Background: Global evidence suggests that better quality of care is associated with reductions in
maternal and newborn mortality. The routine measurement of the quality of care is important to ensure
the proper functioning of a health care system but there is no consensus on the best way to measure
quality of care, especially relating to the process of care. While the direct observation of clinical care
(especially as it relates to labor, delivery and essential newborn care) may be a gold standard, the
routine use of this method is not feasible in most resource poor settings. This dissertation examines
the relationship between different process quality of care measurement methods for selected
maternal and newborn care services in Malawi including adherence to clinical guidelines,
consistency and quality of health worker performance, and the provision of respectful maternity care.
The results of an analysis of the quality of essential newborn care and respectful maternity care are
also provided.
Methods: Using data from an evaluation of a neonatal resuscitation program (Helping Babies
Breathe or HBB) in Malawi, Paper One examines the validity of clinical simulations as a measure
of health worker performance of essential newborn care, self-reported provision of the active
management of the third stage of labor, and partograph use when compared to the gold standard of
direct clinical observations. Paper Two assesses the consistency and overall quality of health
worker performance of essential newborn care practices. Paper Three uses direct clinical
observation data to provide estimates of prevalence of disrespect and abuse during childbirth and
develops and validates a scale to routinely measure respectful maternity care.
Results: Results from Paper One show that clinical simulations are a valid measure of most
processes involved in providing essential newborn care (other than hand hygiene) while self-report
is a valid measure of the active management of the third stage of labor. Paper Two shows that
health workers did not always perform all essential newborn care steps consistently on every
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newborn they were observed providing care for and that there was variation in performance between
health workers. Paper Three shows that health worker communication with clients during labor and
delivery was generally low. The overall prevalence of physical and verbal abuse was low but
privacy and the encouragement of a support person to be present during labor and delivery were also
low. Results from the development of a scale to measure respectful maternity care showed that two
factors (provider to client communication and provider encouragement during the first stage of
labor) could be used to assess the provision of respectful maternity care using direct clinical
observation data.
Conclusions: Through the generation of valid data using feasible methods, measurement can be a
key driver in improving the quality of maternal and newborn care. This dissertation used clinical
simulation data and direct clinical observation data to show that a low cost measurement method
(clinical simulations) can be a valid proxy for direct clinical observations to measure the provision of
essential newborn care. This finding has implications from the level of policymakers, quality
improvement specialists, facility-level supervisors and even researchers who can confidently use this
method to measure most of the processes involved in effectively managing a newborn when
resources are limited or when data need to be generated routinely. This dissertation has also added
to the set of tools available to measure respectful maternity care through the development of a scale
using direct clinical observations. The tool has its limitations in terms of the type of data that can be
generated from it, but it if used in conjunction with other tools, it can provide an estimate of the
prevalence of disrespect and abuse during facility-based deliveries that adhere to international
human rights guidelines. Finally, the findings also show that there are still improvements to be made
in the overall provision of maternal and newborn care in Malawi. Health workers were not always
adhering to clinical guidelines for essential newborn care, were not always following evidence-based
maternal health practices (use of a partograph and provision of the active management of the third
stage of labor) and were not always treating their patients with dignity and respect. The findings
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provide evidence that further work needs to be done to ensure that women who deliver in these
facilities are receiving the best care possible.