February 24, 2017

Halving maternal and newborn deaths in health facilities in nine countries

By Karen Kirk and Charlotte Warren

Last week, nine countries joined the new Network for Improving Quality of Care for Maternal, Newborn and Child Health. The Network is a product of the WHO’s “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities,” which was released in 2016, and is an effort to halve preventable deaths of pregnant women and newborns in health facilities within five years in these countries.

Pre-eclampsia is a life-threatening, pregnancy-induced condition marked by high blood pressure and excess protein in the urine after 20 weeks gestation. The symptoms associated with preeclampsia can often be misinterpreted in communities or overlooked at facilities. At Ending Eclampsia, we’re thrilled to see these new guidelines that are putting quality of care at facilities in the spotlight. Three of our project countries (Bangladesh, Ethiopia, and Nigeria) are among the nine countries that have committed to achieving this important health goal.

The nature of hypertensive disorders in pregnancy, like pre-eclampsia and eclampsia (PE/E), necessitate strong health systems with facilities that are staffed by competent and committed providers and have the necessary drugs, commodities and equipment. Globally, PE/E is the second most common direct cause of maternal mortality and increases the risk of preterm birth, low birth weight, and perinatal death.

The WHO standards of care framework expound eight standards of care and 31 statements on quality. Twenty-two of the 31 quality statements can be explicitly, implicitly or indirectly connected to aspects of prevention, detection, and management of PE/E.

Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines.
Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn.
Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred.
Standard 4: Communication with women and their families is effective and responds to their needs and preferences.
Standard 5: Women and newborns receive care with respect and preservation of their dignity.
Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability.
Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications.
Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications.

The quality statements that explicitly impact PE/E cross three Standards (1, 7, and 8) which express the importance of evidence-based care, the need for competent, motivated staff and facility preparedness. These quality statements address what a woman, especially one with PE/E, requires of a health facility to ensure the best health outcomes for herself and her baby.

Quality statement 1.2 specifically states that, “women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines.” Women with PE/E often deliver early, therefore statements 1.6a and 1.6b for premature labor and preterm birth are critical to ensure survival of the infant born to a women with PE/E.

Quality statements 7.1 and 7.2 insist that women have access to at least one skilled birth attendant as well as to support staff who are trained to competence with the skills required to provide the highest quality of care. While these two statements do not mention PE/E specifically, the impact on women with PE/E is explicit in that skilled birth attendants who are accessible to their patients have the knowledge to detect and manage complications like PE/E.

Another statement with an explicit impact on women with PE/E is quality statement 8.3: An adequate stock of medicines, supplies and equipment is available for routine care and management of complications. The importance of medicines, supplies and equipment is amplified when it comes to potential or diagnosed cases of PE/E; antihypertensive drugs, magnesium sulphate, syringes, sphygmomanometer, are among the many supplies that are critical to detecting and managing PE/E.

Standard 3 focuses on referral for those women and newborns where their care cannot be dealt with effectively which has important implications for women with PE/E. Often, primary health centers are unable to provide the quality care needed to appropriately and effectively manage cases of PE/E and must refer women to higher facilities for follow up care. While we will continue to strive to improve quality at all levels of the health system, strong referral systems can help save the lives of women experiencing such complications in pregnancy.

Standards 2, 4, 5 and 6 are pertinent for every woman and newborn and are focused around providing women centred care, information, respect, and ensuring the woman has a companion of choice

These standards set out the critical areas to provide quality of care for mothers and newborns. Ending Eclampsia supports this agenda and will continue to collaborate with stakeholders throughout health systems to ensure women and their newborns have access to quality facility-based care.

Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines.
1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care.
1.1b: Newborns receive routine care immediately after birth.
1.1c: Mothers and newborns receive routine postnatal care.
1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines.
1.3: Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO guidelines.
1.4: Women with delay in labour or whose labour is obstructed receive appropriate interventions, according to WHO guidelines.
1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines.
1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines.
1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines.
1.7a: Women with or at risk for infection during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines.
1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines.
1.8: All women and newborns receive care according to standard precautions for preventing hospital-acquired infections.
1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period.
Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn.
2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period.
2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth.
Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred.
3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay.
3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time.
3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff.
Standard 4: Communication with women and their families is effective and responds to their needs and preferences.
4.1: All women and their families receive information about the care and have effective interactions with staff.
4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals.
Standard 5: Women and newborns receive care with respect and preservation of their dignity.
5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected
5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services.
5.3: All women have informed choices in the services they receive, and the reasons for interventions or outcomes are clearly explained.
Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability.
6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice.
6.2: Every woman receives support to strengthen her capability during childbirth.
Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications.
7.1: Every woman and child has access at all times to at least one skilled birth attendant and support staff for routine care and management of complications.
7.2: The skilled birth attendants and support staff have appropriate competence and skills mix to meet the requirements of labour, childbirth and the early postnatal period.
7.3: Every health facility has managerial and clinical leadership that is collectively responsible for developing and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement.
Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications.
8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functional, reliable, safe and sufficient to meet the needs of staff, women and their families.
8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care.
8.3: An adequate stock of medicines, supplies and equipment is available for routine care and management of complications.

 

Karen Kirk is the project assistant for the Ending Eclampsia project at the Population Council. She works closely with her colleagues on the Maternal and Newborn Health team and provides communications, research and management support for MNH projects.

Charlotte E. Warren is a senior associate based in the Population Council’s Washington, DC office and director of the Ending Eclampsia project. A nurse by training, Warren has extensive experience in research, policy, and program development in maternal and neonatal health, reproductive health, family planning, and primary health care. Warren has wide experience building the skills of policymakers and program managers to address critical public health issues. Most notably, she uses implementation research to support ministries of health to develop policy, implement best practices, and scale up programs to improve maternal and newborn health.



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