methodology and tools for quality improvement in maternal and newborn health care
TRANSCRIPT
International Journal of Gynecology and Obstetrics 114 (2011) 4–9
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International Journal of Gynecology and Obstetrics
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REVIEW ARTICLE
Methodology and tools for quality improvement inmaternal and newborn health care
Joanna Raven ⁎, Jan Hofman, Adetoro Adegoke, Nynke van den BroekMaternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, UK
⁎ Corresponding author at: Maternal and NewbReproductive Health Group, Liverpool School of TropicLiverpool L3 5QA, UK. Tel.: +44 151 705 3257; fax: +4
E-mail address: [email protected] (J. Raven).
0020-7292/$ – see front matter © 2011 International Fedoi:10.1016/j.ijgo.2011.02.007
a b s t r a c t
a r t i c l e i n f oArticle history:
Received 26 October 2010Received in revised form 16 February 2011Accepted 7 April 2011Keywords:Maternal health careNewborn health careQuality improvement
Objective: To gain an overview of approaches, methodologies, and tools used in quality improvement of maternaland newborn health in low-income countries. Methods: Electronic search of MEDLINE and organizationaldatabases for literature describing approaches, methodologies, and tools used to improve the quality of maternaland newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized.Results: Developing a culture of quality is an important requisite for successful quality improvement.Methodologies to improve quality include the development of standards and guidelines and the performanceof mortality, near-miss, and criterion-based audits. Tools for data collection and process description wereidentified, and examples ofwork to improve quality of care are provided. Conclusion: The documented experience
with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve adesirable improvement in quality of care. The choice of methodologies and tools depends on the healthcaresystem and its available resources. There is a lack of studies that describe the process of quality improvement anda need for research to provide evidence of the effectiveness of the identified methods and tools.© 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.1. Introduction
Between 350 000 and 500 000 women die each year of pregnancy-related causesworldwide, and 99% of these deaths occur in low-incomecountries [1]. In addition, an estimated 4 million neonatal deaths occureachyear, accounting for 36%of deaths in children aged less than5 years[2]. Over 75% of these deaths could be prevented or avoided throughactions that are proven to be effective and affordable [3]. According tonational confidential enquires into maternal deaths and smaller-scalestudies assessing the quality of healthcare provision [4–7], poor-qualitycare contributes to the high levels ofmaternal and neonatal deaths. Lackof appropriately trained staff, provision of incorrect treatments, lack offacilities, poor staff attitudes, delay in referral, poor cooperationbetween health providers, and inadequacy of supplies and equipmentare evident in many resource-poor settings [4–7].
The recognition of what quality of care is and how it can beevaluated is essential in improving services. However, defining thequality of maternal and newborn health care is challenging for severalreasons: most women accessing maternity services are well, but somewill develop conditions requiring a higher level of maternity care;maternity care is aimed at at least 2 recipients—the mother and thenewborn; and childbirth is a culturally and emotionally sensitive area,so nonbiomedical outcomes may be more important than in otherareas of health care [8].
orn Health Unit, Child andal Medicine, Pembroke Place,4 151 705 3329.
deration of Gynecology and Obstetrics
Quality can be analyzed using various models. The perspectivesmodel is basedon theunderlyingprinciple that the quality of care canbeviewed from various perspectives [9]: the perspective of women andtheir families, that of healthcare providers, and that of managers. Morerecently, 6main characteristics—safety, effectiveness, patient-centered-ness, timeliness, equity, and efficiency—were used to define the qualityof health care [10]. The quality of care is related to various dimensions ofa healthcare system and can also be measured at different points in thesystem. The quality of the structure of a healthcare service (includingresources and management), the quality of the actual healthcareactivities (or processes), and the quality of the outcomes are allmeasurable, and together these 3 constitute quality of care [11].
In the present paper, the terms “approaches,” “methodologies,” and“tools” are used to classify ways to improve the quality of care.Approaches are seen as underlying the methodologies and tools. Amethodology isdefinedasa set ofpractices used toexplore thequality ofcare. Tools are defined as the instruments used to collect data on quality.Many tools for measuring quality will additionally act as interventionsto improve quality.
The objective of the present narrative review was to gain anoverviewof the approaches,methodologies, and tools used to improvethe quality of maternal and newborn health in low-income countries.
2. Methods
An electronic search ofMEDLINE (papers published between January31, 1966, and May 31, 2010) was conducted by combining search termsfor quality (“quality of care,” “quality assurance,” and “quality improve-ment”) with those for the field of interest (“maternal health,” “safe
. Published by Elsevier Ireland Ltd. All rights reserved.
5J. Raven et al. / International Journal of Gynecology and Obstetrics 114 (2011) 4–9
motherhood,” or “obstetrics;” “newborn” or “neonatal;” and “developingcountries” or “resource-poor settings”) to identify published articles onapproaches, methodologies, and tools for quality improvement (QI) inmaternal and newborn health care. Additional articles and reports wereobtained from databases of organizations working in maternal andnewborn health,maternal and neonatal health programs, conferences ormeetings, and experts in the field. References were also identified fromthe reference lists of papers and reports.
Two independent researchers selected literature that described orreported approaches, methodologies, and tools to improve the qualityof maternal and newborn health care in low-income countries. Thecitations found in the searches were sifted for relevance by readingthe titles and abstracts.
3. Results
The search generated 6812 articles, which were filtered down to94articles by reading the titles and abstracts (Fig. 1). In total, 34 relevantpapers or reports were included in the present review. The results arepresented in 3 sections: approaches to QI; methodologies used in QI;and tools used in the QI of maternal and newborn health.
4. Approaches
4.1. Developing a culture of quality
When developing a culture of quality in facilities and the widerhealth system, it is important to involve all members of staff—frommanagement to the support staff—in order to create anawareness of andcommitment to quality. This will also help create ownership of any QIprogram that is introduced [12,13]. The establishment of a culture ofquality canenable staff to viewpatients aspartners in care andpromotesa more respectful attitude between staff and patients. A focus onsystems and processes is maintained. Poor quality is often a function ofweaknesses in the system and its operational processes or of problemsin implementing such processes, rather than being the fault ofindividuals [14,15]. By emphasizing this aspect, a culture of improve-ment and quality, rather than a culture of blame, is developed.
Papers and reports identified from full search
(n=6812)
Papers and reports considered relevant from the title and
abstract(n=94)
Papers and reports included in the review(n=34)
Fig. 1. Flow chart of papers and reports selected for the present review.
Where QI has been successful, the culture of quality within facilitieshas been developed over a period of time. An example of this is seen inZambia [14], where, over a period of 5 years, senior staff establishedstructures and built capacity for QI throughout the country, generatedenthusiasm for QI, and initiated teamwork on quality-of-care issuesamong motivated health staff. To create these structures and buildcapacity, healthcare providerswere trained inQI and a national networkof coaches was established to support the activities at each facility.However, the sustainability and expansion of QI were threatened by ashortage of trained personnel at the central level, the lack of a nationalpolicy on QI, and limited QI expertise in the districts.
Another example is seen in Yemen [15], where a culture thatvalues QI was developed in a steady manner, starting with aconsultation with local stakeholders. Quality goals were establishedby taking the available resources and structures into considerationand by building step by step on achieved successes.
4.2. Using QI champions or leaders
Leaders are individuals who have vision and can motivate peopleto follow and build that vision, who can set an example for others,and who promulgate the values and goals of the organization. Qualityimprovement requires the cultivation of leadership qualities among arange of managers at different levels in the organization. The impactof successful QI leaders is evident in programs in Honduras andZambia [12,14].
In Honduras, faster results were achieved if facility managers tookan active role in QI planning and activities, for example by being amember of the QI team and by being part of the maternal deathreview process [12]. The focus was on finding solutions rather than onidentifying barriers to providing good-quality care. For example,multiple solutions (rather than just 1 or no solution) were identifiedto address water shortage at a hospital: digging another well,inserting wider pipes, and installing water pumps. By contrast, infacilities where leaders did not provide active support to QI activities,such gains were not made and the focus continued to be onidentifying obstacles to implementing QI including the lack ofresources and the need for private sector support. Although suchbarriers do exist in resource-poor settings, an attitude that looksbeyond obstacles and searches for creative solutions could create anatmosphere in the organizational culture that promotes change.
In Zambia, Central Board of Health leaders initiated QI activitiesthroughout the country [14]. At the district level, coaches weretrained to provide support and motivation to facility-level QI teams.However, having only a small number of QI leaders at the central levelmade it difficult to expand the QI process. Careful selection of coachesand adequate support for their activities was also necessary to ensurethat regular visits were made. The degree of coaching support to theteams seemed to depend on the willingness and ability of individualcoaches and on the availability of adequate resources such astransport facilities for coaching visits.
4.3. Establishing QI teams
Quality improvement focuses on participation and teamwork.The impact of QI activities is most powerful when team members areable draw on the participation, experience, and knowledge of majorparticipants and stakeholders. The more team members are involvedin identifying problems, developing solutions, and solving problems,the more they will take responsibility for suggesting and makingimprovements in their work. Quality is not the product of a soleindividual, but a product of working together and of valuing one'sown work as well as that of others.
In Honduras, QI teams were established to improve the quality ofobstetric care in facilities [12]. Improvements were seen across mostaspects of obstetric care including monitoring of labor, neonatal care,
Identification of maternal deaths
Data collection and interviews
Analysis of findingsRecommendations and action
Evaluation and refinement
Fig. 2. Maternal death audit cycle.
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and postnatal care. When addressingmaternal mortality, the QI teamsidentified transport as a major barrier for women to access essentialobstetric care. The QI teams established a network of cars in thecommunity for the transfer of the women. The improvements werefurther enhanced by coordination and information-sharing betweenQI teams in other facilities and districts.
Kelley et al. [13] assessed the ability of QI teams in Morocco toidentify problems, prioritize and select key problems, analyze thecauses for these problems, develop solutions, implement thesolutions, and evaluate their actions. This evaluation revealed thatteam members were highly motivated in their QI work and good atidentifying and analyzing problems, but required more support indeveloping solutions.
5. Methodologies
5.1. Standards, guidelines, and protocols
Standards, guidelines, and protocols are widely used to standard-ize and improve the quality of maternal and neonatal health care andto ensure safety for patients and healthcare providers.
Standards have been defined as “a means of describing the level ofquality that healthcare organizations are expected to meet or aspireto” [16]. The performance of healthcare providers and health servicescan be assessed against written standards of care, which are usuallyformulated and agreed by authoritative bodies, such as professionalassociations, ministries of health, or the WHO, or alternatively byhealth institutions for the care within the institution.
Guidelines are key recommendations on the delivery of health carebased on the best available evidence and expert opinions. Guidelinesmay be used directly or, preferably, may be translated into standardsand protocols before use.
A clinical protocol consists of instructions based on the bestavailable evidence and expert opinions on the diagnosis andmanagement of an illness, injury, or condition. Protocols are oftenmade available at the level of clinics and wards to guide clinicians inthe delivery of health care.
Using existing national and international guidelines, healthcareproviders andmanagers in 3 districts inMalawi developed standards forpostpartum hemorrhage during 3 interactive workshops [17]. Subse-quently, the healthcare providers conducted an audit of facility-basedcare using these standards. By including all cadres of staff who providematernal and newborn care in this setting (including obstetricians,doctors, midwives, and clinical officers) in the development of thestandards, ownership and sustainability were promoted. Equallyimportant was the involvement of managers and policy makers in theprocess because this facilitated the implementation of the recommen-dations and the mobilization of resources where this was required.
Studies looking at the development of guidelines [18,19] foundthat healthcare providers were positive about the potential ofguidelines to improve and standardize practice. However, this initself was not enough to change practice [18,19]. Several barriers canprevent or inhibit the process of guideline development. Theseinclude time constraints, lack of awareness and understanding ofthe process, difficulties in searching for evidence, and problems inensuring the involvement of different cadres of staff and of patients.The translation of evidence into context-specific and user-friendlyformats often requires additional resources, support, and skills.
5.2. Audit
Several types of audit are currently used in low- and high-incomecountries. These include maternal and perinatal death audits,confidential enquiries into maternal and perinatal deaths, reviews ofsevere acute maternal morbidity (“near-miss” cases), and criterion-based (or standards-based) audits.
A maternal death audit (MDA) is an in-depth investigation of thecauses of maternal death and of personal, family, or communityfactors that may have contributed to it [20]. The process involves 5main steps, namely identification of maternal deaths, data collectionand interviews, analysis of findings, recommendations and action, andevaluation and refinement (Fig. 2). There are 3 types of MDA, whichcan be applied separately or in combination: community-basedmaternal death review; facility-based maternal death review; andconfidential enquiry into maternal deaths. An MDA may also beexpanded to include perinatal deaths (stillbirths and early neonataldeaths) [21].
Maternal and perinatal death reviews help to identify specific areasof service that need change and provide examples of care that is“substandard.”Most publications that describe the findings of maternaland perinatal death reviews do not, however, describe the process ofimplementing change or document the effect of death audits on serviceuse and maternal or newborn health outcomes [22,23]. Yet, whereevidence is available, it indicates that conducting maternal deathreviews results in observable changes in clinical practice through theuse of QI teams in hospitals [24,25]. A study from Malawi [24] showedthat MDAs and standards-based audits increased the use of essentialobstetric care services and decreased the number of maternal deathsfrom acute obstetric complications. However, the study did not evaluatewhether these improvements were brought about by the combinationof both types of audit or by either type alone.
There are challenges to conducting an MDA [25,26]. These includefear of repercussions, lack of anonymity during audit sessions,resistance of healthcare providers to have their care evaluated bypeers or to evaluate care given by peers, lack of staff commitment, andlack of knowledge and skills among some healthcare providers. Inaddition, documentation on patient care may be absent and deathreviews are time-consuming. There is often a delay in implementingrecommendations, or reviews may not lead to the formulation ofrecommendations for change in the first place.
A confidential enquiry is an anonymous investigation of maternaldeaths occurring at a regional or national level to identify the causes ofand factors associated with these deaths. This may also includeperinatal deaths. There are good examples [7,27] of how nationalconfidential enquiries into maternal deaths have helped to identifyspecific problems (e.g. lack of appropriately trained staff, provision of
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incorrect treatments, lack of available and functioning healthcarefacilities, poor staff attitude, delays in referral, poor cooperationbetween health providers, and inadequate supplies and equipment)in the provision of maternal and newborn health services. Findingsfrom confidential enquiries have been used to directly inform nationalhealth policy, develop strategic plans for maternal and newbornhealth care, and improve service provision [7]. In addition, suchfindings have contributed to changes in training curriculums forhealthcare providers and to the development of new protocols andtraining manuals [7,27]. However, in many resource-poor settings,there are challenges to implementing such wide-scale enquiries,including human and financial resource constraints, lack of sustain-able systems for reporting maternal or newborn deaths, and lack ofpolitical will.
The term “near miss” is used to describe a womanwho nearly diedbut survived a complication that occurred during pregnancy,childbirth, or within 42 days of the termination of her pregnancy[28]. In the last decade, identification of cases of severe acutematernalmorbidity or near-miss cases has emerged as a promising comple-ment or alternative to the investigation of maternal deaths. Near-missreviews can be undertaken on individual cases or on all casesoccurring in 1 or more health facilities. Severe acute obstetriccomplications occur more frequently than maternal deaths, so areparticularly useful in settings where maternal deaths are uncommon.Near-miss reviews also create the opportunity to include theperspective of the surviving mother in the review, enabling a morecomprehensive analysis [29]. However, routine implementation andwider application of near-miss case reviews has so far been limitedbecause uniform case identification criteria are missing. A WHOworking group has recently proposed such criteria and providedguidance for the implementation of near-miss reviews to contributeto the assessment and improvement of quality in obstetric care [28].
A standards-based or criterion-based audit can be defined as a QIprocess that seeks to improve patient care and outcomes bysystematically reviewing care against explicit standards, with iden-tification and implementation of changes needed to achieve thedesired standard of care [20] (Fig. 3). Standards should be set with aclear objective, and structure, process, and outcome criteria need to beclearly defined. The standards and criteria for audit can be developedby expert teams or by the QI teams themselves [26]. The latter
Establish standard of best practice
Measure current practice
Analyze findings and give feedback
Recommendations and implement
change
Re-evaluation and refinement
Fig. 3. Standards-based audit cycle.
enhances ownership of the QI process by those implementing thechanges at service-delivery level.
Studies in a variety of resource-poor setting have demonstratedthe effectiveness and feasibility of using standards-based audits tomeasure and improve the quality of maternal and neonatal healthcare [30,31]. In a small audit focusing on the management ofpostpartum hemorrhage [30], improvements were seen in terms ofmore frequent typing and cross-matching of blood groups, morefrequent measurement of hematocrit or hemoglobin values, andbetter maintenance of fluid intake/output charts. However, the rate offatalities caused by postpartum hemorrhage did not change. Whenwomen-friendly care was audited [31], significant improvementswere noted with regard to previously agreed standards pertaining towelcoming women to the facility. These standards included ensuringthere was support by a companion during labor, allowing women toadopt different birthing positions, cleanliness of maternity wards,speaking to women in simple language, and ensuring privacy withcurtains or screens. A review of randomized controlled studies fromUganda, Thailand, and Laos [32] similarly showed a positive effect ofaudit and feedback on healthcare practice and healthcare outcomes,although the effect size was modest.
6. Tools
The literaturedescribes a varietyof tools that can be used inQI. Theseinclude tools for data collection, such as questionnaires and checklistsfor the assessment of quality of care, topic guides for interviews anddiscussions, and observation checklists; tools to describe the process ofcare, such as clinical algorithms and observation checklists; and tools forcollaborative work, such as force-field analysis and root-cause analysis.Table 1 describes each of the tools identified in the present review andgives examples of how they have been used in a variety ofmaternal andnewborn healthcare settings.
In addition, the literature describes integrated models whereseveral methods and tools are used in combination. Examples includethe client-oriented, provider-efficient (COPE) process developed byEngenderHealth (New York, NY, USA), which uses a definedframework and provides a series of tools for improving quality inmaternal health [33], and the Initiative for Maternal MortalityProgramme Assessment (IMMPACT), which provides a set of toolsto evaluate safe motherhood programs more generally [34].
7. Conclusion
Poor-quality or “substandard” care contributes to poor healthoutcomes for women and their infants, but little is known about howthis can be addressed effectively. The present review of the literatureidentified approaches, methods, and specific tools to improve thequality of care with a focus on low-income countries (Table 2).
Developing a culture of quality within facilities and healthcaresystems through the establishment of multidisciplinary QI teams andthrough identified leaders or champions is an important requisitefor successful QI. Methodologies to improve the quality of maternaland newborn health care include the development and audit ofstandards of care, such as standards for women-friendly and infant-friendly care, and the audit of maternal deaths and near misses. Suchaudits help to identify what was done well, what was not done well,and how care can be improved. Useful and practical tools identifiedin the present review include tools for data collection, tools todescribe the process of care, and tools for collaborative work.
Experience with using these methodologies and tools indicates thatnone is sufficient by itself to achieve a desirable improvement in qualityof care. The choiceofmethodologies and tools depends on thehealthcaresystem and its available resources. Emerging evidence indicates thatthesemethods and tools lead to demonstrable changes in care practices.However,more information is neededonhowto implementQImethods.
Table 1Tools for quality improvement.
Purpose Tool Description Uses
Data collection In-depth interviews andfocus group discussions
Can be conducted with providers, women, and their families tocapture complex feelings and perspectives.
In-depth interviews were conducted with postpartum womenabout the care they received in hospital, their impressions ofthe hospital environment, and any suggestions forimprovement [35]. In Ghana, Indonesia, and Burkina Faso,perceptions of quality were explored using interviews, focusgroup discussions, and participant observation [36].
Observations Checklists can be used to observe equipment, infrastructure,cleanliness, etc.
General observation techniques are important in theassessment of basic quality indicators such as cleanliness,crowding, state of equipment, and provider–patientinteractions [37]
Exit interviews Interviews are conducted as a woman exits the facility afterreceiving maternal healthcare services. They are short, held inprivate, and obtain information on the course of the woman'slabor, the decision-making process, the circumstancesinfluencing the timing of presentation, the choice of facility,and the experience of care.
Exit interviews have been used in many settings to collectinformation about satisfaction with services received and todocument practices used during childbirth [37].
Questionnaires andsurveys
Surveys can be conducted in the facilities and/or communitiesto identify users’ and providers’ experiences and views ofquality of care.
A reproductive-health needs assessment was conducted inrural China to gather information about women's healthconditions, their perceptions, and their use of services [38].
Process description Flow charts Flow charts are used to describe the flow of patients,information, materials (e.g. flow of supplies from centralpharmacy to the wards) and thought (e.g. clinical algorithms).A patient flow analysis is a useful tool for analyzing patientmovement and staff use in a health facility. The healthcareproviders then develop an action plan to help resolve theproblems identified during the assessment.
Flow charts have been used in Kenya, the USA, and Nigeria;waiting times were reduced significantly through addressingstaffing problems and re-organizing services [33,39].
Process mapping Process maps assist workers in identifying areas forintervention to improve safety and quality. This involvesexamining the process in question from a new perspective inorder to discover where the greatest risks exist.
Process maps are external representations of the system andbecome tools for problem solving, reasoning, and decision-making about risks and improvements [40].
Cause–effect analysis Cause–effect analysis does not only depict the chronologicalsequence of events, but also seeks to describe the causes of acondition of interest.
A cause-effect diagram can be constructed to clarify thecontributing factors to maternal or neonatal mortality andsevere morbidity [41].
Observations Participant and nonparticipant observations can be usedfor the evaluation of processes such as prenatal examinationand delivery.
General observation techniques are important in theassessment of provider–patient interactions [37].
Self-assessment guides Self-assessment guides are sets of questions that help staffthink about the way in which services are provided andwhether adequate supervision, training, and equipment areavailable at their facility.
These tools were used in Kenya and Guinea and maternityservices were improved, for example by repairing equipment,training staff, and providing women with leaflets aboutnutrition during pregnancy [42].
Collaborative work Nominal grouptechnique
Nominal group technique is a technique to ensure equalparticipation among group members. Each member nominateshis or her priority issues and then ranks them.
A team of researchers in China asked grassroots reproductivehealth workers to generate an extensive list of potentialindicators for monitoring and improving reproductive healthin rural China and then used nominal group technique toprioritize the indicators that could be practically and feasiblyobtained/measured [43].
Supportive supervision Supportive supervision aims to improve the quality of care.This approach emphasizes mentoring, joint problem solving,and 2-way communication between a supervisor and thesupervised.
Through evaluating the performance of health workers,supportive supervision can facilitate improvements in theprovision of care [44].
SWOT analysis SWOT analysis is a method of identifying factors that promotechange and factors that oppose change. It enables healthprofessionals to participate more fully in the analysis andimplementation of healthcare improvement. There are 4dimensions: strengths, weaknesses, opportunities, and threats.Strengths andweaknesses are internal factors (i.e. characteristicsof the initiative under assessment), whereas opportunities andthreats are external factors (i.e. environmental factors that affectthe development of the initiative).
SWOT analysis of the process of conducting maternal deathaudits was conducted with healthcare providers in Malawi [26].
Force-field analysis Force-field analysis can analyze the opposing forces involvedin change. In any situation, there are both driving forces thatpush for change and restraining forces that act against change.
Force-field analysis can be used for health promotion amongadolescents because this tool provides a systematic andmultilevel approach to problem assessment, resolution, andsocial change that is particularly appropriate for adolescents [45].
Root-cause analysis Root-cause analysis is a comprehensive and systematicmethodology to identify the gaps in hospital systems and theprocesses of health care that may not be immediately apparentand that may have contributed to the occurrence of an event. Itfocuses on systems and processes, not on individualperformance, examines extensively for underlyingcontributing factors and root causes, and identifies changesthat could be made to improve systems and processes toprevent the re-occurrence of similar events.
In Haiti, researchers and community members implementedroot-cause analysis tools such as mapping, scoring, focusgroups, and root-cause analysis to discover perceptions ofsocioeconomic and health contexts of the community. Theywere able to identify maternal health priorities and potentialresources, and offered insights into the practicalimplementation of research tools [41].
Abbreviations: SWOT, strengths, weaknesses, opportunities and threats.
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Table 2Key messages.
Developing a culture of quality within health systems and in facilities is a prerequisite for successful quality improvement initiatives.Maternal and perinatal death audits and standards-based audits can bring about measurable changes in clinical practice, and improve the quality of maternal and newbornhealth.
A variety of tools are available to assess the quality of care. These can also intentionally improve the quality of care.Very few studies have evaluated the process of quality improvement or the effect of quality improvement on maternal and newborn health outcomes, indicating an importantneed for research.
9J. Raven et al. / International Journal of Gynecology and Obstetrics 114 (2011) 4–9
In addition, there is a need to identify clearer indicators of quality and forresearch to provide evidence of the effectiveness of such approaches inthe field of maternal and newborn health.
Conflict of interest
The authors have no conflicts of interest.
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