British Medical Bulletin 67:73-83 (2003)
© 2003 Oxford University Press
Promoting standards for quality of maternal health care
A Metin Gülmezoglu
HRP—UNDP/UNFPA/WHO/World Bank Special Programme on Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
Correspondence to: A Metin Gülmezoglu, HRP—UNDP/UNFPA/WHO/World Bank Special Programme on Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva 27, CH-1211 Switzerland. E-mail: gulmezoglum{at}who.int
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Abstract
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Evidence-based health care with its emphasis on the need for
searching, retrieving, summarizing and utilizing the best available
evidence in decision-making has become essential in setting
standards. Accordingly, maternity care standards should be based
on best available evidence identified through systematic reviews
of the literature. Promotion of standards relies on access to
information, active strategies to facilitate professional behaviour
change and efforts to sustain the change. Access to information
is essential but insufficient to improve standards on its own.
Changing professional behaviour is not accomplished easily.
Active strategies based on the nature of the health care problem
and an evaluation of the barriers that are likely to operate
against change are required to influence professional behaviour.
Once implemented, the standards should be regularly monitored
and revised as new evidence becomes available.
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Introduction
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A variety of problems are caused when clinical practices that
are not based on sound scientific evidence find their way into
established medical/health care practice. It is generally acknowledged
that removing an entrenched practice is much more difficult
than introducing a new one. Thus, not only valuable resources
continue to be used for practices of unknown effectiveness,
but also, research is needed later to evaluate the usefulness
of these practices. For example, large trials had to be conducted
to show that routine episiotomy is not beneficial
1
. Furthermore,
routine electronic fetal monitoring during labour
2, and routine
ultrasound assessment during pregnancy
3, have not been shown
to decrease morbidity and mortality. Yet these two practices
are used widely in some developing countries. A more effective
resource allocation, complemented by efforts to implement only
those practices that are effective, should be a priority in
order to improve the quality of maternity services in developing
countries. Several steps are needed to improve and maintain
high-quality care standards. Although the focus of this article
is on clinical practices, the ‘standards’ should
not be seen only within this context. The interpersonal dimensions
of care and services are crucial to improving quality. This
is especially relevant to reproductive health where the users
of services are healthy women or couples in the majority of
cases
4.
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Pathways to improving standards
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Access to information
A pre-requisite for need- and evidence-based allocation of resources
and appropriate health care practices is to have access to scientifically
solid and up-to-date information. Without access to information,
it is extremely difficult to maintain or improve the quality
of care, which places a further burden on the limited resources
for health care in developing countries as ineffective and/or
harmful practices remain in practice.
Most health workers and policy-makers in developing countries do not have easy access to the latest reliable information on effective care. This is not only because of the high cost and erratic delivery of most subscription journals, but also because few medical journals publish comprehensive systematic reviews on the effectiveness of health care interventions in developing countries. Such information remains scattered in different papers in numerous journals, making it very difficult for health practitioners to get a good overview of all the data available on a given subject.
The challenge therefore is to develop a strategy to provide access to good quality and up-to-date information. Furthermore, the information provided should be comprehensive enough to reduce the need for additional information to guide decision-making. The WHO Reproductive Health Library (RHL) is a collaborative effort between the World Health Organization, the Cochrane Collaboration and scientists in developing countries that attempts to meet this challenge5. RHL includes Cochrane systematic reviews in all areas of reproductive health with commentaries from individuals with knowledge of the typical settings in low-income countries. RHL is available to health workers on a free subscription in low- and middle-income countries and its contents are updated and expanded on an annual basis. The free subscription system and the assistance of WHO collaborating institutions worldwide provide RHL access to more than 30,000 health workers every year. The CD-ROM format enables annual updates and revisions as and when new evidence becomes available. Furthermore, RHL includes tools such as implementation manuals, video clips and slide shows to facilitate the adoption of evidence-based practices.
Another recently initiated project is the Health Internetwork (HINARI)6. This project coordinated by the World Health Organization provides access to the Internet versions of the main health care journals (around 2000 journals) free or at very low prices in low-income countries. Notwithstanding the difficulties of poor quality telephone lines and Internet access costs, the project is important in bringing the major publishers together for the purpose of providing access to information7.
Innovative approaches are required to reach health workers in low-income countries efficiently. The developments in information technology provide more opportunities. For example, The Health Channel launched by the Interactive Health Network and WorldSpace aims to provide information to lay public and health workers through radio and data casting using satellite technology8. Although the effectiveness of such approaches remains to be seen, it seems worthwhile to explore alternative routes.
Facilitating behaviour change and establishing the standards
The objective of accessing information is to keep up-to-date and change practices that are ineffective or harmful in favour of those that have been demonstrated to be more effective by rigorous research methods.
However, although access to information is crucial, it is rarely sufficient on its own to lead to change. Improving or changing clinical practice with the availability of new knowledge is a complex and often difficult process. These difficulties are increasingly recognized. The new knowledge needs to be assessed taking into consideration the socio-cultural and economic contexts. Even when there is general acceptance of a new treatment, there may be barriers to overcome. Grol et al9 outlined attributes of practice guidelines that make them more or less amenable to adoption. The guidelines that were on controversial issues, including change in daily routines, and that were vague were less likely to be implemented. Even for those practices that are clear, non-controversial and do not require major changes in daily work, some additional measures are required to implement the practice within a given period of time10. It must be acknowledged that adoption of new practices almost always involves trade-offs. These trade-offs may relate to beneficial effects versus side-effects or to socio-cultural and economic contexts11.
Planned dissemination and implementation strategies using appropriate tools for appropriate target populations are necessary to bring improvements in standards of care. Several different strategies exist alone or in combination, based on different theories of behavioural change. Of these, continued educational meetings in the form of interactive workshops seem to have moderate effects in improving practice12. Educational outreach, targeting local opinion leaders, reminders and audit and feedback are some of the strategies that have been used with varying degrees of success. More evidence on implementation strategies can be found in several systematic reviews published in the Cochrane Library by the Cochrane Effective Practice and Organization of Care Group13.
Best practices are selected from those that have been shown to have more benefit than harm according to the results of systematic reviews. In a similar way, principles of evidence-based health care should be followed when selecting the strategy for implementing the best practices as shown in Figure 1. The assessment of the barriers is an essential step to guide the selection of the strategy for implementing change. There may be fewer or easier barriers to overcome to change some practices while others may be more complex. It must be remembered that it may not be possible or feasible to elucidate all potential barriers upfront. For example, changing from one type of uterotonic (ergometrine) to another (oxytocin) would be expected to be relatively straightforward if the agent is available (although a new procurement policy may not be that easy to generalize in a bureaucratic setting). Using oxytocin instead of ergometrine for the management of the third stage of labour would not require changes in daily routine, learning new procedures or cost more. However, the implementation of a programme of labour companionship to reduce obstetric interventions and increase maternal satisfaction with care is likely to be more complex. The facilities may lack sufficient privacy, the staff may not be too keen on having other non-professional people around, the labour companions may need training, and there may be some costs and other unforeseen barriers. The process outlined in Figure 1 can be useful to facilitate the change. It is important to consciously assess the barriers because the design (or the target) of the intervention to establish the change will be based on overcoming those particular barriers.
Another important concern is to maintain the standards once the change has been accomplished. In this respect, clinical audit could be an important tool. Clinical audit is a useful strategy to improve the clinical care alone, although the effect size could be modest14.
Some locally developed implementation projects using evidence-based strategies exist. The Better Births Initiative is a collaborative project attempting to improve and maintain standards of care during labour and childbirth15. This project involves educational workshops in maternity wards focusing on evidence-based and humane practices concerning the care of women during labour and childbirth. An audit programme is also proposed as part of the workshops so that the staff can monitor the standards of care themselves.
Best practices in maternal health care
The WHO Programme To Map Best Reproductive Health Practices16 together with the Cochrane Collaboration and other partner institutions develop and maintain systematic reviews of reproductive health practices that are especially relevant to low-income countries. These practices are included in RHL together with tools to facilitate their incorporation into services. Some of the important practices are listed in Tables 1–6 according to their level of effectiveness. These tables are included in RHL to provide a snapshot of effectiveness of practices and are also linked to the evidence supporting those statements.
The practices listed in Tables 1 and 2 indicate those that are more likely to have benefits than harm. It should be noted that these practices vary according to the outcomes. That is, an intervention may be beneficial in preventing an adverse outcome but may be ineffective for another. Similarly, for some practices, in addition to the benefits, there may be a possibility of harm (Table 3). The decision then depends on the trade-offs and how acceptable those are to individual women and to the communities.
There are some pregnancy pathologies for which our understanding of the pathophysiology is poor and the preventive or therapeutic interventions are either non-existent or weak. Pre-eclampsia/eclampsia and preterm birth are good examples. However, there are many interventions where strong evidence exists regarding effectiveness and these should be transferred to services as a matter of urgency. We do not have an effective preventive strategy for pre-eclampsia but we have magnesium sulphate to prevent eclampsia and reduce further convulsions in women who have experienced eclamptic convulsions. Another concern in the field of pregnancy and childbirth is the removal of practices that are ineffective or harmful (Tables 5 and 6). Unfortunately, practices implemented following logical arguments decades ago remain entrenched even if there is compelling evidence against them.
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Conclusions
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During the past decades, significant developments in health
care research methodologies, health care provision and programme
development have been taking place. The nature of information
dissemination, access and utilization is also rapidly changing.
Innovative strategies to disseminate and improve access to information
are necessary to keep up with the pace of development in the
twenty-first century. Evidence-based health care with its emphasis
on utilizing the best available evidence in decision-making
is here to stay. Consequently, clinicians and policy-makers
need to be familiar with concepts such as search strategies,
critical appraisal and meta-analysis. Maintaining standards
increasingly requires interdisciplinary collaboration among
doctors, midwives, librarians, statisticians and other health
professionals. Evidence-based health care practice should be
complemented by evidence-based implementation strategies.
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References
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- Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: a randomised controlled trial. Lancet 1993; 342: 1517–8[Medline]
- Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software
- Neilson JP. Ultrasound for fetal assessment in early pregnancy (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software
- Bruce J. Fundamental elements of quality of care. Stud Fam Plann 1990; 21: 61–91[CrossRef][ISI][Medline]
- WHO Reproductive Health Library, No. 6. Geneva: World Health Organization, 2003 (WHO/RHR/03.5)
- Health Internetwork. http://www.healthinternetwork.org/index.php?lang=en (accessed 27 May 2003)
- Smith R. Closing the digital divide. BMJ 2003; 326: 238[Free Full Text]
- Interactive Health Network. http://www.ihn.info (accessed 01 June 2003)
- Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998; 317: 858–61[Abstract/Free Full Text]
- EBHC. Getting evidence into practice. Effective Health Care 1999; 5: 1–16
- Irwig L, Zwarenstein M, Zwi A, Chalmers I. A flow diagram to facilitate selection of interventions and research for health care. Bull World Health Organ 1998; 76: 17–24[ISI][Medline]
- Thomson O’Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software
- Effective Practice and Organization of Care Group. http://www.epoc.uottawa.ca/ (accessed 02 June 2003)
- Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software
- Better Births Initiative. http://www.liv.ac.uk/lstm/bbimainpage.html (accessed 27 May 2003)
- The WHO Programme To Map Best Reproductive Health Practices. http://www.who.int/reproductive-health/rhl/index.html (accessed 02 June 2003)
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Abstract
Introduction