-up activities and staff interviews within the quality of care assessments. This prevents them from providing information, so the new approach to audit (confidentiality, no blame, no punishment, interviews, etc.) was not easy to implement. Migration and turnover of health professionals trained in EPC and BTN methodologies makes sustainability difficult in some cases. All MPS components need the involvement of academics and updating of contents and training methods in schools of medicine and midwifery: this process is still incomplete.
Challenges Strengths The EPC training ensures improvement of clinical practices around childbirth and optimises communication and collaboration between obstetric and neonatal teams. Similarly, the BTN approach improved emergency obstetric care, strengthened the use of updated clinical guidelines, ensured better team work around childbirth and enhanced the role of midwives. Quality of care assessments promote better awareness about gaps and the effect of limiting health system factors on quality of care at both health facility and health system levels; they are also useful to introduce the concepts of peer review, participatory assessment and supportive supervision. Both BTN and quality assessments include views of women and families about the quality of care provided to them and their babies, and what happened in near-miss cases; this was clearly a novel approach for most healthcare professionals. Incorporating the views of mothers on several aspects of care is an important way to promote mother-friendly and family-friendly attitudes among staff, involvement of mothers and families in the decision-making process, as well as creating awareness among mothers about their own health and rights. All MPS components facilitated the introduction of supportive supervision and peer-to-peer review concepts and
ª 2014 Royal College of Obstetricians and Gynaecologists
Challenges in implementation include several issues: the initial one is to plan the introduction of MPS components in accordance with specific national situations and achievements (for example achieving a critical mass of professionals implementing EPC as a basis of introduction of BTN). Standards, training and assessment tools are essential, but on their own they are not sufficient to promote a sustained effort towards quality improvement; a third crucial component is the existence of driving forces capable of stimulating change. Continuity of commitment by Ministries of Health and top-level managers, linked to national strategies and plans, is a key requisite to ensure stable improvement and medium-term as well as long-term results. Another key factor is the commitment of healthcare professionals to quality improvement, but this is dependent on the role of professional associations, which are still often weak in most countries and need to be further strengthened and empowered. Challenges in improving quality of maternal and neonatal care include ensuring continuous technical overview, and sustained and coordinated support by the United Nations and other development partners, keeping in consideration the fact that improving the quality of perinatal care is not a short-term engagement, it is crucial to maintain a continuous dialogue among key stakeholders, and
13
Bacci
continue planning, implementation and monitoring over a period of several years.
Conclusions Making Pregnancy Safer is an example of successful implementation of a series of coordinated synergistic activities that involved national key stakeholders in the process of improving quality and organisation of care for mothers and newborn babies. The timing, sequence and interplay of different strategic components and interventions is important when planning such a programme. No tool per se or on its own makes the difference. The most important issue is the way any new tool, concept or practice is endorsed by national driving forces and the way it is used. Providing other key health system interventions (e.g. improving infrastructure, and ensuring essential medicines and equipment, appropriate human resources, and basic benefit packages are in place) will optimise results. Using benchmarking among countries (‘if the neighbouring country has developed clinical guidelines and introduced BTN, we should do even better’ a Ministry of Health representative) encouraged by WHO, proved to be an effective strategy, which in some cases created a ‘snowball effect’ of good practices. Finally, the synergistic role of international organisations is pivotal for strengthening progress in this area in the European Region.
Disclosure of interest None.
Details of ethics approval None.
Funding None.
Acknowledgements We thank Giorgio Tamburlini for writing and editorial assistance and Gunta Lazdane and Ida Stromgren for significant support in the planning and implementation of the Making Pregnancy Safer programme. &
References 1 WHO Health For All Database. [www.euro.who.int/en/data-andevidence/databases/european-health-for-all-database-hfa-db]. Accessed 4 December 2013. 2 Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank estimates. Geneva: World Health Organization; 2012.
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3 World Health Organization. Neonatal and Perinatal mortality: Country, Regional and Global Estimates. Geneva: WHO; 2006 [http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf]. Accessed 4 December 2013. 4 WHO European Strategic Approach for Making Pregnancy Safer. [www.euro.who.int/en/health-topics/Life-stages/maternal-and-new born-health/policy-and-tools/european-strategic-approach-for-makingpregnancy-safer]. Accessed 4 December 2013. 5 Effective Perinatal Care training package, WHO Regional Office for Europe. [www.euro.who.int/en/health-topics/Life-stages/maternal-andnewborn-health/policy-and-tools/effective-perinatal-care-trainingpackage-epc]. Accessed 4 December 2013. 6 Berglund A, Lefevre-Cholay E, Bacci A, Blyumina A, Lindmark G. Successful implementation of evidence-based routines in Ukrainian maternities. Acta Obstet Gynecol Scand 2010;89:230–7. 7 Royal College of Obstetricians and Gynaecologists. Guidelines translated into Russian. [http://www.rcog.org.uk/womens-health/ guidelines/search-guideline/guidelines-translated-russian]. Accessed 29 March 2014. 8 WHO Integrated management of pregnancy and childbirth (IMPAC). Russian version. [http://www.euro.who.int/en/health-topics/Lifestages/maternal-and-newborn-health/policy-and-tools/integratedmanagement-of-pregnancy-and-childbirth-impac]. Accessed 24 March 2014. 9 Bacci A, Wyn Huis D, Baltag V, Lazarus JV. Introducing evidence based medicine and guidelines for maternal and newborn health in the Republic of Moldova. Cent Eur J Public Health 2005;13:200–1. 10 Borchert M, Bacci A, Baltag V, Hodorogea S, Drife J. Improving maternal and perinatal health care in the Central Asian Republics. Int J Gynaecol Obstet 2010;110:97–100. 11 WHO, Department of Reproductive Health and Research. Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer. Geneva: World Health Organization; 2004. 12 Bacci A, Lewis G, Baltag V, Betran AP. The introduction of Confidential Enquiries into Maternal Deaths and Near-Miss Case Reviews in the WHO European Region. Reprod Health Matters 2007;15:145–52. 13 Baltag V, Filippi V, Bacci A. Putting theory into practice: the introduction of obstetric near-miss case reviews in the Republic of Moldova. Int J Quality Health Care 2012;24:1–7. 14 Making Pregnancy Safer: Assessment tool for the quality of hospital care for mothers and newborn babies. [www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/ 2009/making-pregnancy-safer-assessment-tool-for-the-quality-ofhospital-care-for-mothers-and-newborn-babies]. Accessed 4 December 2013. 15 Assessment tool for the quality of outpatient antepartum and postpartum care for women and newborns. [www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/ 2013/assessment-tool-for-the-quality-of-outpatient-antepartum-andpostpartum-care-for-women-and-newborns]. Accessed 4 December 2013. 16 Tamburlini G, Siupsinskas G, Bacci A. Quality of maternal and neonatal care in Albania,Turkmenistan and Kazakhstan: a systematic, standard-based, participatory assessment. PLoS ONE 2011;6:e28763. 17 Tamburlini G, Yadgarova K, Kamilov A, Bacci A, for the The Maternal and Neonatal Care Quality Improvement Working Group. Improving the quality of maternal and neonatal care: the role of standard based participatory assessments. PLoS ONE 2013;8: e78282.
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