Approaches towards improving the quality of maternal and newborn health services in South Asia: challenges and opportunities for healthcare systems.

BACKGROUND: South Asia is experiencing a dismal state of maternal and newborn health (MNH) as the region has been falling behind in reducing the levels of maternal and neonatal mortality. Most of the efforts are focused on enhancing coverage of MNH services; however, quality remains a serious concern if the region is to achieve expected outcomes in terms of standardised MNH services within healthcare delivery systems. This research consists of a review of South Asian quality improvement (QI) approaches/interventions, specifically implemented for MNH improvement. METHODS: A literature review of QI approaches/interventions was conducted using the PRISMA guidelines. Online databases, including PubMed, the Cochrane Library and Google Scholar, were searched. Primary studies published between 1998 and 2013 were considered. Studies were initially screened and selected based upon the selection criteria for data extraction. A thematic synthesis/analysis was performed to organise, group and interpret the key findings according to prominent themes. RESULTS: Thirty studies from six South Asian countries were included in the review. Findings from these selected studies were grouped under eight broad, cross-cutting themes, which emerged from a deductive approach, representing the most commonly employed QI approaches for improving MNH services within different geographical settings. These consist of capacity building of healthcare providers on clinical quality, clinical audits and feedback, financial incentives to beneficiaries, pay-for-performance, supportive supervision, community engagement, collaborative efforts and multidimensional interventions. CONCLUSIONS: Employing and documenting QI approaches is essential in order to measure the potential of an intervention, considering its cost-effectiveness, feasibility and acceptability to communities. This research concluded that QI approaches are very diverse and cross-cutting, because they are subject to the varied requirements of regional health systems. This high level of variability leads to implementation and knowledge-management challenges for MNH programme planners and managers in the countries of the South Asia region.

Determining the potential scalability of transport interventions for improving maternal, child, and newborn health in Pakistan.

BACKGROUND: Pakistan is far behind in achieving the Millennium Development Goals regarding the reduction of child and maternal mortality. Amongst other factors, transport barriers make the requisite obstetric care inaccessible for women during pregnancy and at birth, when complications may become life threatening for mother and child. The significance of efficient transport in maternal and neonatal health calls for identifying which currently implemented transport interventions have potential for scalability. METHODS: A qualitative appraisal of data and information about selected transport interventions generated primarily by beneficiaries, coordinators, and heads of organizations working with maternal, child, and newborn health programs was conducted against the CORRECT criteria of Credibility, Observability, Relevance, Relative Advantage, Easy-Transferability, Compatibility and Testability. Qualitative comparative analysis (QCA) techniques were used to analyse seven interventions against operational indicators. Logical inference was drawn to assess the implications of each intervention. QCA was used to determine simplifying and complicating factors to measure potential for scaling up of the selected transport intervention. RESULTS: Despite challenges like deficient in-journey care and need for greater community involvement, community-based ambulance services were managed with the support of the community and had a relatively simple model, and therefore had high scalability potential. Other interventions, including facility-based services, public-sector emergency services, and transport voucher schemes, had limitations of governance, long-term sustainability, large capital expenditures, and need for management agencies that adversely affected their scalability potential. CONCLUSION: To reduce maternal and child morbidity and mortality and increase accessibility of health facilities, it is important to build effective referral linkages through efficient transport systems. Effective linkages between community-based models, facility-based models, and public sector emergency services should be established to provide comprehensive coverage. Voucher scheme integrated with community-based services may bring improvements in service utilization.