Concepts and methods for assessing the quality of essential obstetric care

Approaches to reducing maternal mortality and morbidity have attracted much attention in the last decade. It is recognized that availability and use of essential obstetric care (EOC) of sound quality by women in labor would reduce the burden of illness and death resulting from pregnancy. However, the literature on methods for defining, assessing and improving the quality of EOC at the point of service delivery in developing countries is quite weak. Drawing upon fundamental concepts of quality assurance, statistics, clinical practices and health service management, this article presents unifying concepts and methods for defining, assessing and improving the quality of EOC in developing country settings. It argues that any intervention that would improve the quality of EOC must act through at least one of three mechanisms: improve the clinical management of uncomplicated labor; improve the detection of complications of labor; or, improve the clinical management of complications of labor. The text presents the basis for using quantitative and qualitative methods to assess the quality of EOC. It concludes that any method to assess the quality of EOC, as a basis for improvement at the health center level, must satisfy the following seven criteria: (i) be derived from scientifically sound and locally defined guidelines for what constitutes care of good quality; (ii) enable objectively verifiable measurements of the performance of critical tasks; (iii) be sufficiently discriminating to detect variations in quality among health centers, thereby enabling managers to focus on improving care in those health centers providing care of lower quality; (iv) facilitate production of visual aids within each health center, thereby enabling midwives, doctors and their supervisors to use information for improving their work on a daily basis; (v) include qualitative assessments to facilitate interpretation of quantitative information; (vi) be reasonably simple to use without unsustainable foreign technical assistance; and, (vii) be affordable within the limited resources of public health facilities and District Health Management Teams.