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Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana.

Nesbitt RC, Lohela TJ, Manu A, Vesel L, Okyere E, Edmond K, Owusu-Agyei S, Kirkwood BR, Gabrysch S - PLoS ONE (2013)

Bottom Line: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana.Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality.While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

View Article: PubMed Central - PubMed

Affiliation: Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany.

ABSTRACT

Objective: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana.

Methods: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality.

Findings: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as "low" or "substandard" for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was "low" or "substandard" in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with "high" or "highest" quality in all dimensions.

Conclusion: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

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Estimating skilled attendance: percentage of births in facilities with high quality across four dimensions, n=15,884 births.The coverage gap is the difference between current and universal coverage of skilled attendance; with 68% facility delivery in the study region, this gap is estimated at 32%. The quality gap is the difference between coverage with facility delivery (68%), and provision of “effective and client friendly care” i.e. delivery in a facility rated “high” or “highest” on all 4 dimensions of quality (18%). The quality gap was estimated at 50% in the study region (68% - 18%).
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pone-0081089-g003: Estimating skilled attendance: percentage of births in facilities with high quality across four dimensions, n=15,884 births.The coverage gap is the difference between current and universal coverage of skilled attendance; with 68% facility delivery in the study region, this gap is estimated at 32%. The quality gap is the difference between coverage with facility delivery (68%), and provision of “effective and client friendly care” i.e. delivery in a facility rated “high” or “highest” on all 4 dimensions of quality (18%). The quality gap was estimated at 50% in the study region (68% - 18%).

Mentions: There were 16,329 deliveries between November 2008 and December 2009 in the study area, of which 16,168 were live births (99%)[23]. Birthplace was known for 15,884 (98%) of live births, of which 10,782 (68%) were in a health facility. In Brong Ahafo, facility delivery can be used as a proxy for skilled attendance because there are hardly any home deliveries with a skilled provider [24]. In fact, 68% was also the reported national average for skilled attendance in Ghana in 2011 [25]. However, estimates of skilled attendance would be lower if quality of care at facilities was taken into account (Figure 3). Considering the dimensions individually, 49% of deliveries were in facilities with “high” or “highest” quality routine care, 43% with basic or comprehensive EmOC, 20% with “high” or “highest” quality EmNC and 33% with “high” or “highest” non-medical quality. Only 18% of women delivered in a facility rated “high” or “highest” quality on all four dimensions of care simultaneously (fulfilled by three facilities in the study area), and thus can be assumed to have truly received skilled attendance. One facility, a hospital, was in the highest category for all four dimensions, and a small proportion of deliveries occurred at this facility (0.4%). The “coverage gap,” i.e. the difference between current coverage (68% of deliveries in a facility) and universal (100%) coverage, is thus compounded by an even larger “quality gap,” i.e. the difference between coverage with any facility care (68%) and with good quality care (18%). This results in 50% of births in the study area not receiving high quality care although they were in a health facility, representing a large missed opportunity (Figure 3) [26].


Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana.

Nesbitt RC, Lohela TJ, Manu A, Vesel L, Okyere E, Edmond K, Owusu-Agyei S, Kirkwood BR, Gabrysch S - PLoS ONE (2013)

Estimating skilled attendance: percentage of births in facilities with high quality across four dimensions, n=15,884 births.The coverage gap is the difference between current and universal coverage of skilled attendance; with 68% facility delivery in the study region, this gap is estimated at 32%. The quality gap is the difference between coverage with facility delivery (68%), and provision of “effective and client friendly care” i.e. delivery in a facility rated “high” or “highest” on all 4 dimensions of quality (18%). The quality gap was estimated at 50% in the study region (68% - 18%).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3842335&req=5

pone-0081089-g003: Estimating skilled attendance: percentage of births in facilities with high quality across four dimensions, n=15,884 births.The coverage gap is the difference between current and universal coverage of skilled attendance; with 68% facility delivery in the study region, this gap is estimated at 32%. The quality gap is the difference between coverage with facility delivery (68%), and provision of “effective and client friendly care” i.e. delivery in a facility rated “high” or “highest” on all 4 dimensions of quality (18%). The quality gap was estimated at 50% in the study region (68% - 18%).
Mentions: There were 16,329 deliveries between November 2008 and December 2009 in the study area, of which 16,168 were live births (99%)[23]. Birthplace was known for 15,884 (98%) of live births, of which 10,782 (68%) were in a health facility. In Brong Ahafo, facility delivery can be used as a proxy for skilled attendance because there are hardly any home deliveries with a skilled provider [24]. In fact, 68% was also the reported national average for skilled attendance in Ghana in 2011 [25]. However, estimates of skilled attendance would be lower if quality of care at facilities was taken into account (Figure 3). Considering the dimensions individually, 49% of deliveries were in facilities with “high” or “highest” quality routine care, 43% with basic or comprehensive EmOC, 20% with “high” or “highest” quality EmNC and 33% with “high” or “highest” non-medical quality. Only 18% of women delivered in a facility rated “high” or “highest” quality on all four dimensions of care simultaneously (fulfilled by three facilities in the study area), and thus can be assumed to have truly received skilled attendance. One facility, a hospital, was in the highest category for all four dimensions, and a small proportion of deliveries occurred at this facility (0.4%). The “coverage gap,” i.e. the difference between current coverage (68% of deliveries in a facility) and universal (100%) coverage, is thus compounded by an even larger “quality gap,” i.e. the difference between coverage with any facility care (68%) and with good quality care (18%). This results in 50% of births in the study area not receiving high quality care although they were in a health facility, representing a large missed opportunity (Figure 3) [26].

Bottom Line: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana.Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality.While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

View Article: PubMed Central - PubMed

Affiliation: Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany.

ABSTRACT

Objective: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana.

Methods: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality.

Findings: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as "low" or "substandard" for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was "low" or "substandard" in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with "high" or "highest" quality in all dimensions.

Conclusion: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

Show MeSH