BMJ Open Qual: first published as 10.1136/bmjoq-2018-000525 on 13 February 2019. Downloaded from Open access Original article Use of WHO standards to improve quality of maternal and newborn hospital care: a study collecting both mothers’ and staff perspective in a tertiary care hospital in Italy Marzia Lazzerini, Emanuelle Pessa Valente, Benedetta Covi, Chiara Semenzato, Margherita Ciuch To cite: Lazzerini M, Valente EP, ABSTRACT of health services cost.1–6 Currently, there is Covi B, et al. Use of WHO Background WHO developed a list of standards for a large debate on what are the most effective standards to improve quality of improving maternal and newborn hospital care. However, maternal and newborn hospital interventions to improve quality of maternal there is little experience on their use, and no precise care: a study collecting both and newborn care (QMNC) in different mothers’ and staff perspective guidance on their implementation. This study aimed at settings. In high-income countries, in spite in a tertiary care hospital documenting the use of the WHO standards for improving of a generally low maternal and newborn the quality of maternal and neonatal care (QMNC) in a in Italy. BMJ Open Quality mortality when compared with low-income 2019;8:e000525. doi:10.1136/ tertiary hospital, Northeast Italy. bmjoq-2018-000525 Methods The study was conducted between May 2016 countries, still several challenges exist: studies and May 2018, in three phases: phase I—sensitisation and show that the implementation of evidence- ► Additional material is training of health professionals; phase II—data collection based practices is still suboptimal; there is a published online only. To view, on the WHO standards through a survey among service diffuse fear of litigation, with a risk of over- please visit the journal online (http:// dx. doi. org/ 10. 1136/ users and providers; phase III—based on the findings of medicalisation; systems for monitoring and bmjoq- 2018- 000525). phase II, development of recommendations for improving evaluating the QMNC using a comprehen- the QMNC. sive list of quantitative indicators are gener- Results Overall, 101 health professionals were ally lacking; in general, mothers’ perception Received 10 September 2018 successfully trained. 1050 mothers and 105 hospital of the experience of care is rarely included Revised 29 November 2018 staff participated in the survey. Key indicators of QMNC http://bmjopenquality.bmj.com/ Accepted 30 November 2018 in the assessment of the QMNC, and rarely (and related prevalence) from the mothers survey 7–10 included: caesarean section (23.1%); episiotomy (18.3%); considered for planning purposes. restrictions to free movements during labour (46.5%), Among the initiatives aiming at improving lithotomy position for staff choice (69.3%); skin to skin the QMNC, in 2015 WHO developed a frame- (80.8%); early breast feeding (67.2%); information work which defines the key components of on newborn danger signs (47.2%); high satisfaction quality hospital services for the mother and with QMNC (68.8%). Only 1.2% and 0.7% of women the newborn.11 The WHO framework identi- respectively reported discrimination or abuse. Key fies two key dimensions of quality: ‘provision indicators (and prevalence) reported from staff included: of care’—including evidence-based practices, availability of clinical protocols (37%); regular training efficient information and referral systems (14%); health information system used for quality on October 1, 2021 by guest. Protected copyright. improvement (16.3%); training on effective communication and ‘experience of care’—including effec- (9.7%) and on emotional support (19.6%); protocols tive communication, respect, dignity and emotional support. The cross-cutting areas © Author(s) (or their to prevent mistreatment and abuse (6.9%). On several employer(s)) 2019. Re-use indicators, the opinions of mothers on QMNC was better of the framework include the availability permitted under CC BY-NC. No than those of staff. Overall, 55 quality improvement of competent, motivated human resources commercial re-use. See rights recommendations were agreed. and of the physical resources, identified are and permissions. Published by Conclusions Information on the WHO standards can be prerequisites for good quality of care in health BMJ. collected from both services users and providers and can facilities.11 In 2016, based on this framework, WHO Collaborating Centre for be proactively used for planning improvements on QMNC. Maternal and Child Health, a list of WHO ‘Standards for improving Institute for Maternal and Child maternal and newborn care in health facil- Health IRCCS Burlo Garofolo, INTRODUCTION ities’ was released.12 The WHO standards Trieste, Italy International agencies, governments and civil define what healthcare planners, managers Correspondence to society organisations have recognised quality and care providers should ensure in order to Dr Marzia Lazzerini; of care as a crucial aspect of human rights and guarantee high-quality care around the time 12 marzia. lazzerini@ burlo. trieste. it as a key determinant of health outcomes and of birth. The WHO standards are declined Lazzerini M, et al. BMJ Open Quality 2019;8:e000525. doi:10.1136/bmjoq-2018-000525 1 BMJ Open Qual: first published as 10.1136/bmjoq-2018-000525 on 13 February 2019. Downloaded from Open access into 31 quality statements. For each quality statement advertised. Participation to the training was free of charges a sets of quality measures is provided, for a total of 318 and open, on a voluntary basis, to all type of staff, both quality measures, including measures of inputs, output from hospital and outpatient, working with mothers or and outcomes.12 The standards are to be used according newborn, including doctors, registrars, nurses, midwives the ‘Plan Do Study Act’ model, that is, conducting a base- and midwifery undergraduate students. line situation analysis, defining priorities for actions and Key subjects for training included: human rights interventions to improve care, monitoring progresses and and key definitions relevant to maternal and newborn refining the strategy.12 healthcare (such as disrespect and abuse during child- Currently, there is little experience on the use of the birth)18; the WHO standards to the improve the QMNC WHO standards, and detailed guidance on their imple- and related key literature12 19 20; the Respectful Mater- mentation has not been released yet. WHO recommends nity Care Charter17; epidemiology19 21–23 and underlying that ‘ideas for implementing the standards should be causes20 of mistreatment of women during childbirth; based on each country’s experience and on adaptive key examples of evidenced-based practices (mostly using learning within and between countries'. Local adaptation the WHO guidelines); key legal aspects of maternal and of the standards is also envisaged.12 However, the precise newborn healthcare (eg, general responsibility during source of information to be used for each quality measure, care, legal aspects related to the concepts of autonomy and the tool to be used to collect such information, are and self-determination and the importance of effec- not clarified yet. The aim of this study was to explore as tive communication for the informed consent). A team pilot experience methods for using the WHO standards of specialists in the QMNC, with senior experience in for collecting information on the hospital QMNC from the WHO guidelines/standards, and a layer expert both service users (ie, mothers) and service providers (ie, in women rights acted as trainer. Methods of training hospital staff) and for reaching the stage of developing included lectures and small group work sessions for plans for improving QMNC in a participative manner. case-study discussion (four case-study were developed for this purpose). For the ECM courses evaluation procedures included: i) a multiple-choice questionnaire METHODS for assessing participants final knowledge; ii) a standard Study design national form to assess the general quality, effectiveness The study was designed as a quality improvement study and additional value of the training according to partic- and is reported according to the Standards for Quality ipants evaluation. Improvement Reporting Excellence guideline V.2.013–15 (online supplementary table 1). Phase II: assessment of the QMNC Context The primary objective of this phase was to conduct an The study was conducted between May 2016 and May assessment on the hospital QMNC. Both service users http://bmjopenquality.bmj.com/ 2018 in a large public tertiary level university hospital in (mothers) and service providers (hospital staff) were Northeast Italy. Every year about 1700–1800 mothers give involved, using two different questionnaires. birth in the hospital.16 For the survey among mothers, mothers who gave birth in the hospital from December 2016 to May 2018 were Intervention invited to participate. Exclusion criteria were: maternal The intervention included three main phases. Phase I was death, perinatal death (including stillbirth), refuse to a sensitisation and training phase, where hospital staff was participate, psychiatric or psychosocial problems with informed on key concepts of respectful care and on the inability to fill in the questionnaire and age under 18 existence of the WHO standards.12 17 Phase II aimed at years. Data were collected using a field-tested, anon- conducting a situation analysis, in the form of a survey, ymous, self-administrated