Quality Of Newborn Care Research Articles

Essential Care for Every Baby: improving compliance with newborn care practices in rural Nicaragua

BackgroundNeonatal mortality comprises an increasing proportion of childhood deaths in the developing world. Essential newborn care practices as recommended by the WHO may improve neonatal outcomes in resource limited settings. Our objective was to pilot a Helping Babies Breathe and Essential Care for Every Baby (HBB and ECEB) implementation package using HBB-ECEB training combined with supportive supervision in rural Nicaragua.MethodsWe employed an HBB-ECEB implementation package in El Ayote and Santo Domingo, two rural municipalities in Nicaragua and used a pre- and post- data collection design for comparison. Following a period of pre-intervention data collection (June–August 2015), care providers were trained in HBB and ECEB using a train-the- trainer model. An external supportive supervisor monitored processes of care and collected data. Data on newborn care processes and short-term outcomes such as hypothermia were collected from facility medical records and analyzed using standard run charts. Home visits were used to determine breastfeeding rates at 7, 30 and 60 days.ResultsThere were 480 institutional births during the study period (June 2015–June 2016). Following the HBB-ECEB implementation package, cord care improved (pre-intervention median 66%; post-intervention shift to ≥85%) and early skin-to-skin care improved (pre-intervention median 0%; post-intervention shift to ≥56%, with a high of 92% in June 2016). Rates of administration of ophthalmic ointment and vitamin K were high pre-intervention (median 97%) and remained high. Early initiation of breastfeeding increased with a pre-intervention median of 25% and post-intervention shift to ≥28%, with a peak of 81% in June 2016. Exclusive breastfeeding rates increased short-term but were not significantly different by 60-days of life (9% pre-intervention versus 21% post-intervention).ConclusionsThe implementation of the HBB-ECEB programs combined with supportive supervision improved the quality of care for newborns in terms of cord care, early skin-to-skin care and early initiation of breastfeeding. The rates of administration of ophthalmic ointment and vitamin K were high pre- intervention and remained high afterwards. These findings show that HBB-ECEB programs implemented with supportive supervision can improve quality of care for newborns.

Adapting the Quality Maternal and Newborn Care (QMNC) Framework to evaluate models of antenatal care: A pilot study.

BackgroundRecent evidence indicates that continuity models of maternity care result in improved clinical and psychosocial outcomes, but their causal mechanisms are poorly understood. The recent Lancet Series on Midwifery’s Quality Maternal and Newborn Care Framework describes five components of quality care and their associated characteristics. As an initial step in developing this Framework into an evaluation toolkit, we transformed its components and characteristics into a topic guide to assess stakeholder perceptions and experiences of care provided and received. The main purpose of this study was to assess the feasibility of this process.MethodsWe conducted twelve focus groups in two Scottish health board areas with 13 pregnant women, 18 new mothers, 26 midwives and 12 obstetricians who had experience of a range of different models of maternity care. Transcripts were analysed using a six-phase approach of thematic analysis. We mapped the identified themes and sub-themes back to the Framework.ResultsThe emerging themes and sub-themes demonstrated the feasibility of using the QMNC framework as a data collection tool, and as a lens for analysing the data. Of the four emerging themes, only Organisation Culture / Work Structure’ mapped directly to a single Framework component. The others—‘Relationships’; ‘Information and support’; and ‘Uncertainty’–mapped to between two and five components, illustrating the interconnectedness of the Framework’s components. Some negative sub-themes mirrored positive Framework characteristics of care. Some re-phrasing and re-ordering of the topic guides in later focus groups ensured we could cover all aspects of the Framework adequately.ConclusionAdapting the Quality Maternal and Newborn Care Framework enabled us to focus on aspects of care which worked well and which didn’t work well for these key stakeholders. Identifying ‘what works for whom and why’ in different models of care is a necessary step in reinforcing and replicating the most effective models of care.

Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study

BackgroundTargeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework.MethodsWe used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period.ResultsKey bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns.ConclusionsImproving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.

Improving immediate newborn care practices in Philippine hospitals: impact of a national quality of care initiative 2008-2015.

To determine whether intrapartum and newborn care practices improved in 11 large hospitals between 2008 and 2015. Secondary data analysis of observational assessments conducted in 11 hospitals in 2008 and 2015. Eleven large government hospitals from five regions in the Philippines. One hundred and seven randomly sampled postpartum mother-baby pairs in 2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after delivery. A national initiative to improve quality of newborn care starting in 2009 through development of a standard package of intrapartum and newborn care services, practice-based training, formation of multidisciplinary hospital working groups, and regular assessments and meetings in hospitals to identify actions to improve practices, policies and environments. Quality improvement was supported by policy development, health financing packages, health facility standards, capacity building and health communication. Sixteen intrapartum and newborn care practices. Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns receiving hygienic cord handling and the hepatitis B birth dose decreased by 11-12%. Except for reduced induction of labor, inappropriate maternal care practices persisted. Newborn care practices have vastly improved through an approach focused on improving hospital policies, environments and health worker practices. Maternal care practices remain outdated largely due to the ineffective didactic training approaches adopted for maternal care.

Midwifery education: Challenges for the future in a dynamic environment

Iceland and the Netherlands both have a long history of midwifery education and midwifery practice. Starting as a midwife requires a direct entry BSc program in midwifery in The Netherlands, where Iceland requires a nurse-midwife model.This paper presents an overview of midwifery education and its dynamic in these countries. Subsequently, we explore two most notable components that were identified as important for the future of midwifery education. In the concluding section, we reflect how these components support the scope of practice as presented in the Lancet framework for quality maternal and newborn care.

Improvements in Essential Newborn Care and Newborn Resuscitation Services Following a Capacity Building and Quality Improvement Program in Three Districts of Uttar Pradesh, India.

Background:Neonatal death remains a global challenge contributing to 45% of underfive deaths. With rising institutional delivery, to accelerate decline in neonatal mortality rate (NMR) improvement in the quality of perinatal care requires attention.Objectives:This implementation research targeted improving service delivery readiness for quality of newborn care at public health facilities in three districts of Uttar Pradesh, India, with high NMR.Materials and Methods:This before-after study assessed the facility readiness and quality of newborn services at 42 health facilities. The changes in 26 signal functions for routine and emergency obstetric and newborn care were tracked.Results:There was marked improvement in newborn service availability: skilled birth attendants (51%), resuscitation (30%), and kangaroo mother care (27%) at these facilities. A multifold rise in newborn resuscitation efforts and documentation (n = 4431 vs. n = 144 in preintervention period) with high success rate (98.6%) was observed. There was also improvement in obstetric care services including partograph use (31%) and active management of third stage of labor (46%). However, several infrastructural indicators (electricity, water supply, toilets, and sanitation) remained unchanged.Conclusion:Overall improvements were observed in the majority of the signal functions for perinatal care and newborn resuscitation efforts. There was a limited impact on the infrastructural and supervision components.

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis.

BackgroundWhat constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.ObjectivesTo develop a conceptualisation of RMC.Search strategyKey databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.Selection criteriaPrimary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.Data collection and analysisA combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.Main resultsSixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.ConclusionsThis review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.Tweetable abstractUnderstanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Experience of skill labs to improve quality of newborn care at birth in three district of Uttar Pradesh, India

Background: Retention of neonatal resuscitation skill among birth attendants have been a challenge in developing countries. The objective of the study was to document the performance of skill labs and its impact on the skill and knowledge of the birth attendants in India.Methods: In three districts of Uttar Pradesh, impact assessment of twelve skill labs was done adopting mixed quantitative and qualitative methodology.Results: Twelve skill labs supported skill building of 606 birth attendants over one year. Six of the units performed well and four moderately and too units poorly. The health functionaries at all levels were positive about their experience about the skill labs. Majority of them hoped sustenance of these units. There was marked retention of resuscitation skill after one year.Conclusions: The skill labs appear to be useful modality for promoting retention of the resuscitation skills of birth attendants.

What if the baby doesn't survive? Health-care decision making for ill newborns in Ethiopia

Despite efforts to improve access to and quality of care for newborns, the first month after birth remains the most dangerous period of life. Given high neonatal mortality in low-income countries, saving newborn lives is a key priority for global and national health policy agendas. However, little is known about how these policies resonate with local understandings, experiences and household priorities. In this qualitative study we examined families' decision making and health-care-seeking in Butajira, Ethiopia. Data were collected through observation in hospital, in-depth interviews (41), and focus group discussions (7) with family members, health-care workers, and community members (October–November 2015). Transcripts and field notes were analyzed inductively using qualitative content analysis. Findings indicate that newborn health was not always the family's priority. Local perceptions of newborns as not yet useful members of the household alongside costly health-care services delayed decision making and care-seeking. While sickness was recognized as dangerous for the ill newborn, seeking health-care could be harmful for the economic survival of the family. In a resource-constrained setting, families' focused on productive assets in order to minimize long-term risks, and waited before seeking newborn health-care services. Until the baby had survived the first vulnerable weeks and months of life, the unknown newborn was not yet seen as a social person by the community. Personhood evolved progressively as the baby became a part of the family. A newborn death was surrounded by silence, and families received minimal support from traditional financial associations, iddirs. Decisions regarding health-care were contingent upon families' understandings of newborns and their resource-constrained circumstances. Improving newborn health involves recognizing why families choose to (not) seek health-care, and their actual opportunities and constraints in making such decisions. The everyday realities of vulnerable newborns must be at the center of global and national policy discussions and local implementation.

Measuring facility capability to provide routine and emergency childbirth care to mothers and newborns: An appeal to adjust for delivery caseload of facilities.

BackgroundMeasurement of Emergency Obstetric Care capability is common, and measurement of newborn and overall routine childbirth care has begun in recent years. These assessments of facility capabilities can be used to identify geographic inequalities in access to functional health services and to monitor improvements over time. This paper develops an approach for monitoring the childbirth environment that accounts for the delivery caseload of the facility.MethodsWe used data from the Kenya Service Provision Assessment to examine facility capability to provide quality childbirth care, including infrastructure, routine maternal and newborn care, and emergency obstetric and newborn care. A facility was considered capable of providing a function if necessary tracer items were present and, for emergency functions, if the function had been performed in the previous three months. We weighted facility capability by delivery caseload, and compared results with those generated using traditional “survey weights”.ResultsOf the 403 facilities providing childbirth care, the proportion meeting criteria for capability were: 13% for general infrastructure, 6% for basic emergency obstetric care, 3% for basic emergency newborn care, 13% and 11% for routine maternal and newborn care, respectively. When the new caseload weights accounting for delivery volume were applied, capability improved and the proportions of deliveries occurring in a facility meeting capability criteria were: 51% for general infrastructure, 46% for basic emergency obstetric care, 12% for basic emergency newborn care, 36% and 18% for routine maternal and newborn care, respectively. This is because most of the caseload was in hospitals, which generally had better capability. Despite these findings, fewer than 2% of deliveries occurred in a facility capable of providing all functions.ConclusionReporting on the percentage of facilities capable of providing certain functions misrepresents the capacity to provide care at the national level. Delivery caseload weights allow adjustment for patient volume, and shift the denominator of measurement from facilities to individual deliveries, leading to a better representation of the context in which facility births take place. These methods could lead to more standardized national datasets, enhancing their ability to inform policy at a national and international level.

Assessment of the quality of neonatal care in the Solomon Islands.

To identify strengths and obstacles for improving the quality of newborn care in the Solomon Islands. Improving the quality of newborn care is a priority in the Sustainable Development Goals and the Action Plan for Healthy Newborns in the Western Pacific. The neonatal mortality rate in the Solomon Islands, a lower-middle-income country, has improved slower than overall child mortality. In 2013, neonatal mortality (13.2/1000) constituted 44% of under-5 deaths (30.1/1000). A cross-sectional study of newborn care in five provincial hospitals using a World Health Organization assessment tool for hospital quality of care. Twelve months of neonatal records of the National Referral Hospital (NRH) labour ward and nursery were audited. Essential medications and basic equipment were generally available. Challenges included workforce shortages and lack of expertise, high costs, organisation and maintenance of equipment, infection control and high rates of stillbirth. Over 12 months at the NRH labour ward, there were 5412 live births, 65 (1.2%) 'fresh' stillbirths and 96 (1.8%) 'macerated' stillbirths. Over the same period, there were an associated 779 nursery admissions, and the main causes of mortality were complications of prematurity, birth asphyxia, congenital abnormalities and sepsis. Total neonatal mortality at NRH was 16 per 1000 live births, and 77% of deaths occurred in the first 3 days of life. Infrastructure limitations, technical maintenance and equipment organisation were obstacles to newborn care. Greater health-care worker knowledge and skills for early essential newborn care, infection control and management of newborn complications is needed.

Cross-sectional observational assessment of quality of newborn care immediately after birth in health facilities across six sub-Saharan African countries

ObjectiveTo present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers'...

Care of newborn in the community and at home.

India has contributed immensely toward generating evidence on two key domains of newborn care: Home Based Newborn Care (HBNC) and community mobilization. In a model developed in Gadchiroli (Maharashtra) in the 1990s, a package of Interventions delivered by community health workers during home visits led to a marked decline in neonatal deaths. On the basis of this experience, the national HBNC program centered around Accredited Social Health Activists (ASHAs) was introduced in 2011, and is now the main community-level program in newborn health. Earlier in 2004, the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program was rolled out with inclusion of home visits by Anganwadi Worker as an integral component. IMNCI has been implemented in 505 districts in 27 states and 4 union territories. A mix of Anganwadi Workers, ASHAs, auxiliary nursing midwives (ANMs) was trained. The rapid roll out of IMNCI program resulted in improving quality of newborn care at the ground field. However, since 2012 the Ministry of Health and Family Welfare decided to limit the IMNCI program to ANMs only and leaving the Anganwadi component to the stewardship of the Integrated Child Development Services. ASHAs, the frontline workers for HBNC, receive four rounds of training using two modules. There are a total of over 900 000 ASHAs per link workers in the country, out of which, only 14% have completed the fourth round of training. The pace of uptake of the HBNC program has been slow. Of the annual rural birth cohort of over 17 million, about 4 million newborns have been visited by ASHA during the financial year 2013–2014 and out of this 120 000 neonates have been identified as sick and referred to health facilities for higher level of neonatal care. Supportive supervision remains a challenge, the role of ANMs in supervision needs more clarity and there are issues surrounding quality of training and the supply of HBNC kits. The program has low visibility in many states. Now is the time to tap the missed opportunity of miniscule coverage of HBNC; that at least half of the country's birth cohort should be covered by this program by 2016, coupled with rapid scale up of the community-based treatment of neonates with pneumonia or sepsis, where referral is not possible.

Evaluation of an Intervention to Improve Essential Obstetric and Newborn Care Access and Quality in Cotopaxi, Ecuador.

Despite improvements in health-care utilization, disadvantages persist among rural, less educated, and indigenous populations in Ecuador. The United States Agency for International Development-funded Cotopaxi Project created a provincial-level network of health services, including community agents to improve access, quality, and coordination of essential obstetric and newborn care. We evaluated changes in participating facilities compared to non-participating controls. The 21 poorest parishes (third-level administrative unit) in Cotopaxi were targeted from 2010 to 2013 for a collaborative health system performance improvement. The intervention included service reorganization, integration of traditional birth attendants (TBAs) with formal supervision, community outreach and education, and health worker technical training. Baseline (n = 462) and end-line (n = 412) household surveys assessed access, quality and use of care, and women's knowledge and practices. TBAs' knowledge and skills were assessed from simulations. Chart audits were used to assess facility obstetric and newborn care quality. Provincial government data were used for change in neonatal mortality between intervention and non-intervention parishes using weighted linear regression. The percentage of women receiving a postnatal visit within first 2 days of delivery increased from 53 to 81 in the intervention group and from 70 to 90 in the comparison group (p ≤ 0.001). Postpartum/counseling on newborn care increased 18% in the intervention compared with 5% in the comparison group (p ≤ 0.001). The project increased community and facility care quality and improved mothers' health knowledge. Intervention parishes experienced a nearly continual decline in newborn mortality between 2009 and 2012 compared with an increase in control parishes (p ≤ 0.001). The project established a comprehensive coordinated provincial-level network of health services and strengthened links between community, primary, and hospital health care. This improved access to, quality, use, and provision of essential obstetric and neonatal care and survival. Ecuador's Ministry of Health is scaling up the model nationally.

Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana

BackgroundWith the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011–2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. ObjectiveUsing scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. MethodsThe quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. ResultsResults show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. ConclusionEngaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders.

Improving newborn care quality with a training and QI intervention in a rural hospital in Gujarat, India

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care.

BackgroundImplementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care.MethodsA systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models’ characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria.ResultsFrom 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0–32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported.ConclusionsThe QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Mortalidad neonatal en una institución de tercer nivel de atención

IntroductionNeonatal mortality is an important indicator of the quality of newborn care. Approximately 60% of all infant deaths in the first year of life occur during the neonatal period. ObjectiveTo determine the newborn mortality rate in a tertiary level care centre, and identify causes of death. Material and methodA retrospective study was conducted on all infants who died in the first twenty eight days of life. A record was made of gestational age, weight at birth, and causes and age at death. ResultsThe mortality rate was 18.5 per 1000 live births, of which 51.6% occurred in the first 24h due to genetic anomalies, 25.4% between 1-7 days of life, mainly due to neurological and respiratory diseases, and 22.8% after 7days, mainly due to cardiac malformations. The mean age at death was: 31.1 (23.1-39.1) weeks. The mean weight at death was 1,345g (390-3,325g). ConclusionsMortality rate was 18.5 per 1,000 live births and the overall main cause of death were cardiac malformations.

The importance of evaluating primary midwifery care for improving the health of women and infants.

In most countries, maternal and newborn care is fragmented and focused on identification and treatment of pathology that affects only the minority of women and babies. Recently, a framework for quality maternal and newborn care was developed, which encourages a system-level shift to provide skilled care for all. This care includes preventive and supportive care that works to strengthen women’s capabilities and focuses on promotion of normal reproductive processes while ensuring access to emergency treatment when needed. Midwifery care is pivotal in this framework, which contains several elements that resonate with the main dimensions of primary care. Primary health care is the first level of contact with the health system where most of the population’s curative and preventive health needs can be fulfilled as close as possible to where people live and work. In this paper, we argue that midwifery as described in the framework requires the application of a primary care philosophy for all childbearing women and infants. Evaluation of the implementation of the framework should therefore include tools to monitor the performance of primary midwifery care.

Women's views and experience of their maternity care at a referral hospital in Ghana

Reducing death and morbidity by promoting high quality maternal and newborn care is a key goal for global health programmes. A recent systematic review defined quality care as preventive and supportive care with effective treatment for problems when they arise ( Renfrew et al, 2014 ). It showed that women want health professionals who combine clinical skills with interpersonal competence. This article describes a qualitative study to explore the experiences of eleven newly delivered women at a large referral hospital in Accra, to identify which factors contributed to a positive or negative birth experience. The study found that women's satisfaction or dissatisfaction were due to their perceptions of clinical competency (basic, practical, timely monitoring and treatment) and emotional support (respect, kindness and reassurance).