Democratic prioritization of maternity care: a rational basis for planning a clinical effectiveness programme

The aim of the study was to evaluate the use of a democratic process for prioritizing the ASQUAM (Achieving Sustainable Quality in Maternity) clinical effectiveness programme.

Twenty-two improvements in the standards of maternity care were chosen as top-topic priorities at the 1996 and 1997 ASQUAM meetings. We wished to assess the relative priorities of local and national delegates, by comparing their voting patterns at the two meetings. The setting was North Staffordshire ASQUAM prioritization days, and the subjects were all the delegates at the 1996 and 1997 ASQUAM meetings. Main outcome measures were comparison of numbers of votes cast by local and national delegates for each of the 20 topics presented at the two ASQUAM meetings, and proportions of the 11 top-topics decided at each meeting that were chosen by local and national delegates.

In 1996, significantly more local than national delegates voted for two topics related to maternal mortality or morbidity (incontinence and hypertensive diseases of pregnancy), but there were no statistically significant differences between the proportions of votes cast for any of the other 18 topics presented on the day. Indeed, local delegates had prioritized 11/11 of the final top-topics, and only one was omitted by the national delegates (10/11). In 1997, significantly more national than local delegates voted for three topics relating to professional stress levels, user involvement in working groups and antibiotic prophylaxis, but there were no statistically significant differences between the proportions of votes cast for any of the other 17 topics presented on the day. Again, local delegates had prioritized 11/11 of the final topics, with only one being omitted by the national delegates (10/11).

There appeared to be a remarkable concordance between local and national delegates at both meetings, suggesting an underlying rationality to decision making. We believe this to be a reflection of the process of careful evaluation of outcome and intervention supported by the protection of a secret ballot, allowing free expression of individual's values.