Standards for improving quality of maternal and newborn care in health facilities

STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES

STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES WHO Library Cataloguing-in-Publication Data: Standards for improving quality of maternal and newborn care in health facilities. 1.Maternal Health Services. 2.Maternal Welfare. 3.Infant, Newborn. 4.Child Health Services. 5.Delivery of Health Care – standards. 6.Perinatal Care. I.World Health Organization. ISBN 978 92 4 151121 6 (NLM classification: WA 310) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non- commercial distribution– should be addressed to WHO Press through the WHO website (http://www. who.int/about/licensing/copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by the WHO Document Production Services, Geneva, Switzerland. Design by Inís Communication – www.iniscommunication.com Acronyms and abbreviations iv Acknowledgements v Executive summary 1 1. Background 5 1.1 Introduction 5 1.2 Priorities for reducing maternal and perinatal mortality 6 1.3 Rationale 6 1.4 Target audience 7 2. Method and process 8 2.1 Overview 8 2.2 Scope 8 2.3 Development of the framework and standards of care 9 2.4 Development of quality measures 10 3. Definition and framework of quality of care 14 3.1 Evidence and summary of findings 14 3.2 Definition of quality of care 14 3.3 Quality of care framework 15 3.4 Strategic areas of work 17 4. Standards of care 18 4.1 Evidence and summary of findings 18 4.2 Definition and structure of standards 18 4.3 Scope and use of standards and quality statements 19 4.4 List of standards and quality statements 20 5. Quality statements and measures 24 5.1 Outcome of the Delphi process 24 5.2 Using quality measures 24 5.3 Measures for quality statements 25 6. Operationalization 63 6.1 Dissemination 63 6.2 Implementation approach 63 7. Monitoring and evaluation 65 8. Updating the standards 66 References 67 Annex 1. Participants in the meeting of the guideline development group, Geneva, 3–4 June 2015 69 Annex 2. List of participants in the Delphi study 70 Contents iv Acronyms and abbreviations ICD International Classification of Diseases NICE National Institute for Health and Care Excellence UNICEF United Nations Children’s Emergency Fund vAcknowledgements The WHO departments of Maternal, Newborn, Child and Adolescent Health and of Reproductive Health and Research gratefully acknowledge the contributions of many individuals to preparation of this document. Special thanks go to the experts who participated in and contributed to the framework for the quality of maternal and newborn care, standards of care and quality statements at a meeting in June 2015: Pierre Barker, Institute for Healthcare Improvement, USA; Nynke van den Broek, Liverpool School of Tropical Medicine, United Kingdom; Sheena Currie, Maternal and Child Health Integrated Program, USA; Kim Dickson, UNICEF, USA; Claudia Hanson, Karolinska Institute, Sweden; Kathleen Hill, JHPIEGO, USA; Asia Kassim Hussein, UNICEF, United Republic of Tanzania; Lily Kak, United States Agency for International Development, USA; Joy Lawn, London School of Hygiene and Tropical Medicine, United Kingdom; Tess Lawrie, Evidence- based Medicine Consultancy Ltd, United Kingdom; Norman Lufesi, Ministry of Health, Malawi; Silke Mader, European Foundation on the Care of Newborn Infants, Germany; Ziaul Matin, UNICEF, Bangladesh; Goldy Mazia, Maternal and Child Survival Program, USA; Georgina Msemo, Ministry of Health and Social Welfare, United Republic of Tanzania; Jim Neilson, University of Liverpool, United Kingdom; Lee Pyne-Mercier, Bill & Melinda Gates Foundation; USA; Isabella Sagoe-Moses, Ministry of Health, Ghana; Memuna Tanko, National Health Insurance Authority, Ghana; Donna Vivio, United States Agency for International Development, USA; and Nabila Zaka, UNICEF, USA. We acknowledge the contributions of the 116 experts in 46 countries who participated in the Delphi study to build consensus on the quality measures (listed in Annex 2). External consultants who supported the work at various stages are Carolyn MacLennan, Rashmi Mathur, Senait Kebede and Tess Lowrie. Staff members in the WHO Interdepartmental Guidelines Steering Group were Rajiv Bahl, Bernadette Daelmans, Matthews Mathai, Fran McConville, Annie Portela, Severin von Xylander and Wilson Were, Maternal, Newborn, Child and Adolescent Health; Metin Gülmezoglu, Olufemi Oladapo, Özge Tuncalp, and Joshua Vogel, Reproductive Health and Research; Neelam Dhingra, Shamsuzzoha Syed, Service Delivery and Safety; Margaret Montgomery and Michaela Pfeiffer, Public Health and Environment; Mwansa Nkowane, Health Workforce; and Gerardo Zamora and Lisa Rogers, Nutrition for Health and Development. This Publication was coordinated by staff members in the Maternal and Newborn Quality of care Core Working Group: Bernadette Daelmans, Olufemi Oladapo, Özge Tuncalp, Wilson Were and Severin von Xylander. We also acknowledge and thank all WHO staff in regions and countries who participated in the meetings, reviewed the text and provided input. We acknowledge and thank the Bill & Melinda Gates Foundation, which provided financial support for this work.

1Executive summary Much progress has been made during the past two decades in coverage of births in health facilities; however, reductions in maternal and neonatal mortality remain slow. With increasing numbers of births in health facilities, attention has shifted to the quality of care, as poor quality of care contributes to morbidity and mortality. The period around childbirth is the most critical for saving the maximum number of maternal and newborn lives and preventing stillbirths. WHO sees a future in which “Every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth and the postnatal period”. To realize this vision, WHO has defined “quality of care” and has prepared a framework for improving the quality of care for mothers and newborns around the time of childbirth. The framework contains eight domains of quality of care that should be assessed, improved and monitored within the health system. The health system provides the structure for access to high-quality care in the two important, inter-linked dimensions of provision and experience of care. Within this framework and in line with the Organization’s mandate, WHO will work towards realization of its vision in six strategic areas, which will be the basis for a systematic, evidence-based approach to providing guidance for improving the quality of maternal and newborn care. The six areas are: clinical guidelines, standards of care, effective interventions, measures of quality of care, relevant research and capacity-building Standards of care and measures of quality were prioritized because there is currently no substantive guidance, although it is the key to ensuring the quality of care. Standards explicitly define what is required in order to achieve high-quality care around the time of childbirth. In the first phase, a rigorous approach was used to identify existing resources, conduct an extensive literature search and map the standards of care of various organizations in order to define and determine their structure. It was proposed that broad standards be set, underpinned by specific quality statements and a number of input, output or process and outcome measures. Eight standards were formulated, one for each of the eight domains of the quality of care framework. To ensure that the standards are specific and focused, 2–13 quality statements were formulated for each standard to drive measurable improvements in the quality of care around childbirth. A WHO interdepartmental steering group and a core working group were established to review and synthesize the evidence. Between January 2015 and February 2016, the working group reviewed published studies to define “quality of care” and to formulate the framework for ensuring the quality of maternal and newborn care. The framework was presented to the guideline development group at a consultation held in Geneva on 3–4 June 2015, where the group reviewed and discussed the definition of “quality of care”, the proposed framework, standards of care, quality statements and criteria for defining measures of quality. Agreement on the definition, the domains of the framework, standards of care and the quality statements 2was reached by consensus. The guideline development group also discussed the criteria for defining the measures that would be used to assess, measure and monitor the quality of care. In the second phase, the interdepartmental guidelines steering group collated, reviewed and formulated input, output and outcome measures for each quality statement. These measures were derived from indicators used by WHO and other internationally recognized organizations in the public domain. Measures were then drafted by the relevant technical department and refined by consultation in the guidelines steering group. The resulting list was reviewed in two rounds of a Delphi process to ensure wider geographical (46 countries) and stakeholder (116 experts) consensus. Health facility teams can use the measures to identify gaps in the quality of care and improve the provision and experience of care according to the standards and quality statements. They are for use by health facility leaders, planners, managers and providers to assess and monitor the availability of resources, performance, areas for improvement and the impact of interventions, leading to better quality. The eight standards of care and 31 quality statements are listed below. Standards of care and quality statements Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Quality statements 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. 1.1b: Newborns receive routine care immediately after birth. 1.1c: Mothers and newborns receive routine postnatal care. 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines. 1.3: Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO guidelines. 1.4: Women with delay in labour or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. 1.7a: Women with or at risk for infection during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. 1.8: All women and newborns receive care according to standard precautions for preventing hospital-acquired infections. 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. 3Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Quality statements 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period. 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Quality statements 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Quality statements 4.1: All women and their families receive information about the care and have effective interactions with staff. 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals. Standard 5: Women and newborns receive care with respect and preservation of their dignity. Quality statements 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. 5.3: All women have informed choices in the services they receive, and the reasons for interventions or outcomes are clearly explained. Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability. Quality statements 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. 6.2: Every woman receives support to strengthens her capability during childbirth. 4Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Quality statements 7.1: Every woman and child has access at all times to at least one skilled birth attendant and support staff for routine care and management of complications. 7.2: The skilled birth attendants and support staff have appropriate competence and skills mix to meet the requirements of labour, childbirth and the early postnatal period. 7.3: Every health facility has managerial and clinical leadership that is collectively responsible for developing and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Quality statements 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functional, reliable, safe and sufficient to meet the needs of staff, women and their families. 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. 8.3: An adequate stock of medicines, supplies and equipment is available for routine care and management of complications. 51. Background 1.1 Introduction During the past two decades, considerable efforts have been made to ensure skilled birth attendance, with the aim of reducing morbidity and mortality among mothers and newborns. These efforts have substantially improved the number of births in health facilities, the proportion of deliveries attended by skilled health personnel in developing countries having increased from 56% in 1990 to 68% in 2012. Despite this increased coverage, 800 women and 7700 newborns still die each day from complications during pregnancy and childbirth and in the postnatal period; an additional 7300 women experience a stillbirth. With increasing numbers of births in health facilities, more avoidable maternal and perinatal mortality and morbidity are occurring in those facilities. The outcome of the care for women and newborns around the time of birth in health facilities reflects the evidence-based practices used and the overall quality of services provided. The quality of care depends on the physical infrastructure, human resources, knowledge, skills and capacity to deal with both normal pregnancies and complications that require prompt, life-saving interventions. Improving the quality of care in health facilities is thus increasingly recognized as an important focus in the quest to end preventable mortality and morbidity among mothers and newborns. Research has shown that maximizing coverage of essential interventions is insufficient to reduce maternal mortality and severe morbidity. Additionally, there is a complex interplay between experience of care and pregnancy outcomes. To end preventable maternal and newborn morbidity and mortality, every pregnant woman and newborn should have skilled care at birth with evidence-based practices delivered in a humane, respectful, supportive environment. Good-quality care requires appropriate use of effective clinical and non-clinical interventions, strengthened health infrastructure, optimum skills and a positive attitude of health providers. These will improve health outcomes and give women, their families and the health care providers a positive experience. High-quality care is integral to the right to health and the route to equity and the preservation of dignity for women and children. Ensuring access to skilled birth attendance and essential obstetric care that is effective and of good quality help reduce maternal and newborn mortality and morbidity (1). The WHO standards for the quality of maternal and newborn care are based on prioritized, evidence- based interventions during critical periods of care. WHO envisions a world in which “every pregnant woman and newborn receives quality care throughout pregnancy, childbirth and the immediate postnatal period” (2) This statement is aligned with two complementary global action agendas: “Strategies toward ending preventable maternal mortality” (3) and the “Every newborn: an action plan to end preventable deaths” (4). 61.2 Priorities for reducing maternal and perinatal mortality Globally, over 70% of maternal deaths are due to complications of pregnancy and childbirth such as haemorrhage, hypertensive disorders, sepsis and abortion (5). Complications of preterm birth, asphyxia, intra-partum perinatal death and neonatal infections account for more than 85% of newborn deaths (6). Studies show that effective, high-quality care to prevent and manage complications during this critical period is likely to reduce the numbers of maternal deaths, stillbirths and early neonatal deaths significantly (7). Hence, the time of childbirth and the period immediately after are particularly critical for maternal, foetal and neonatal survival and represent an opportunity to increase the return on investments to improve care. Effective prevention and management of conditions in late pregnancy, childbirth and the early newborn period are likely to reduce the numbers of maternal deaths, antepartum and intrapartum-related stillbirths and early neonatal deaths significantly. Therefore, improvement of the quality of preventive and curative care during this critical period could have the greatest impact on maternal, foetal and newborn survival. On the basis of the current evidence on burden and impact, the following thematic areas are considered high priorities for evidence- based practices in routine and emergency care (2). • routine care during childbirth, including monitoring of labour and newborn care at birth and during the first week; • management of pre-eclampsia, eclampsia and its complications; • management of difficult labour with safe, appropriate medical techniques; • management of postpartum haemorrhage; • newborn resuscitation; • management of preterm labour, birth and appropriate care for preterm and small babies; and • management of maternal and newborn infections. 1.3 Rationale Quality of care is increasingly recognized internationally as a critical aspect of the unfinished maternal and newborn health agenda, mainly with respect to care around labour and delivery and in the immediate postnatal period (8). It is recognized that high coverage alone is not enough to reduce mortality. To reduce maternal and neonatal mortality substantially and move towards elimination of preventable causes of maternal and newborn death, increased coverage should be accompanied by improved quality throughout the continuum of care (9, 10). The WHO Multicounty Survey on Maternal and Newborn Health (11), with data on more than 300 000 women attending 359 health care facilities in 29 countries, showed a poor correlation between coverage of “essential interventions” (e.g. the proportion of the population who had received an indicated intervention, such as women with eclampsia who received magnesium sulfate) and maternal mortality in health facilities. Studies also show that high-quality care requires appropriate use of the available infrastructure, staff and commodities to ensure effective case management (12). High-quality care requires appropriate use of evidence-based clinical practices and non-clinical interventions, strengthened health infrastructure and optimum skills and a positive attitude of health providers. 7Providing high-quality antenatal, intrapartum and postnatal care must be integral to any quality improvement strategy. Human rights norms, medical ethics and technical standards encourage integration of these services, directly or through effective referral, as a fundamental element of the quality of care.1 The right to health is a fundamental human right that is central to accelerating reductions in maternal, neonatal and child mortality and morbidity and is the route to equity and preservation of the dignity of women and children (13). 1.4 Target audience The quality of care framework, standards of care and quality measures may be used to guide the preparation of national standards of care and measures for improving, assessing and monitoring the quality of care provided to mothers and newborns in health facilities. The framework can also be used as a basis for quality improvement strategies and activities and for incorporating quality into existing national programmes. The framework, standards of care and quality measures are intended primarily for use by policy-makers, programme managers, health planners at national, subnational, district and facility levels, maternal and newborn health care professionals, and professional bodies or technical partners involved in quality of care or which advise ministries of health. They can also be used as a resource in medical training institutions. In recognition of the differences between countries with regard to the organizational structure of health facilities and the health workers who provide maternal and neonatal care, the document focuses on the standards of care, competence, services and physical resources necessary to ensure that maternal and neonatal health conditions are appropriately assessed, managed or referred within a functioning health system in order to provide the optimal care. The standards of care and quality measures should be adapted to the local context to ensure their applicability and to obtain the desired outcomes for mothers and newborns. 1 Germain A. Meeting human rights norms for the quality of sexual and reproductive health information and services. Commissioned discussion paper presented at the international conference on population and development beyond 2014. International conference on human rights, Noordwijk, 7–10 July 2013. 82. Method and process 2.1 Overview The vision of the quality of care, the framework, the standards of care and the measures of quality were defined in three phases. In the first, consensus was reached on the WHO vision, and the quality of maternal and newborn care was defined. In the second phase, agreement was reached on a conceptual framework for quality of care, a strategic approach to implementation and strategic areas for improving the quality of care. In the third phase, the group addressed gaps identified in strategic work areas and defined standards of care and measures for monitoring improvement in the quality of care in health facilities. These phases included a literature review, expert consultations and consensus-building in a Delphi process. 2.2 Scope The scope of the work was such as to provide comprehensive guidance to international and national stakeholders to meet the WHO global vision of improving the quality of care for mothers and newborns. This required a framework to define the domains of measurement, the means by which interventions can be expected to achieve the desired health outcomes and the measures required for assessment. A consultation was initiated in 2015 under the guidance of the Assistant Director-General of the Family, Women and Children cluster. An interdepartmental guidelines steering group was set up, consisting initially of members from the two departments directly responsible for maternal and newborn health: the Department of Maternal, Newborn, Child and Adolescent Health and the Department of Reproductive Health and Research. Once the vision had been defined, the steering group was expanded to include the departments of Public Health, Environmental and Social Determinants of Health, Service Delivery and Safety, Health Workforce and Nutrition for Health and Development. A core working group with members from the departments of Maternal, Newborn, Child and Adolescent Health and Reproductive Health and Research led evidence retrieval and synthesis and ensured coordination. The guidelines steering group met every two weeks to achieve consensus on the WHO vision of maternal and newborn quality of care and to define the scope of their work. Three categories of review were identified: • of definitions of quality of care in the context of maternal and newborn health; • of existing models of quality of care and the design of a systematic framework of important domains of maternal and newborn quality of care; and 9• of the literature and definition of an effective strategy for clinical and health service interventions to improve the quality of care at country level. These areas were addressed during the first and second phases as the basis for defining quality of care and the quality of care framework and identifying strategic work areas. Definition of standards of care was identified as a major gap. 2.3 Development of the framework and standards of care The core working group reviewed published and unpublished literature that reported definitions of quality of care, models of care, quality of care frameworks and strategic approaches that have been used to improve the quality of care in general and specifically for maternal and newborn health. The findings were presented to the interdepartmental guidelines steering group for review and discussion, and consensus was reached on a definition of quality of care, the conceptual framework and the strategic implementation approach (2). Standards represent benchmarks against which improvements can be measured and should therefore be measurable. Defining standards of care was identified as a priority, because there was little guidance available, except for evidence-based clinical practice guidelines. In a first step, a definition, taxonomy and structure were devised, and then standards of care were formulated. Consensus was reached on the definition, draft framework, and standards of care, which were then presented to a meeting of the guideline development group in June 2015 (Annex 1). 2.3.1 Evidence retrieval and synthesis MEDLINE, WHO publications and other databases were searched for relevant publications that provided definitions and models of quality of care, with the search terms “standard [definition] [criteria], [service delivery], [clinical or guidelines], [standard operating procedures]”. Additional searches were conducted by adding ‘maternal and newborn’ to the key words. Publications were located on organizations’ websites by utilizing the site’s search box or a specific section of their site dedicated to publications. Organizations that were likely to have developed standards in general and for maternal and newborns in particular including international quality and safety organizations, government agencies, nongovernment and professional organizations were identified. Box 1 lists the organizations the publications of which were used as the main sources for the definition, taxonomy and structure of standards of care. A general internet search with the Google search engine and the same key words was also conducted. The documents were then reviewed and analysed to identify a standard in terms of definition, description, format, measurement and taxonomy. The group also reviewed experience in improving the quality of care in various projects completed by WHO departments. 10 Box 1. Resources reviewed to define standards • International Organization for Standardization • International Society for Quality in Health Care • The Joint Commission (USA) • National Institute for Health and Care Excellence (NICE), United Kingdom • Council for Health Service Accreditation of Southern Africa • National Department of Health: National Core Standards for Health Establishment in South Africa (2011) • Safecare Basic Health Care Standards (PharmAccess Foundation of the Netherlands, the Joint Commission International of the USA and the Council for Health Service Accreditation of Southern Africa) • Australian Commission on Safety and Quality in Health Care: National safety and quality health service standards (2012) • WHO standards for maternal and newborn health. Group 1: General standards of care for healthy pregnancy and childbirth (2007) • WHO Regional Office for South-East Asia: Standards of Midwifery Care (1999) 2.3.2 Expert review and consensus-building In order to reflect the diversity of expert opinion and technical perspectives appropriately, the quality of care framework and standards of care were defined in a participatory process. The draft was reviewed by relevant WHO departments to ensure technical accuracy and consistency and with WHO regional offices and country representatives to assess their applicability in different contexts. The consultation was conducted electronically and at face-to-face meetings, followed by a one-day meeting of the members of the interdepartmental guideline development group to review, finalize and draft the framework and standards of care for presentation and discussion by the guideline development group. In June 2015, an expert meeting (Annex 1) was held to review the WHO vision and framework and to achieve consensus on the WHO approach and the draft standards of care. The experts reviewed the background information and drafts to determine the comprehensiveness of the review and whether the proposed definition of quality of care, framework and standards of care reflected current knowledge and understanding of quality of care, their applicability to values in low-resource settings and the feasibility of implementation. Consensus was reached on most items and by a show of hands only exceptionally. The drafts were finalized on the basis of the outcome of the meeting. 2.4 Development of quality measures Measures of quality are a fundamental component of standards of care. They are required to measure inputs, the process of care or service provision and, if appropriate, the outcome of care and thus to monitor progress towards achievement of a particular standard of care. Defining measures of quality is challenging, however, in view of variations in definitions, complex interactions among the factors responsible for outcomes and the context of their use and application. 11 The group sought realistic parameters and a balanced approach to measuring interventions in health facilities. They sought both appropriate direct measures and measures that reflect the combined effect of interventions The initial step was to identify the elements of interventions that define the standards of care, on the basis of WHO guidelines and other relevant sources. A list of quality measures was then collated, and the relevant WHO technical unit formulated a quality statement. These were reviewed by the interdepartmental guidelines steering group before a Delphi process for consensus-building. 2.4.1 Collating and drafting quality measures WHO technical departments drafted the quality measures for each statement in collaboration with the core working group. The group mapped and collated existing measures from WHO guidelines, several WHO tools for assessing health facilities and collecting data and from national and international partners. When no measures were found in these sources, new measures were formulated on the basis of current guidelines and discussed within the relevant WHO units. The measures were collated, and the interdepartmental guidelines steering group drafted a list of 318 measures for the 31 quality statements, to be reviewed in the wider consultation. 2.4.2 Consensus-building on quality measures To build consensus on the quality measures, a wider consultation was undertaken, initially within WHO technical units and regional and country offices and then globally in a Delphi process. Prospective participants in the global consultation were identified who had a wide spectrum of expertise, from the provision of care to the experience of care. They included experts in quality of care, professionals (e.g. obstetricians, a neonatologist, paediatricians, midwives, nurses, communication specialists, lawyers), researchers, academics, users and implementers at various levels and representatives of consumer organizations, professional societies and international and bilateral agencies. Invitations were sent to 215 prospective participants in 60 countries to gauge their interest and obtain consent to participate. The aim was to recruit approximately equal numbers of participants in the various sectors of health and social care, with global representation. Of 215 invitees, 130 (60%) in 48 low-, middle- and high-income countries agreed to participate. The quality measures were sent to those who consented to participate in the consultation, which was conducted in two rounds over 14 weeks. Online software (SurveyMonkey®) allowed participants to submit their comments and rankings of measures in two rounds. In the first round, participants were asked to review the list of 318 quality measures for validation and completeness, provide comments and propose any additional measures. In the second round, participants were asked to prioritize the measures on the basis of the criteria agreed at the guideline development group expert meeting. Round one of the Delphi survey In the first round, the 130 participants were sent the list of quality measures divided into three sections, the first covering provision of care (standards 1–3), the second covering experience of care (standards 4–6) and the third on cross-cutting areas (standards 7 and 8). Participants could choose to address either provision or experience of care plus cross-cutting areas or all three sections, depending on their expertise. They were asked to provide general comments on the validity and completeness of the measures for each quality statement and, if necessary, 12 to propose additional measures. The survey was open for two weeks, during which time three reminder e-mails were sent. The participants were encouraged to complete the survey at their own pace and to review their answers before submitting them. The core working group analysed the text comments and the quality measures proposed by the respondents and grouped them for each quality statement. Text comments were analysed and organized into categories, which were refined and clustered by the aspects of care covered by the quality statements. The categories included comments that provided insight into areas that were not covered but considered important, those that suggested reformulation of a measure and those that extended a statement in some way. The proposed additional quality measures were also grouped into themes. The relevant technical units then reviewed the grouped comments and additional measures and compiled a list for round 2 of the Delphi process. Round two of the Delphi survey The second round was conducted six weeks after the first, when the list was sent to 116 respondents who had expressed preferences in the first round. Three surveys were designed: one on the provision of care plus the cross-cutting areas (standards 1–3, 7 and 8), a second on experience of care plus cross-cutting areas (standards 4–6, 7 and 8) and the third on all the quality statements. The online survey was open for four weeks, and four reminder e-mails were sent during this period. In this round, respondents were asked to score the quality measures on the basis of the following five criteria, agreed upon by the guideline development group: • Importance: The topic of the measure is significant and strategically important to stakeholders (e.g. patients, clinicians, purchasers, public health officials, policy-makers). Health importance: The aspect of health that the measure addresses is important, as indicated by high prevalence or incidence and/or a significant effect on the burden of illness (i.e. effect on mortality and morbidity in a population). • Measurability: The requirements for data collection for the measure are understandable and feasible. The data source required for implementing the measure is available and accessible within the timeframe for measurement. • Reliability: The results of the measurement are reproducible for a fixed set of conditions, irrespective of who makes the measurement or when it is made. • Validity: The measure truly measures what it purports to measure. • Usefulness: The measure provides a meaningful measure of change over time, for decision-making. For each of the above criteria, participants had six graded options, from which to choose one: • No: This quality measure does not fulfil this criterion. • Probably no: This quality measure probably does not fulfil this criterion. • Not sure: I am not sure whether this quality measure fulfils this criterion. • Probably yes: This quality measure probably fulfils this criterion. • Yes: This quality measure fulfils this criterion. • No expertise: I don’t have expertise in this area. 13 Ranking of quality measures The ratings given in round 2 by the survey respondents were used to estimate a mean score for each quality measure, as follows: • No: This quality measure does not fulfil this criterion. = 0 points • Probably no: This quality measure probably does not fulfil this criterion. = 0.25 point • Not sure: I am not sure whether this quality measure fulfils this criterion. = 0.5 point • Probably yes: This quality measure probably fulfils this criterion. = 0.75 point • Yes: This quality measure fulfils this criterion. = 1 point • No expertise: I don’t have expertise in this area. = Blank “Blank” responses were not included in calculation of the mean scores. Calculation of mean scores A mean score was calculated for each quality measure on each criterion and termed the “intermediate” score, calculated as equal to the sum of all the scores for a particular criterion divided by the number of respondents (excluding blanks). The intermediate score for a quality measure for one criterion = mean score (C) for that quality measure by the number of participants. “C” is equal to the sum of the scores for that criterion divided by the total number of respondents (excluding blanks). As there were five criteria, the mean of the five intermediate score was calculated to obtain the final priority score for each quality measure. The final priority score for each quality measure was calculated by adding the intermediate scores for that measure on the five criteria, divided by 5. Final score for a quality measure = Mean of the intermediate scores for the five criteria = (C1+C2+C3+C4+C5)/5. The input, output and outcome quality measures were then ranked for each quality statement, according to the final priority score. 14 3. Definition and framework of quality of care 3.1 Evidence and summary of findings No one, universally accepted definition of quality of care was found in the literature (14–18). Quality of care was found to be multi-faceted and described from different perspectives and dimensions, including by health care providers, managers or patients and the health care system; on the basis of quality characteristics such as safety, effectiveness, timeliness, efficiency, equity and patient-centredness; and as the provision and experience of care (Box 2). A number of models of quality of care have been proposed since that of Donabedian in 1988 (18): Maxwell (19), Ovretveit et al. (20), Hulton et al. (21), the Institute of Medicine (16) and WHO (17). The three models most commonly used and most clearly defined were perspective, characteristics and systems models, which have been used to operationalize the characteristics of quality of care on the basis of various elements. The most compelling was the WHO model (17), which advanced health systems thinking by identifying six building blocks – service delivery; health workforce; information, medical products, vaccines and technology; financing, leadership and governance; and a structure for establishing health systems analysis and points of intervention. The health system creates the structure that enables access to high-quality care. These models were used to design a conceptual framework for defining, assessing and monitoring the quality of maternal and newborn care. The definition and framework of maternal and newborn quality of care described below were based on the above analysis and the consensus reached at the guideline development group expert meeting. 3.2 Definition of quality of care On the basis of several definitions in the literature, the WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred” (2). 15 Box 2. Operational definitions of the characteristics of quality of care • Safe – delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors • Effective – providing services based on scientific knowledge and evidence-based guidelines • Timely – reducing delays in providing and receiving health care • Efficient – delivering health care in a manner that maximizes resource use and avoids waste • Equitable – delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status • People-centred – providing care that takes into account the preferences and aspirations of individual service users and the culture of their community The quality of care for women and newborns is therefore the degree to which maternal and newborn health services (for individuals and populations) increase the likelihood of timely, appropriate care for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and take into account the preferences and aspirations of individual women and their families. This definition takes into consideration the characteristics of quality of care and two important components of care: the quality of the provision of care and the quality of care as experienced by women, newborns and their families. 3.3 Quality of care framework As quality of care is multidimensional, various models were used to prepare a conceptual framework to guide health care providers, managers and policy-makers in improving the quality of health services for mothers and newborns. Building on these models and the WHO health systems approach, a quality of care framework (Fig. 1) was designed by identifying domains that should be targeted to assess, improve and monitor care in health facilities in the context of the health system (2). The framework has eight domains of quality of care within the overall health system. Although it focuses on the care provided in facilities, it also accounts for the critical role of communities and service users in identifying their needs and preferences and in managing their own health. The perspectives of women, their families and their communities on the quality of maternity care services influence their decision to seek care and are essential components in creating a demand for and access to high-quality maternal and newborn services (12). Community engagement is therefore an important aspect to be considered, beyond health facilities, and should be an integral component of improving the quality of care for women and newborns. 16 Fig. 1. WHO framework for the quality of maternal and newborn health care Health system St ru ct ur e Quality of Care O ut co m e Pr oc es s Individual and facility-level outcomes Coverage of key practices People-centred outcomes Health outcomes PROVISION OF CARE EXPERIENCE OF CARE 7. Competent, motivated human resources 8. Essential physical resources available 1. Evidence based practices for routine care and management of complications 2. Actionable information systems 3. Functional referral systems 4. Effective communication 5. Respect and preservation of dignity 6. Emotional support The framework of eight domains of quality of care for pregnant women and newborns in facilities increases the likelihood that the desired individual and facility outcomes will be achieved. The health system approach provides the structure for quality improvement in the two linked dimensions of provision and experience of care. Provision of care includes use of evidence-based practices for routine and emergency care, information systems in which record- keeping allows review and auditing and functioning systems for referral between different levels of care. Experience of care consists of effective communication with women and their families about the care provided, their expectations and their rights; care with respect and preservation of dignity; and access to the social and emotional support of their choice. The cross-cutting areas of the framework include the availability of competent, motivated human resources and of the physical resources that are prerequisites for good quality of care in health facilities. This framework can be used to assess the characteristics or dimensions of quality of care in various sectors of the health system, from the perspectives of service users, service providers and managers. On the basis of this framework and in line with the organizational mandate, six strategic areas of work were identified for improving the quality of maternal and newborn care. These six areas were used as the basis for a systematic, evidence-based approach to preparing guidelines, standards of care, effective interventions, indicators of quality of care and research and capacity-building for improving the quality of maternal and newborn care. 17 3.4 Strategic areas of work The six strategic areas for improving the quality of care and ending preventable mortality and morbidity among mothers and newborns are research, guidelines, standards of care, effective intervention strategies, indicators for monitoring at global, national and facility levels and strengthening capacity for quality improvement, measurement and programming (2). Guided by the framework, work in these strategic areas will support improvement of the quality of maternal and newborn care, with targeted national capacity strengthening and technical support. A review indicated, however, that, whereas evidence-based clinical practice guidelines are generally available, there was no guidance on expected standards of care and appropriate measures of quality. Therefore, standards of care and quality measures were prioritized as the first normative products. 18 4. Standards of care 4.1 Evidence and summary of findings The search for definitions, taxonomy and the structure of standards of care resulted in no consistent “definition” or specific, standardized “structure”. The majority of the sources identified were from non-health related areas that defined a standard as a statement that provides guidance to ensure consistency in processes and products (22). Health related standards were predominantly from high-income settings (23, 24). The National Centre for Health and Care Excellence (NICE) provided examples of maternal and newborn standards, including standards for antibiotics for neonatal infection, hypertension in pregnancy, induction of labour, caesarean section, postnatal care and antenatal care (25). The PharmAccess Foundation in the Netherlands (26), the Joint Commission International in the USA (23) and the Council for Health Service Accreditation of Southern Africa (24) have issued standards for low- and middle-income countries. In 2007, WHO published a limited number of standards for maternal and newborn care (27), none of which were specific to the time around childbirth. These health-related sources defined standards primarily for “accreditation”, although a few were for “quality improvement”, providing “criteria” for meeting standards in “prioritized areas”, with recognized gaps in quality and safety. While most recommended the need for “measurement criteria”, few provided such measurements. 4.2 Definition and structure of standards On the basis of these findings, for maternal and newborn care, a “standard” is defined as “a description of what is expected to be provided to achieve high-quality care around the time of childbirth”. The standard of care has two main components: the quality statement and the quality measure (Fig. 2). A quality statement sets out the requirements to achieve compliance with the standard and quality measures provide objective evidence for determining whether or not the requirements have been met. Quality statements are concise statements of priorities for measurably improving quality of care around childbirth (adapted from NICE quality standards (25). They define the markers of quality derived from evidence on the thematic area and the resources required. Quality measures are criteria for assessing, measuring and monitoring the quality of care as specified in the quality statement. They are of three types: • input: what must be in place for the desired care to be provided (e.g. physical resources, human resources, policies, guidelines), 19 • output: whether the desired process of care was provided as expected and • outcome: the effect of the provision and experience of care on health and people-centred outcomes. Fig. 2. Structure of standards In line with the eight domains in the WHO quality of care framework, eight standards have been formulated to define the priorities for quality improvement: 1. evidence-based practices for routine care and management of complications; 2. actionable information systems; 3. functioning referral systems; 4. effective communication; 5. respect and preservation of dignity; 6. emotional support; 7. competent, motivated personnel; and 8. availability of essential physical resources. The standards are accompanied by two or three quality statements; the exception is standard 1 on evidence-based practices for routine care and management of complications, for which there are 13 quality statements to reflect specific priorities for intervention. There are a total of 31 quality statements. For standard 1, some are annotated with ‘a’ if they cover only the woman, ‘b’ if they cover the baby and ‘c’ if they cover both the mother and the baby. Each of the 31 quality statements has 6–18 measures of input, output and outcome. 4.3 Scope and use of standards and quality statements The standards of care cover the routine care and management of complications occurring for women and their babies during labour, childbirth and the early postnatal period, including those of small babies during the first week of life. They are centred on the woman, the newborn and the family and are applicable to all health facilities that offer maternity services. They are in line with WHO guidelines and designed to address the specific priorities identified in section 1.2. The standards of care provide a basis for what is expected and required, support the monitoring and measurement of performance against measures of best practice in order to identify priorities for improvement and provide information on how best practice can be used to support high- quality care or service delivery. They define priorities for improving the quality of maternal and newborn care for use by planners, managers and health care providers to: Quality measures (input, output and outcome) Two or three quality statements per standard Eight standards, one for each WHO quality of care framework domain 20 • prepare evidence-based national and subnational standards of care to ensure high-quality, effective maternal and neonatal health services around the time of childbirth; • introduce the expected standards of care and delivery in order to identify the components of care that require improvement to ensure high-quality service; • use available resources to achieve optimal health care outcomes and improve the use by and satisfaction of individuals, families and communities with maternal and neonatal health services; • monitor service improvements, show that high-quality maternal and newborn care or services are being provided and highlight areas for improvement; and • provide a benchmark for national health facility audits, accreditation and rewards for provider performance. They should be adopted and streamlined within national quality of care strategies and frameworks for the delivery of maternal and newborn health services to ensure that the services provided are of high quality. 4.4 List of standards and quality statements Evidence-based practices for routine care and management of complications Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Aim: The aim of this standard is to ensure the expected evidence-based management of labour, childbirth and the immediate postnatal period to mothers and to newborns in the first few days of life. It includes routine care, early diagnosis of complications and their appropriate management. Many conditions require attention during this period; the standard has therefore been limited to those associated with high morbidity and mortality. Managing these conditions appropriately will drastically reduce the number of deaths and improve outcomes of women and newborns during this period. Quality statements Quality statement 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. Quality statement 1.1b: Newborns receive routine care immediately after birth. Quality statement 1.1c: Mothers and newborns receive routine postnatal care. Quality statement 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.3: Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.4: Women with delay in labour or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. Quality statement 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. 21 Quality statement 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. Quality statement 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. Quality statement 1.7a: Women with or at risk for infection during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. Quality statement 1.8: All women and newborns receive care according to standard precautions for preventing hospital-acquired infections. Quality statement 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. Actionable information systems Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Aim: The aim of this standard is to record all information in the health facility accurately and to use it appropriately to improve the care of women and newborns. This will require the availability of standard forms for collecting information on all patients throughout their stay in the facility and trained, skilled staff for data collection, analysis and use of the results to provide feedback to monitor and improve performance at all levels of the health care system, including the performance of health care staff. Quality statements Quality statement 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period Quality statement 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Functional referral systems Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Aim: The aim of this standard is to ensure timely, appropriate referral of all patients who need care that cannot be provided in the health facility. The decision to refer a patient should be made as soon as a condition that cannot be treated in the health facility is diagnosed, once the required pre-referral treatment has been given. Communication should be made with the centre to which the referral is made before transfer of the patient, so that appropriate arrangements can be made to receive the patient. A complete hand-over should be given to the receiving health facility, and feedback on the condition of the patient should be sought periodically to improve care in both the referring and referral health facility. 22 Quality statements Quality statement 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. Quality statement 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. Quality statement 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Effective communication Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Aim: The aim of this standard is effective communication, which is an essential component of the experience of care received by the patient and her family. The patient should receive all information about her care and should feel involved in all decisions taken regarding her treatment. Effective communication between the health care provider and the patient can reduce unnecessary anxiety and make childbirth a positive experience for the woman. Quality statements Quality statement 4.1: All women and their families receive information about the care and have effective interactions with staff. Quality statement 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals Respect and preservation of dignity Standard 5: Women and newborns receive care with respect and can maintain their dignity. Aim: The aim of this standard is to give total respect and to preserve the dignity of all women throughout their stay in the health facility. Their privacy and confidentiality should be respected at all times, and any kind of mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services, should be avoided. Quality statements Quality statement 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected. Quality statement 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. Quality statement 5.3: All women can make informed choices about the services they receive, and the reasons for interventions or outcomes are clearly explained. Emotional support Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability. 23 Aim: Emotional support is an essential component of the experience of care. Having the birth companion of her choice helps a woman to go through childbirth more confidently. Every woman receives support that strengthens her own capability during childbirth. Quality statements Quality statement 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. Quality statement 6.2: Every woman receives support to strengthen her capability during childbirth. Competent, motivated human resources Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Aim: All labour and childbirth areas of the health facility should have competent, well-trained staff and skilled birth attendants present 24 h a day in sufficient numbers for the expected work load. Good leadership and management in the health facility are essential to provide support and ensure continuous quality improvement. Quality statements Quality statement 7.1: Every woman and child has access at all times to at least one skilled birth attendant and to support staff for routine care and management of complications. Quality statement 7.2: The skilled birth attendants and support staff have appropriate competence and skills mix to meet the requirements of labour, childbirth and the early postnatal period. Quality statement 7.3: Every health facility has managerial and clinical leadership that is collectively responsible for developing and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Essential physical resources available Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Aim: Every health facility should have basic infrastructure and amenities, including water, sanitation, hygiene and electricity, waste disposal, a stock of essential medicines, supplies and equipment to meet the health care needs of the women and newborns in the facility. Areas for labour, childbirth and postnatal care should be hygienic, comfortable and logically designed and organized to maintain continuity of care. Quality statements Quality statement 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functioning, reliable, safe and sufficient to meet the needs of staff, women and their families. Quality statement 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. Quality statement 8.3: Adequate stocks of medicines, supplies and equipment are available for routine care and management of complications. 24 5. Quality statements and measures 5.1 Outcome of the Delphi process Most of the 318 measures drafted for the online Delphi consultation were input and output measures, as outcome measures are not necessarily covered by a single quality statement. Outcomes measures are mainly those that could be used at local level to reliably assess the quality of care and allow comparisons between facilities or changes over time. In round 1, 116 of the 130 participants who received the survey (89%) responded. In general, they agreed that the quality measures considered covered the inputs, process and outcomes of the quality of the care that women and newborns receive around the time of birth. Of the comments received, some indicated important areas that had not been covered, proposed reformulation of some measures or extended the reflection beyond the quality statements. Some were not directly related to the quality statements but reflected participants’ general views on the quality of care. A number of quality statements were clarified on the basis of the comments, 10 were deleted, and 41 new measures were added, resulting in a total of 350 quality measures for consideration in round 2. In round 2, a total of 81 participants in 46 high-, middle- and low-income countries completed one of the three surveys, for a response rate of 70% (81/116). Sixty-one of 83 respondents commented on the provision of care and 48 of 74 on the experience of care. Most of the quality measures were ranked highly, from a high of 94.8 to a low of 64.3; only three measures were ranked below 70. For provision of care, the mean score was > 90 for 35 measures, 80–90 for 116 measures and < 80 for 45 measures. For experience of care, the mean score was > 90 for nine measures, 80–90 for 47 measures and < 80 for 16 measures. For cross- cutting measures, the mean score was ≥ 90 for 12 measures, 80–90 for 50 measures and ≤ 80 for 16 measures. Thus, 56 quality measures received a ranking of > 90. Most of the most highly ranked quality statements were input measures. 5.2 Using quality measures Health facility teams can use the quality measures to identify gaps in the quality of care and to improve the provision and experience of care according to the standard and the relevant quality statement. Health facility leaders, planners, managers and providers can use them to assess and monitor the availability of resources, the performance of processes, areas that require improvement and the impact of interventions, hence driving quality improvement. The 25 measures should be adapted to each context, but standards must be implemented consistently to ensure quality improvement. The quality measures include input, output/process and outcome measures. Input measures include physical resources, human resources, policies, protocols and guidelines. Output measures include coverage of key practices and most are expressed as proportions, such as “The proportion of all women who gave birth in the health facility whose urinalysis result was appropriately recorded during labour, childbirth and the early postpartum period.” The outcome measures include people centred and health outcomes. Most quality statements are followed by measures that are highly specific to that statement; however, some measures might be relevant to more than one statement, especially with regard to physical resources (standard 8). The numbering of the quality measures reflects the order in which they were listed in the survey. The score received by each measure is given in brackets, and the three most highly ranked quality measures for each statement are marked with an asterisk. 5.3 Measures for quality statements Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Quality statement 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. Rationale: Assessment of women and regular monitoring on admission and during labour and birth are critical to ensure essential care that is appropriate to the woman’s case, to prevent the onset of complications and to identify risks or complications that require urgent action or referral for better outcomes of pregnancy and labour for both the mother and the newborn. On admission, women undergo a full review of their antenatal care records, pregnancy and labour history, a vaginal examination and confirmation of labour. Fetal heart rate, fetal lie, position and presentation, blood pressure, pulse and temperature are determined and recorded. Blood group and Rhesus typing, haemoglobin, urine protein and glucose, and HIV status, if appropriate, are tested and recorded. The progress of labour is monitored with a partograph; blood pressure, pulse, temperature and fetal heart rate are assessed regularly and at a 4-h action line. Pain relief is offered, and the mother’s choice is respected. Spontaneous vaginal birth is supported and guided by the mother’s urge to push. The third stage of labour is managed actively, with intravenous or intramuscular oxytocin given immediately after the birth. Any complications at admission and during labour and birth are rapidly identified and appropriately managed (see quality statements 1.2, 1.3, 1.4, 1.5, 1.6a and b, 1.7a and b). 26 Quality measures Input measures 1. The health facility has the basic essential equipment and supplies for routine care and detection of complications (thermometers, sphygmomanometers, fetal stethoscopes, urine dipsticks) available in sufficient quantities at all times in the areas of the maternity unit for labour and childbirth*. (93.38) 2. The health facility has written, up-to-date clinical protocols for assessing intrapartum care and action in the labour and childbirth areas of the maternity unit that are consistent with WHO guidelines*. (89.37) 3. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training and regular refresher sessions at least once every 12 months in the identification and management of obstetric emergencies during labour and childbirth. (83.42) 4. Health-care staff in labour and childbirth areas receive at least monthly drills or simulation exercises and supportive supervision in routine care and detection of obstetric complications during labour and childbirth. (78.65) Output/process measures 1. The proportion of all women who gave birth in the health facility whose blood pressure, pulse and temperature were appropriately recorded during labour, childbirth and the early postpartum period (and acted on if appropriate). (87.25) 2. The proportion of all women who gave birth in the health facility who received oxytocin within 1 min of the birth of their baby. (86.18) 3. The proportion of all women who gave birth in the health facility whose progress in labour was correctly monitored and documented with a partograph and a 4-h action line. (84.56) 4. The proportion of all women who gave birth in the health facility whose urinalysis result was appropriately recorded during labour, childbirth and the early postpartum period (and acted on if appropriate). (78.45) 5. The proportion of all women who gave birth in the health facility who received any option for pain relief during labour and childbirth. (73.04) Outcome measures 1. The health facility perinatal mortality rate [number of foetal death (stillbirths) or early neonatal deaths / the total number of births of babies weighing at least 1000 g or of 28 weeks’ gestation (stillbirths + live births) x 1000] *. (91.39) 2. Intrapartum stillbirth rate (number of stillbirths occurring during the intrapartum period per 1000 births). (88.42) 3. The proportion of all women admitted to the health facility in active labour who gave birth within 12 h. (72.83) Quality statement 1.1b: Newborns receive routine care immediately after birth. Rationale: Routine care of newborns immediately after birth facilitates adaptation of the newborn to the new environment, meets his or her immediate needs in the best possible way and avoids preventable complications. Immediately after birth, newborns are dried thoroughly and placed in skin-to-skin contact with the mother for at least 1 h. Clamping of the umbilical cord is delayed until 1–3 min after birth, and breastfeeding is supported in the first hour after birth. Any complications are identified and managed appropriately. 27 Quality measures Input 1. The health facility has written, up-to-date, clinical protocols for essential newborn care that are consistent with WHO guidelines and are available in the labour and childbirth areas of the maternity unit*. (91.09) 2. The health facility has supplies of sterile cord ties (or clamps) and scissors (or blades), available in sufficient quantities at all times for the expected number of births*. (89.86) 3. The health facility has supplies of clean towels in the labour and childbirth areas for immediate drying of newborns, available in sufficient quantities at all times for the expected number of births. (84.83) 4. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training or regular refresher sessions in essential newborn care and breastfeeding support at least once every 12 months. (83.94) 5. The health facility has local arrangements and a mechanism to maintain a documented room temperature in the labour and childbirth areas at or above 25 °C and free of draughts. (77.9) 6. Health-care staff in the labour and childbirth areas receive at least monthly drills or simulation exercises and supportive supervision in essential newborn care and supporting breastfeeding. (77.82) Output/process 1. The proportion of all newborns who were breastfed within 1 h of birth*. (86.42) 2. The proportion of all newborns who were kept in skin-to-skin contact (with body and head covered) with their mothers for at least 1 h after birth. (83.34) 3. The proportion of all newborns who received all four elements of essential newborn care: immediate and thorough drying, immediate skin-to-skin contact, delayed cord clamping and initiation of breastfeeding in the first hour. (78.93) 4. The proportion of all newborns whose umbilical cord was clamped 1–3 min after birth. (76.56) 5. The proportion of all newborns who were dried immediately and thoroughly at birth. (76.53) Outcome 1. The proportion of all newborns who had a normal body temperature (36.5–37.5 °C) at the first complete examination (60–120 min after birth). (85.37) Quality statement 1.1c: Mothers and newborns receive routine postnatal care. Rationale: Routine postnatal care represents the use of best practices for prevention, early detection and treatment of complications in the mother and baby and counselling of mothers on how best to take care of themselves and their newborns. Postnatal care, the individualized care provided to a mother and her baby after childbirth should address any variation from the expected normal recovery after birth. Blood pressure, temperature, bleeding and urine voiding are monitored frequently during the first 48 h after childbirth. Complications are identified and managed, and exclusive breastfeeding is supported. Mothers are counselled on danger signs in themselves and their babies and on birth spacing and family planning methods. Newborns receive a complete physical assessment, are kept in skin-to-skin contact with the mother and given eye and umbilical cord care. Bathing is delayed for 24 h, vitamin K and vaccines are given as per the national guidelines, temperature is monitored, and complications are identified and managed. Low-birth-weight and small babies are given additional care as needed (see Quality statement 1.6b). 28 Quality measures Input 1. The health facility has written, up-to-date clinical protocols for postnatal care in the maternity and/ or postnatal care areas of the maternity unit that are consistent with WHO guidelines*. (90.10) 2. The health facility practises and enables rooming-in to allow mothers and babies to remain together 24 h a day*. (86.57) 3. The health facility has a written breastfeeding policy that is routinely communicated to all health care and support staff. (83.18) 4. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in routine postnatal care and breastfeeding at least every 12 months. (83.04) 5. The health facility has local arrangements to ensure that every mother knows when and where postnatal care for herself and her newborn will be provided after discharge from the hospital. (79.98) 6. The health facility has local arrangements for alternative feeding methods, including cup or cup-and- spoon feeding, and avoids bottle-feeding. (78.97) 7. The health facility has local arrangement to inform pregnant women and their families about the benefits and management of breastfeeding. (74.49) 8. The health facility ensures that feeding of infant formula is demonstrated to mothers and family members of newborns only when needed, with a full explanation of the hazards of improper use. (71.85) Output/process 1. The proportion of all newborns on postnatal care wards or areas in the health facility who received vitamin K and full vaccination as per national guidelines*. (91.23) 2. The proportion of all stable newborns in the health facility who are fed exclusively on breast milk from birth to discharge. (84.37) 3. The proportion of all women in postnatal care wards or areas in the health facility who have documented problems of blood pressure, pulse rate, vaginal bleeding, lochia or breastfeeding. (84.02) 4. The proportion of all newborns in the health facility who received a full clinical examination before discharge. (83.13) 5. The proportion of all healthy mothers and newborns who received care for at least 24 h after an uncomplicated vaginal birth in a health facility. (82.50) 6. The proportion of all newborns on postnatal care wards or areas in the health facility for whom there is documented information on the newborn body temperature, respiratory rate, feeding behaviour and the absence or presence of danger signs. (82.41) 7. The proportion of all healthy mothers on postnatal wards or areas in the health facility who received breastfeeding counselling and support from a skilled health care provider. (82.14) 8. The proportion of all women who gave birth in the health facility who were allowed to room-in with their newborn 24 h a day. (78.90) 9. The proportion of all postpartum women in the health facility who were offered counselling on birth spacing and family planning methods before discharge. (77.84) Outcome 1. The proportion of all newborns in the health facility who were exclusively breastfed at the time of discharge from hospital. (85.55) 2. The proportion of all postpartum women in the health facility who received contraception counselling on birth spacing and family planning before discharge. (84.03) 29 Quality statement 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions. Rationale: Pregnancy-induced hypertension, pre-eclampsia and eclampsia are major causes of maternal mortality, stillbirth and neonatal mortality. Prevention, early diagnosis and timely, appropriate treatment can drastically reduce the associated mortality and morbidity. Women with severe pre-eclampsia are immediately given intravenous or intramuscular magnesium sulfate and an antihypertensive, as appropriate. A pre-referral loading dose of magnesium sulfate should be given if the woman is to be transferred. Signs of organ dysfunction and other danger signs (blood pressure, respiratory rate, fluid balance, urine output, tendon reflexes and foetal heart rate) are monitored. Laboratory testing of urea and electrolytes determines the progression of disease. If the woman is at term or the foetus is nonviable, labour is induced with instrumental intervention or caesarean section, as appropriate. For preterm pregnancies, proactive management with corticosteroids is undertaken if the condition is stable. Quality measures Input 1. The health facility has supplies of oral and intravenous antihypertensive agents and magnesium sulfate available in sufficient quantities at all times in the antenatal, labour and childbirth areas of the maternity unit*. (91.8) 2. The health facility has written, up-to-date clinical protocols on the management of pre-eclampsia that are available in the labour, childbirth and postnatal areas of the maternity unit and are consistent with WHO guidelines. (90.59) 3. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in the use of antihypertensive agents, intravenous infusion and magnesium sulfate for treating pre- eclampsia and eclampsia at least once every 12 months. (84.54) Output/process 1. The proportion of all women with severe pre-eclampsia or eclampsia in the health facility who received the full dose of magnesium sulfate*. (91.37) 2. The proportion of all women with severe pregnancy-induced hypertension in the health facility who received the recommended antihypertensives. (88.02) 3. The proportion of all women with pre-eclampsia in the health facility whose condition progressed to eclampsia. (81.9) Outcome 1. The proportion of all women with pre-eclampsia or eclampsia in the health facility who died as a result of pre-eclampsia or eclampsia*. (91.22) 2. The proportion of all women with pre-eclampsia or eclampsia who arrived at the health facility with a live foetus whose baby died in the perinatal period (stillbirths or early neonatal deaths). (86.55) 3. The proportion of all women with pre-eclampsia or eclampsia in the health facility who experienced maternal near-misses due to pre-eclampsia or eclampsia. (76.88) 30 Quality statement 1.3: Women with post-partum haemorrhage promptly receive appropriate interventions. Rationale: Post-partum haemorrhage is the leading cause of preventable maternal mortality, most deaths occurring in the first 24–48 h of delivery. Early diagnosis and timely, adequate management are the basis for effectively reducing mortality. Postpartum bleeding is monitored routinely. If haemorrhage occurs, it should be promptly managed with intravenous oxytocin, uterine massage, manual removal of retained placenta as appropriate, temporizing measures or surgical interventions when indicated. Continued blood loss, pulse and blood pressure are closely monitored, and shock is managed with immediate resuscitation with intravenous fluid and blood transfusion, if indicated. Quality measures Input 4. The health facility has written, up-to-date clinical protocols for post-partum haemorrhage management that are available in the childbirth and postnatal care areas and are consistent with WHO guidelines*. (90.76)) 5. The health facility has uterotonic drugs and supplies for intravenous fluid and blood administration (syringes, needles, intravenous cannulas, intravenous fluid solutions, blood) available in sufficient quantities at all times in the childbirth and postnatal care areas. (89.55) 6. A functional blood transfusion service is available in the health facility at all times. (86.82) 7. Health-care staff in the labour, childbirth and postnatal care areas of the maternity unit receive in-service training and regular refresher sessions in management of post-partum haemorrhage at least once every 12 months. (84.25) Output/process 1. The proportion of all women with post-partum haemorrhage in the health facility who received therapeutic uterotonic drugs*. (89.75) 2. The proportion of all women in the health facility with post-partum haemorrhage due to a retained placenta for whom manual removal of the placenta was performed by a skilled birth attendant. (80.48) Outcome 1. The proportion of all women who had post-partum haemorrhage in the health facility who died as a result of post-partum haemorrhage*. (92.98) 2. The proportion of all women who gave birth in the health facility by caesarean section who received a blood transfusion. (85.80) 3. The proportion of all women who gave birth vaginally in the health facility who received a blood transfusion. (85.58) 4. The proportion of all women who gave birth in the health facility who had severe post-partum haemorrhage (abnormal bleeding of >1000 mL or any bleeding with hypotension or requiring blood transfusion). (83.69) 5. The proportion of all women who had post-partum haemorrhage in the health facility who experienced maternal near-misses due to post-partum haemorrhage. (77.97) 31 Quality statement 1.4: Women whose progress in labour is delayed or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. Rationale: Obstructed labour is a major cause of both maternal and newborn morbidity and mortality. Undiagnosed obstructed labour can lead to a ruptured uterus, vesico- vaginal fistula or recto-vaginal fistula in the mother and higher risks for stillbirth, neonatal asphyxia, meconium aspiration syndrome and other conditions. Proper monitoring of labour to avoid prolongation and its complications and early detection and timely management of obstructed labour can decrease the incidence of these complications. Interventions for delayed labour include digital vaginal examination at intervals of 4 h and prompt confirmation of the delay in labour with a partograph with a 4-h action line, checking for cephalopelvic disproportion and assessing and managing the woman’s hydration. Labour augmentation with intravenous oxytocin (and with amniotomy if the membrane is not ruptured) is used if there is delay in the first stage with no cephalopelvic disproportion. Delay in the second stage of labour is treated by appropriate use of instrumental delivery (vacuum or forceps) or by caesarean section if there is evidence of foetal compromise or signs of obstruction of labour. Note: Augmentation should be used only in confirmed delay of labour after exclusion of cephalopelvic disproportion and in facilities capable of close, regular monitoring of the foetal heart rate and the pattern of uterine contraction and can manage any adverse effects. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for preventing and managing prolonged labour, which are available in the labour and childbirth areas and are consistent with WHO guidelines*. (90.88) 2. The health facility has the essential supplies and equipment for vacuum or forceps-assisted delivery, including newborn resuscitation equipment, available in sufficient quantities at all times in the childbirth area of the maternity unit*. (90.33) 3. The health facility has an adequately equipped operating theatre close to the childbirth area of the maternity unit*. (90.13) 4. The health facility has an adequate number of staff skilled in performing caesarean section, 24 h a day. (87.93) 5. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training and regular refresher sessions (every 6 months) in managing prolonged and obstructed labour. (82.19) Output/process 1. The proportion of all nulliparous women in the health facility with a singleton cephalic foetus at ≥ 37 weeks’ gestation who underwent caesarean section during spontaneous labour (Robson group 1). (87.27) 2. The proportion of all women in the health facility with prolonged and/or obstructed labour who gave birth by caesarean section. (86.03) 3. The proportion of all women who gave birth in the health facility who underwent instrumental vaginal birth for delayed second stage of labour. (83.21) 4. The proportion of women with prolonged or obstructed labour who underwent emergency caesarean section within 30 min of the decision to perform caesarean section. (79.9) 5. The proportion of all women in the health facility with confirmed delay in progress of the first stage of labour who received oxytocin for augmentation. (79.06) 32 6. The proportion of all women who gave birth in the health facility whose active phase of first stage of labour exceeded 12 h. (76.79) 7. The proportion of all women who gave birth in the health facility who had a prolonged second stage of labour. (74.82) Outcome 1. The proportion of all women who gave birth in the health facility whose uterus ruptured during labour. (89.35) 2. The proportion of all perinatal deaths that occurred in the health facility after prolonged or obstructed labour. (85.23) 3. The proportion of all newborns born in the health facility who had birth injuries (brachial palsy, fractures, cephalhaematoma). (83.75) 4. The proportion of women with prolonged and/or obstructed labour in the health facility who experienced maternal near-misses due to prolonged and/or obstructed labour. (78.0) Quality statement 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. Rationale: Birth asphyxia is one of the leading causes of neonatal deaths within the first week of life and is also responsible for long-term neurological disability and impairment. It can be prevented by appropriate, effective resuscitation of newborns who are not breathing at birth. Newborns who are not breathing spontaneously after thorough drying are rubbed two to three times on the back for extra stimulation. Suction is used only if the newborn had meconium- stained liquor or if secretions are present in the mouth or nose. Positive-pressure ventilation with a self-inflating bag-and-mask is initiated within 1 min of birth, with air for newborns > 32 weeks’ gestation and with 30% oxygen for preterm babies at < 32 weeks’ gestation. The adequacy of ventilation is monitored by measuring the heart rate, chest movement and pulse oximetry (if available). A higher oxygen concentration is given only if the heart rate is < 60/min after 60 s of resuscitation. Quality measures Input 1. The health facility has a suction device, at least two sizes of neonatal mask and a self-inflating bag in the childbirth and neonatal areas of the maternity unit*. (93.83) 2. The health facility has written, up-to-date clinical protocols for managing newborns who are not breathing spontaneously in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.86) 3. All health-care workers providing care for pregnant and postpartum women and newborns in the health facility are skilled in basic newborn resuscitation, as demonstrated by simulating positive- pressure ventilation with a bag-and-mask on a manikin. (89.64) 4. Health care staff in the childbirth and neonatal areas of the maternity unit receive in-service training and regular refresher sessions s in basic newborn resuscitation at least once every 12 month. (87.06) 5. Health care staff in the childbirth and neonatal areas of the maternity unit receive monthly drills or simulation exercises and supportive supervision in basic newborn resuscitation. (83.91) 33 Output/process 1. The proportion of all newborns who were not breathing spontaneously after additional stimulation at the health facility who were resuscitated with a bag-and-mask. (81.10) 2. The proportion of all newborns who were not breathing spontaneously after additional stimulation at the health facility who were resuscitated with a bag-and-mask within 1 min of birth. (75.56) Outcome 1. The proportion of all live babies born at term (≥ 37 weeks) with no major congenital malformations in the health facility who died within 7 days of birth (early neonatal mortality) *. (91.14) 2. The proportion of all live babies born at term (≥ 37 weeks) in the health facility who were not breathing spontaneously but were breathing spontaneously 5 min after resuscitation. (77.92) Quality statement 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. Rationale: Preterm labour (before 37 completed weeks of pregnancy) can result in numerous health risks to the baby, which increase the earlier the baby is delivered. Prevention of preterm labour and appropriate management of imminent preterm labour are imperative to reduce the associated risks to the baby, prevent avoidable complications and improve the outcome and survival of preterm babies. Women in preterm labour are admitted to a facility that has the capacity to manage preterm babies and their complications, conduct a thorough assessment and evaluation to confirm gestational age by ultrasound or date of the last menstrual period, assess them for signs and symptoms of infection and evaluate whether birth is imminent or can be delayed. Antenatal corticosteroids are given, after ruling out chorioamnionitis, for imminent risk of preterm birth at 24–34 weeks of gestation, with tocolysis as appropriate. Antenatal magnesium sulfate is given for preterm labour at < 32 weeks of gestation to protect the foetus from neurological complications. Women with confirmed preterm pre-labour rupture of membranes are routinely given antibiotics. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for management of preterm labour in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.46) 2. The health facility has supplies of antenatal corticosteroids (dexamethasone or betamethasone), antibiotics and magnesium sulfate available in sufficient quantities at all times to manage preterm birth in accordance with WHO guidelines*. (90.06) 3. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in the management of preterm labour at least once every 12 months. (85.52) 4. Health-care staff in the maternity unit receive monthly drills or simulation exercises and supportive supervision in the management of preterm labour. (79.18) 34 Output/process 1. The proportion of all preterm newborns born between 24 and 34 weeks of gestation in the health facility whose mothers received at least one dose of antenatal corticosteroids when indicated. (86.11) 2. The proportion of all preterm newborns born before 32 weeks of gestation in the health facility whose mothers received magnesium sulfate to protect their baby from foetal neurological complications. (78.52) 3. The proportion of all women with preterm pre-labour rupture of membranes who gave birth in the health facility who received prophylactic antibiotics. (87.60) Outcome 1. The proportion of all women with preterm pre-labour rupture of membranes who gave birth in the health facility who received prophylactic antibiotics*. (87.60) 2. The proportion of all babies at risk for birth in the health facility at 24 to < 34 weeks of gestation who were exposed to antenatal corticosteroids. (73.61) 3. The proportion of all babies at risk for birth in the health facility at ≥ 34 weeks of gestation who were exposed to antenatal corticosteroids. (72.43) Quality statement 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. Rationale: Preterm and small babies are at much greater risk for death during the neonatal period and for long-term health problems and lifelong disabilities. They should be cared for in well-equipped neonatal units with well-trained staff present round the clock. Preterm and low-birth-weight babies (< 2500 g) are kept warm at all times and closely monitored for complications; their mothers are given support in providing exclusive breastfeeding or alternative feeding (expressed breast milk, donor breast milk or formula). Clinically stable preterm newborns weighing ≤ 2000 g are given kangaroo mother care. Those who are unstable are cared for in a clean incubator or under a radiant warmer, and their temperature is closely monitored. The risks for common complications (hypothermia, feeding problems, apnoea, respiratory distress syndrome and infections) are assessed, monitored, recognized early and appropriately managed. Antibiotics, safe oxygen therapy, continuous positive airway pressure and surfactant replacement are given as appropriate. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for the care of small and preterm babies in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.41) 2. The health facility has supplies and materials to provide optimal thermal care to stable and unstable preterm babies, including kangaroo mother care (support binders, baby hats, socks), clean incubators and radiant warmers*. (89.14) 3. The health facility has the supplies and materials to provide optimal feeding to preterm babies and support for breastfeeding or alternative feeding (feeding cups and spoons, infant formula, breast pumps, milk-storage facilities, pasteurizers, milk banks if possible, nasogastric tubes, syringe drivers, intravenous fluids and tubing). (86.56) 4. Health care staff in the health facility who work with pregnant and postpartum women and newborns receive in-service training and regular refresher sessions in appropriate care of preterm and low- birth-weight babies at least once every 12 months. (85.82) 35 Output/process 1. The proportion of all low-birth-weight newborns born in the health facility with a birth weight ≤ 2000 g who received near-continuous kangaroo mother care in the first week of life. (83.35) 2. The proportion of all unstable low-birth-weight newborns weighing ≤ 2000 g who cannot receive kangaroo mother care in the health facility who were cared for in a thermo-neutral environment, either under radiant warmers or in incubators, as appropriate. (79.29) 3. The proportion of all low-birth-weight newborns born in the health facility whose mothers received additional support to establish breastfeeding. (77.13) Outcome 1. The proportion of all preterm babies (< 28 weeks, 28–32 weeks and 32–37 weeks of gestational age) born in the health facility who died within the first 7 days of life*. (90.15) 2. The proportion of all low-birth-weight newborns born in the health facility who were exclusively fed on their mother’s milk during their stay in the health facility. (84.57) 3. The proportion of all live preterm babies born in the health facility who had severe neonatal morbidity (respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis). (81.20) 4. The proportion of low-birth-weight baby deaths in the facility attributed to possible serious bacterial infection or sepsis. (80.30) Quality statement 1.7a: Women with or at risk for infections during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. Rationale: Puerperal sepsis is one of the leading causes of maternal mortality and can also cause early-onset sepsis in newborns. The prevention of predisposing factors, aseptic precautions in all interventions and procedures, early, accurate diagnosis and use of appropriate antibiotics for treatment of maternal infection will reduce the occurrence of both maternal and neonatal sepsis and the associated morbidity and mortality. Women at risk for infection are given prophylactic antibiotics if they are undergoing elective or emergency caesarean section, in protracted labour with pre-labour rupture of membranes, in cases of retained placental products, with third- or fourth-degree perineal tears or before manual removal of the placenta. Specimens are obtained for culture and sensitivity before starting antibiotic treatment. Women with signs and symptoms of infection (fever > 38 °C before delivery or during labour, membranes ruptured ≥18 h before birth, foul-smelling or purulent amniotic fluid and abdominal pain and/or offensive vaginal discharge in the postnatal period) are treated with antibiotics and monitored closely, and their management is assessed regularly. Quality measures Input 1. The health facility has supplies of oral and injectable first- and second-line antibiotics (ampicillin or penicillin and gentamicin, clindamycin, cephalosporin and metronidazole) available in sufficient quantities at all times for the expected case load*. (92.15) 2. The health facility has written, up-to-date clinical protocols for treatment of women with, or at risk for, infections during labour, childbirth and the early postnatal period in the childbirth and postnatal care areas of the maternity unit that are consistent with WHO guidelines*. (91.75) 3. Health care staff in the health facility who deal with pregnant and postpartum women receive in-service training and regular refresher sessions in the recognition and management of maternal peri-partum infections at least once every 12 months. (85.20) 36 Output/process 1. The proportion of all women who underwent caesarean section in the health facility who received prophylactic antibiotics before caesarean section*. (90.37) 2. The proportion of all women who gave birth in the health facility with preterm pre-labour rupture of membranes who received antibiotics. (87.44) 3. The proportion of all women in the health facility with third- or fourth-degree perineal tears who received antibiotics. (83.45) 4. The proportion of all birthing or postpartum women in the health facility with signs of infection who received injectable antibiotics. (83.39) 5. The proportion of all women who gave birth in the health facility who had a temperature of > 38 ˚C or other signs of infection (foul-smelling or purulent lochia) after childbirth. (82.87) Outcome 1. The proportion of all women who underwent caesarean section in the health facility who had severe systemic infection or sepsis after the caesarean section. (86.56) 2. The proportion of all women who gave birth in the health facility who had severe systemic infection or sepsis in the postpartum period. (86.15) Quality statement 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. Rationale: Newborns are at higher risk for infection because of their immature immune system. Infections in newborns can lead to death or to long-term disabilities in survivors. Good hand hygiene, cord care and other appropriate aseptic precautions, screening of neonatal sepsis according to the presence of one or more risk factor, early diagnosis of signs and symptoms of neonatal sepsis and appropriate treatment with antibiotics are essential to prevent sepsis and the associated morbidity and mortality. Newborns with risk factors for infection or with signs of infection are given antibiotic treatment according to WHO guidelines. Risk factors for infection are maternal fever (> 38 °C) before delivery or during labour, membranes ruptured ≥ 18 h before birth and foul-smelling or purulent amniotic fluid. Newborns with signs of serious bacterial infection present with inability to feed (or have stopped feeding well), convulsions, fast breathing (> 60 breaths/min) severe chest in-drawing, fever (≥ 38 °C) or low body temperature (< 35 °C), lethargy, movement only when stimulated or no movement at all. A blood culture is obtained before initiation of antibiotics in newborns at risk or with signs of infection. They are treated with an empirical injectable antibiotic for sepsis or suspected sepsis and closely monitored for reassessment of their management. Culture reports are the basis for deciding any change in antibiotics and the duration of treatment. Quality measures Input 1. The health facility has supplies of injectable antibiotics (at least first- and second-line antibiotics for neonatal sepsis and meningitis) available in sufficient quantities at all times for the expected case load*. (92.14) 2. The health facility has a written, up-to-date clinical protocol for early diagnosis and management of neonatal infection in the childbirth areas of the maternity unit that is consistent with WHO guidelines*. (90.47) 37 3. Health care staff in the health facility who care for pregnant and postpartum women and newborns receive in-service training and regular refresher sessions in the recognition and management of suspected newborn infections at least once every 12 months. (85.95) 4. Health care staff in the health facility know the signs of newborn sepsis and how to treat it, according to WHO guidelines. (84.29) Output/process 1. The proportion of all newborns in the health facility with signs of infection who received injectable antibiotics. (86.94) 2. The proportion of all newborns of mothers with signs of infection in the health facility who received injectable antibiotics. (77.53) Outcome 1. The proportion of newborns treated for sepsis in the health facility who died (case fatality rate) *. (89.32) 2. The proportion of all neonatal deaths in the health facility that were due to sepsis. (86.96) 3. The proportion of all severe neonatal morbidity in the health facility that was due to neonatal sepsis. (77.53) Quality statement 1.8: All women and newborns receive care that includes standard precautions for preventing hospital-acquired infections. Rationale: Hospital-acquired infections increase morbidity and mortality, the cost of care and the duration of stay in hospital. Standard precautions are essential to prevent hospital-acquired infections. Standard precautions are observed at all times, including hand hygiene with soap and water or alcohol-based hand rub before and after examining a woman or newborn and appropriate use of gloves; safe storage and disposal of infectious waste and sharps; safe handling of equipment for patient care and soiled linen; and sterilization and disinfection of instruments and the childbirth surface. Quality measures Input 1. The health facility has a reliable water source on site and soap and towels (preferably disposable) or alcohol-based hand rub for hand hygiene*. (94.27) 2. The health facility ensures safe handling, storage and final disposal of infectious waste*. (94.08) 3. The health facility ensures safe handling, storage (puncture resistant) and final disposal of sharps waste*. (93.36) 4. The health facility has appropriate sterilizing facilities and disinfectants for instruments. (92.99) 5. The health facility has a functioning incinerator or other appropriate method for treatment of infectious waste and used instruments. (92.56) 6. The health facility has written, up-to-date guidelines for standard infection control and precautions for transmission. (92.35) 7. Health care staff in the childbirth and neonatal areas of the maternity unit receive training in standard infection control and precautions for transmission at least once every 12 months. (87.27) 38 Output/process 1. The percentage of health care staff in the health facility who clean their hands correctly as per the WHO “5 moments for hand hygiene” audit tool. (87.78) 2. The proportion of newborns with suspected severe bacterial infection who received appropriate antibiotic therapy. (84.76) 3. Safe management of health care waste, from the point of generation to the point of disposal. (82.73) 4. The percentage of staff members in the health facility who meet biosafety standards when administering parenteral drugs. (81.85) Outcome 1. The proportion of all women who gave birth in the health facility who had a severe systemic infection or sepsis in the postnatal period, including at readmission after delivery in the facility. (81.41) 2. The proportion of all women who gave birth in the health facility who had proven hospital-acquired infections. (78.43) 3. The proportion of all neonates born in the health facility who had hospital-acquired infections. (78.00) Quality statement 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. Rationale: Unnecessary and harmful practices can lead to complications and harm mothers and their newborns. They should be avoided and replaced with evidence-based health practices. Unnecessary or harmful practices are not used or practised. These practices include: routine enemas and pubic or perineal shaving before vaginal birth; fundal pressure to facilitate the second stage of labour; augmentation of labour with oxytocin before confirmation of delayed labour; episiotomy (unless indicated); uterine packing to control bleeding (unless indicated); instrumental vaginal childbirth (unless indicated); caesarean section (unless indicated) and suctioning of a newborn (unless indicated); immediate bathing of the baby, keeping well babies in the nursery away from the mother, advertising and promotion of breastfeeding substitutes and bottle-feeding, and applying substances to the cord. Quality measures Input 1. The health facility has written, up-to-date guidance on harmful practices and unnecessary interventions during labour, childbirth and the early postnatal period*. (89.03) 2. The health facility does not display infant formula or bottles and teats, including on posters or placards*. (88.98) 3. The health facility does not give newborns food or drink other than breast milk, unless medically indicated, and does not give pacifiers (also called “dummies” or “soothers”) to breastfeeding babies. (85.13) 4. Health care staff in the facility receive in-service training and regular refresher sessions on harmful practices and unnecessary interventions at least once every 12 months. (83.00) 5. The health facility does not promote infant formula on the wards, and samples are not distributed to mothers or staff. (82.93) 6. Health-care staff in the health facility receive monthly supportive supervision and mentoring on harmful practices and unnecessary interventions. (75.38) 39 Output/process 1. The proportion of all uncomplicated, spontaneous vaginal births in the health facility in which an episiotomy was performed*. (86.01) 2. The proportion of women undergoing caesarean section in the health facility according to Robson classification groups. (83.2) 3. The proportion of all women who gave birth in the health facility who received augmentation of labour with no indication of delay in progress of labour. (80.01) 4. The proportion of all babies born in the health facility who received early bathing and removal of the vernix within 6 h of birth. (79.30) 5. The proportion of all women who gave birth in the health facility who received routine pubic or perineal shaving before a vaginal birth. (77.59) 6. The proportion of all babies born through clear amniotic fluid in the health facility who received routine suctioning. (77.35) 7. The proportion of all women who gave birth in the health facility who received routine enemas at any time before vaginal birth. (76.02) References used in setting standard 1 Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347–370. 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London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Polin RA, Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Paediatrics 2012;129:1006 –1015. Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011;114:4–9. Schuchat A, Zywicki SS, Dinsmoor MJ, Mercer B, Romaguera J, O’Sullivan MJ, et al. Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicentre case-control study. Pediatrics. 2000;105:21–26. Sibanda T, Fox R, Draycott TJ, Mahmood T, Richmond D, Simms RA. Intrapartum care quality indicators: a systematic approach for achieving consensus. Eur J Obstet Gynecol Reprod Biol 2013;166:23–29. Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, et al. Improving quality of care for maternal and newborn health: prospective pilot study of the WHO safe childbirth checklist program. PLoS One 2012;7:e35151. Tietjen L, Bossemeyer D, McIntosh N. Infection prevention guidelines for healthcare facilities with limited resources. Baltimore, Maryland: JHPIEGO; 2003. 40 World Health Organization. International code of marketing of breast-milk substitutes. Geneva; 1981 (http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/). World Health Organization. Standard precautions in health care: aide-memoire. Geneva; 2007 (http:// www.who.int/csr/resources/publications/EPR_AM2_E7.pdf). World Health Organization. WHO guidelines on hand hygiene in health care. Geneva; 2009 (http:// www.who.int/gpsc/information_centre/hand-hygiene-2009/en/). World Health Organization. Evaluating the quality of care for severe pregnancy complications. The WHO near-miss approach for maternal health. Geneva; 2011 (http://whqlibdoc.who.int/ publications/2011/9789241502221_eng.pdf). World Health Organization. WHO recommendations for the prevention and treatment of pre-eclampsia/eclampsia. Geneva; 2011 (http://apps.who.int/iris/ bitstream/10665/44703/1/9789241548335_eng.pdf). World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva; 2012 (http://www.who.int/reproductivehealth/publications/ maternal_perinatal_health/9789241548502/en/). World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines-recommendations- newborn-health.pdf). World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on maternal and perinatal health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines- recommendations-maternal-health.pdf?ua=1). World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva, 2013 (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/). World Health Organization. Safe management of wastes from health-care activities Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1). World Health Organization. WHO recommendations for augmentation of labour. Geneva; 2014 (http:// www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation-labour/en/). World Health Organization. The role of WHO in public health. Geneva; 2015 (http://www.who.int/ about/role/en/). World Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. Geneva; 2015 (http://who.int/reproductivehealth/publications/ maternal_perinatal_health/preterm-birth-guideline/en/). World Health Organization, Partnership for Maternal, Newborn and Child Health. Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities. Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf). World Health Organization, UNICEF. Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva; 2009 (http://www.who.int/nutrition/publications/infantfeeding/ bfhi_trainingcourse/en/). World Health Organization, UNICEF. Indicators for assessing health facility practices that affect breastfeeding. Geneva; 1993 (http://apps.who.int/iris/handle/10665/62140). World Health Organization Regional Office for Europe. Making pregnancy safer: assessment tool for the quality of hospital care for mothers and newborn babies. Copenhagen; 2009 (http://www. euro.who.int/__data/assets/pdf_file/0008/98792/E93128.pdf). World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/2014/hospital-care-for- mothers-and-newborn-babies-quality-assessment-andimprovement-tool.pdf?ua=1). 41 Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Quality statement 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period. Rationale: Complete, accurate medical recording during labour is important for documenting care, clinical follow-up, accurate hand-over, early detection of complications and health outcomes and provides information for identifying areas for improvement. Standardized patient care registers and clinical records for mothers and newborns from admission to discharge are in place and are accurate, complete and legible. Continuity of care records are available (e.g. referral notes, records of antenatal and intrapartum care). Demographic data, times of admission, childbirth and discharge, progress of labour, actions taken and the outcome of childbirth, including stillbirths, are appropriately recorded. Details of newborns, including identification, gestational age, birth weight and examination findings, are recorded in a system that allows linkage of women and their newborns in all records. The International Classification of Diseases (ICD) is used to code diagnoses. Quality measures Input 1. The health facility has registers, data collection forms, clinical and observation charts in place at all time for routine recording and monitoring of all care processes for women and newborns*. (90.34) 2. The health facility has a birth and death registration system in place that is linked to the national vital registration system at all times*. (89.44) 3. The health facility has a system for classifying diseases and birth outcomes, including death, which is aligned with the ICD. (86.33) Output/process 1. The proportion of all newborns currently in the health facility who have a patient identifier and individual clinical medical record*. (89.15) 2. The proportion of all newborns discharged from the health facility within the past 24 h who had an accurately completed record of processes of care, treatments, outcomes and diagnoses (with ICD code). (83.28) 3. The proportion of all women discharged postpartum within the past 24 h who had an accurately completed record of processes of care, treatments, outcomes and diagnoses (with ICD code). (82.88) Quality statement 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Rationale: The purpose of data collection is to provide information that can be analysed and used appropriately to provide feedback and improve health outcomes. Data are collected, verified, analysed and used routinely to make clinical and management decisions for planning and improving clinical services. They are available to, and used by, facility staff for continuous improvement of processes of care and used by physicians, midwives, nurses, supervisors and mentors to plan and improve activities and clinical services. Accurate, complete data are submitted to the appropriate levels in a timely manner and are used for periodic reviews of mortality and morbidity in order to improve quality. 42 Quality measures Input 1. The health facility has conducted reviews of maternal and perinatal deaths and near-misses at least once a month within the past six months and has a mechanism for implementing the recommendations of reviews*. (88.20) 2. The health facility has standard operating procedures and protocols in place at all times for checking, validating and reporting data. (86.35) 3. The health facility has a data system for collecting and analysing relevant indicators and can produce visual outputs and timely reporting on paper or digitally at all times. (85.74) 4. Managers and health care workers in the health facility met at least once a month within the past six months to review process and outcome data. (85.12) 5. Managers and health care workers in the health facility used the recommendations in reviews of data for decision-making and for mentoring improved performance within the past six months. (80.10) Output/process 1. The proportion of all perinatal deaths occurring in the health facility that were reviewed with standard audit tools*. (90.26) 2. The proportion of all maternal deaths and near-misses occurring in the health facility that were reviewed with standard audit tools*. (88.24) 3. The proportion of all maternal deaths and near-misses occurring in the health facility that were notified. (86.84) Outcome 1. Data are collected routinely in the health facility during labour, childbirth and the postnatal period and used regularly to make decisions on quality improvement. (83.08) 2. The proportion of all recommendations in perinatal death reviews at the health facility that have been fully implemented. (81.51) 3. The proportion of all recommendations in maternal death reviews at the health facility that have been fully implemented. (81.37) References used in setting standard 2 Brien ES, Lorenzetti LD, Lewis S, Kennedy J, Ghali AW. Overview of a formal scoping review on health system report cards. Implementation Sci 2010;5:2. Graham WJ, Campbell OM. Maternal health and the measurement trap. Soc Sci Med 1992;35:967–977. Lippeveld T, Sauerborn R, Bodart C. Design and implementation of health information systems. Geneva: World Health Organization; 2000. Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan 2001;16:353–361. UNICEF. The state of the world’s children 2009. Geneva (http://www.unicef.org/sowc09/docs/SOWC09- FullReport-EN.pdf). World Health Organization. Service availability and readiness assessment (SARA). An annual monitoring system for service delivery. Reference manual, version 2.2 Geneva; 2015 (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). World Health Organization, United Nations Population Fund, UNICEF, World Bank. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. Geneva: World Health Organization; 2015. 43 Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Quality statement 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. Rationale: It is vital to recognize cases that require referral rapidly in order to ensure that every patient receives timely, appropriate care and to avoid unnecessary complications. Up-to-date referral protocols and guidelines are in place, are accessible and reflect the health facility’s capacity and resources. There is a triage system at admission, and a mechanism on the wards to assess, identify and respond to emergencies immediately. Facilities are available to provide pre-referral stabilization care and treatment. Quality measures Input 1. The health facility has written, up-to-date clinical protocols and guidelines for the identification, management (including pre-referral care) and referral of women with complications related to pregnancy and childbirth and in newborns*. (89.94) 2. The health facility is equipped with appropriate medicines and medical supplies for stabilization and pre-referral treatment for referred women and newborns*. (89.20) 3. Health care staff in the maternity unit receive in-service training and regular refresher sessions in referral protocols and guidelines at least once every 12 months*. (85.33) Output/Process 1. The proportion of women and newborns seen in the health facility in the past three months who fulfilled the facility’s criteria for referral who were actually referred. (81.79) 2. The proportion of all pregnant or postpartum women who could not be managed at the health facility who were transferred to a higher-level facility for childbirth or further management without delay, accompanied by a health care professional and a completed standardized referral note. (81.47) 3. The proportion of all sick, preterm or small newborns who could not be managed at the health facility who were transferred to an appropriate level of care within 1 h of a decision, accompanied by a health care professional and a completed standardized referral note. (79.90) Outcome 1. The proportion of all women admitted to the labour ward who reported receiving immediate attention on arrival at the health facility. (82.83) Quality statement 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. Rationale: A pre-established plan for referral expedites the process, prevents unnecessary delay and results in better, more timely care for patients. Availability of adequately equipped transport services that operate 24 h a day, 7 days a week, to transport women and newborns as necessary. A list of known network facilities and their telephone numbers is in place. The referral system is supervised and accountable, with a policy that protects women from financial barriers to referral, and there is a procedure to monitor and evaluate the system. 44 Quality measures Input 1. The health facility has ready access to a functioning ambulance or other vehicle for emergency transport of women and newborns to referral facilities*. (90.35) 2. There is an up-to-date list of network facilities in the same geographical area that provide referral care for women and children*. (89.20) 3. The health facility has local arrangements to ensure that women and newborns who cannot be managed at the health facility are referred to an appropriate level of care without delay, 24 h a day, 7 days a week. (87.11) Output/process 1. The proportion of all newborns who died before or during transfer to a higher-level facility for further management*. (87.74) 2. The proportion of all pregnant or postpartum women who died before or during transfer to a higher- level facility for childbirth for further management. (87.04) 3. The proportion of pregnant and postpartum women and newborns who were referred without appropriate emergency transport. (75.62) 4. The proportion of all women referred from the health facility who contributed financially to communication or to transport. (68.93) Outcome 1. The proportion of all women referred from the health facility who completed their referral. (80.97) 2. The proportion of all newborns referred from the health facility who completed their referral. (80.95) 3. The proportion of newborns referred from the facility who reached the referral facility without hypothermia. (76.34) Quality statement 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Rationale: Appropriate information exchange and feedback within and between health facilities improves patient care, increases the motivation of health care workers, helps learning from experience and leads to improved patient care. A functioning communication system (e.g. radio, telephone) within the referral network operates at all times, and formal agreements and arrangements for communication and consultations are in place. Information exchange and feedback protocols on referral and standardized referral and counter-referral forms are available when needed. Quality measures Input 1. The health facility has a standardized referral form to document relevant demographic and clinical information, which includes clinical findings, diagnosis, pre-referral interventions or treatment given and reason for referral*. (89.13) 2. The health facility has reliable communication methods, including a mobile phone, land line or radio, which is functioning at all times, for referrals and consultation on complicated cases*. (87.14) 3. Evidence that the health facility has formal agreements, communication arrangements and a feedback system with referral centre(s) *. (85.55) 45 Output/process 1. The proportion of all referred women seen at the referring facility for whom there was complete counter-referral feedback information. (80.65) 2. The proportion of all referred newborns seen at the referring facility for whom there was complete counter-referral feedback information. (80.12) 3. The proportion of all referred women and newborns seen at the referring facility who received timely care at the referral facility. (79.57) References used in setting standard 3 Lawn J, McCarthy BJ, Ross R. The healthy newborn: a reference manual for program managers. Atlanta, Georgia: Centers for Disease Control, CARE International; 2001. Maine D, Ward V, Eitahir AH. Meeting the community halfway: programming guidelines for the reduction of maternal mortality. New York City, New York: UNICEF; 1993. Murray SF, Pearson S. Maternity referral systems in developing countries: current knowledge and future research needs. Soc Sci Med 2006;62:2205–2215. Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan 2001;16:353–361. World Health Organization. Essential elements of obstetric care at first referral level. Geneva: 1991. World Health Organization. Service availability and readiness assessment (SARA). An annual monitoring system for service delivery. Reference manual, version 2.2. Geneva; 2015 (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). World Health Organization Regional Office for the Western Pacific. District health facilities: Guidelines for development and operations. Manila; 1998. Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Quality statement 4.1: All women and their families receive information about the care and have effective interactions with staff. Rationale: Effective communication with women and their families helps them feel more involved in their care, avoids unnecessary anxiety, misunderstanding and wrong expectations and gives them control of their condition, which contribute to a positive experience. Health care staff have interpersonal communication and counselling skills and are readily approachable. They have a positive attitude, use simple, clear language that women and their families can understand and recognize the communication needs and preferences of all women under their care. Quality measures Input 1. Easily understood health education materials, in an accessible written or pictorial format, are available in the languages of the communities served by the health facility*. (91.01) 2. Health care staff in the maternity unit are oriented and receive in-service training at least once every 12 months to improve their interpersonal communication and counselling skills and cultural competence*. (85.74) 46 3. The health facility has a written, up-to-date policy that outlines clear goals, operational plans and monitoring mechanisms to promote the interpersonal communication and counselling skills of health care staff. (84.69) 4. Health care staff in the maternity unit receive supportive supervision in interpersonal communication, counselling and cultural competence every three months. (80.12) Output/process 1. The proportion of all women discharged from the labour and childbirth area of the facility who received written and verbal information and counselling on the following elements before discharge: nutrition and hygiene, birth spacing and family planning, exclusive breastfeeding and maintaining lactation, keeping their baby warm and clean, communication and play with the baby, danger signs for the mother and newborn and where to go in case of complications*. (85.83) 2. The proportion of all women who gave birth in the health facility who reported that they were given the opportunity to discuss their concerns and preferences. (82.79) 3. The proportion of health care staff in the health facility who demonstrated the following skills: active listening, asking questions, responding to questions, verifying the understanding of women and their families and supporting women in problem-solving. (76.67) Outcome 1. The proportion of all women who gave birth in the health facility who felt they were adequately informed by the care provider(s) about the examinations, actions and decisions taken for their care. (83.58) 2. The proportion of all women who gave birth in the health facility who reported that their needs and preferences were taken into account during labour, childbirth and postnatal care. (80.67) 3. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (80.66) 4. The proportion of all women who gave birth in the health facility who reported that they were satisfied with the health education and information they received from care providers. (76.25) Quality statement 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals. Rationale: Coordinated care and accurate hand-over of information among health care providers is essential to maintain continuity in patient care and to avoid unnecessary delays in treatment. A standard format is used for information exchange between care providers (e.g. during staff shift changes and referrals, with social care services, sending laboratory results), and effective verbal and/or telephone communication is used among caregivers involved in the hand-over of care. There is timely reporting of the results of critical diagnostic tests. Quality measures Input 1. The health facility has a standard form for clinical progress notes and monitoring events during labour (partograph), birth and after birth to facilitate written hand-over*. (91.75) 2. The health facility has written, up-to-date protocols for verbal and written hand-over of women and newborns at shift changes, during intra-facility transfer, on referral to other facilities and at discharge*. (89.14) 47 3. Health-care staff in the maternity unit are oriented and receive in-service training and regular refresher sessions at least once every 12 months in the clinical hand-over policy and communication of important information for hand-over, referral or discharge. (81.53) 4. The health facility has a functioning, reliable communication system for information exchange among relevant service providers. (78.26) Output/process 1. The proportion of women attended during labour and childbirth for whom a partograph has been completed. (81.87) 2. The proportion of all women who gave birth in the health facility who reported that health care staff introduced themselves and showed good knowledge of the women’s history and the care that had been given to date. (73.47) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services*. (83.53) 2. The proportion of health care staff, by cadre, and social professionals who were satisfied with the communication during clinical hand-over among members of the health care team in the health facility. (68.98) References used in setting standard 4 de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Anderson L, Scrimshaw S, Fullilove M, Fielding J, Normand H. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003;24:68–79. Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267. Fealy G, Riordan F. Communication and clinical handover practices: a systematic review. Dublin: University College Dublin and Health Service Executive; 2014. Iedema R, Manidis M. Patient–clinician communication: an overview of relevant research and policy literatures. In: Communication (clinical handover) in maternity services. Sydney: Australian Commission on Safety and Quality in Health Care and UTS Centre for Health Communication; 2014 (National clinical guideline No. 5) (http://health.gov.ie/wp-content/uploads/2015/01/ National-Clinical-Guideline-No.-5-Clinical-Handover-Nov2014.pdf). Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003;4:CD003716. Kongnyu E, van den Broek N. Criteria for clinical audit of women friendly care and providers’ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28. National Institute for Health Care Excellence. Patient experience in adult NHS services. London; 2012 (https://www.nice.org.uk/guidance/qs15/chapter/ quality-statement-2-demonstrated-competency-in-communication-skills#quality-statement-2). The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. Oakbrook Terrace, Illinois; 2010 (http://www. jointcommission.org). 48 Standard 5: Women and newborns receive care with respect and preservation of their dignity. Quality statement 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected. Rationale: Privacy and confidentiality of information make women and families feel respected at all times, protect them from any stigma associated with their problems and build trust in health care providers. Health care staff respect the privacy and confidentiality of care and information. Linen, curtains and screens are available to ensure privacy, and verbal and written records of women’s and newborns’ conditions are kept confidential. Quality measures Input 3. The physical environment of the health facility allows privacy and the provision of respectful, confidential care, including the availability of curtains, screens, partitions and sufficient bed capacity*. (94.80) 4. The health facility has written, up-to-date protocols to ensure privacy and confidentiality for all women and newborns in all aspects of care*. (89.27) 5. The health facility has accountability mechanisms for redress in the event of violations of privacy, confidentiality or consent. (85.16) Output/process 1. The proportion of procedures in the health facility that require written consent for which there is an associated record of the woman’s consent*. (86.90) 2. The proportion of all women undergoing examinations or procedures in the health facility who reported that their permission was sought before the examination or procedures were performed. (84.41) Outcome 1. The proportion of all women who gave birth in the health facility who were satisfied with the degree of privacy during their stay in the labour and childbirth areas. (85.63) 2. The proportion of all women examined and treated in the health facility who expressed satisfaction with the degree of privacy during examinations and treatment. (85.48) 3. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (81.90) Quality statement 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. Rationale: Every woman has the basic human right to the highest attainable standard of health care without discrimination or maltreatment. Health care staff treat all women with kindness, compassion, courtesy, respect, understanding and honesty and preserve their dignity. Women are free to complain without fear of repercussions, and there is no restriction on their movement into or out of the health facility. 49 Quality measures Input 1. The health facility has written, up-to-date, zero-tolerance non-discriminatory policies with regard to mistreatment of women and newborns*. (91.19) 2. The health facility has a system whereby the mothers of small, sick newborns can be close to and nurse their babies*. (89.59) 3. The fee structures for maternity and newborn care are equitable, affordable and clearly displayed*. (89.07) 4. The health facility has written accountability mechanisms for redress in the event of mistreatment. (88.50) 5. The health facility has a written, up-to-date policy and protocols that outline women’s and families’ right to make a complaint about the care received and has an easily accessible mechanism (e.g. a box) for handing in complaints. (88.34) 6. Health care staff in the maternity unit receive in-service training and supportive supervision in respecting the rights of mothers and newborns, respectful care and accountability mechanisms. Orientation is provided for new staff. (87.36) 7. The health facility policy for payment specifically precludes detention of a woman or baby for non- payment. (86.00) 8. The health facility has a complaints box, which is easily accessible to women and their families, is periodically emptied and the contents reviewed. (77.22) Output/process 1. The proportion of all women who gave birth in the health facility who reported physical, verbal or sexual abuse, to themselves or their newborns, during labour or childbirth or after birth. (86.68) 2. The proportion of women who gave birth in the health facility who were satisfied that the facility met their religious and cultural needs. (78.15) 3. The proportion of women who attended the health facility who were refused care because of their inability to pay. (76.97) 4. The proportion of complaints received about respect and preservation of the dignity of women and their families. (74.37) 5. The proportion of women who gave birth in the health facility who were aware of the existence and location of a complaints box. (70.90) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (85.93) 2. The proportion of all women who gave birth in the health facility who reported having been treated with respect and their dignity preserved. (84.13) 3. The proportion of all women in the health facility who made a complaint whose complaints were acted upon without repercussions. (72.82) Quality statement 5.3: All women can make informed choices about the services they receive, and the reasons for interventions or outcomes are clearly explained. Rationale: It is essential that women feel involved in their treatment and care and can make informed choices in order to improve their compliance and satisfaction with the treatment. 50 Women are informed about their rights and options for care and encouraged to ask questions. They are supported in making decisions about all aspects of their care and treatment; their personal values and beliefs are respected, and their consent is obtained before procedures are carried out. Quality measures Input 1. The health facility has a written, up-to-date policy for obtaining informed consent from women before examinations and procedures*. (90.98) 2. The health facility has a standard informed consent form that helps health care staff to provide easily understandable information to women in order to obtain their fully informed consent*. (90.39) 3. Health care staff in the health facility receive in-service training and supportive supervision in effective informed consent procedures and in women’s right to choose care at childbirth. Orientation is provided for new staff*. (87.51) 4. The health facility has written accountability mechanisms for redress in the event that women are denied informed choice, and the mechanism is displayed. (81.41) Output/process 1. The proportion of procedures in the health facility that require written consent for which there is an associated record of consent signed by the woman or a family member. (84.32) 2. The proportion of all women who gave birth in the health facility who felt adequately informed by health care staff regarding decisions taken about their care. (80.82) 3. The proportion of women who received care in the health facility who were aware that they had the right to accept or refuse treatment. (78.55) Outcome 1. The proportion of women who gave birth in the health facility by caesarean section who were aware of the reason for the caesarean section. (87.13) 2. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (82.74) 3. The proportion of women who gave birth in the health facility who felt they had shared decisions about their labour, birth and postnatal care. (75.86) References used in setting standard 5 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015;12:e1001847. de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Dwamena F1, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267. International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99. Kongnyuy E, van den Broek N. Criteria for clinical audit of women friendly care and providers’ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28. Lothian JA. Do not disturb: the importance of privacy in labor, J Perinat Educ 2004;13:4–6. 51 National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. London; 2012 (http://www.nice.org. uk/guidance/cg138). Reader TW, Gillespie A. Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC Health Serv Res 2013;13:156. Valentine NB, de Silva A, Kawabata K, Darby C, Murray CJL, Evans DB. Health system responsiveness: concepts, domains and measurement. In: Murray CJL, Evans DB, editors, Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. World Health Organization. WHO statement on the prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva; 2015 (http://apps.who.int/iris/bitstream/10665/134588/1/ WHO_RHR_14.23_eng.pdf?ua=1&ua=1). Standard 6: Every woman and her family or the companion of her choice are given emotional support that is sensitive to their needs and strengthens the woman’s capability. Quality statement 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. Rationale: Birth companions provide physical, emotional and spiritual support to women during labour and deliver and thus have a positive impact on the women and improved birth outcomes. Women are allowed and encouraged to choose a companion to be present during her labour and childbirth. The companion is oriented in supporting the woman during labour and childbirth, and both the woman and her companion are encouraged to participate actively in the woman’s care. Quality measures Input 1. The labour and childbirth areas are organized in such a way as to allow a physical private space for the woman and her companion at the time of birth*. (91.59) 2. The health facility has a written, up-to-date protocol, which is explained to women and their families, to encourage all women to have at least one person of their choice, as culturally appropriate, with them during labour, childbirth and the immediate postnatal period*. (91.25) 3. Health care staff in the health facility are oriented and receive in-service refresher training sessions at least once every 12 months on the evidence for and positive impact of the presence of a chosen companion during labour and birth. (84.63) 4. Orientation sessions and information (written or pictorial) are available to orient the companion on his or her role in supporting the woman during labour and birth. (83.40) Output/process 1. The proportion of all women who gave birth in the health facility who had a companion of their choice during labour and childbirth*. (91.76) 2. The proportion of all companions who were satisfied with the orientation given on their role during labour and childbirth. (75.19) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (84.84) 52 Quality statement 6.2: Every woman receives support to strengthen her capability during childbirth. Rationale: Every woman should be given emotional support to improve her mental health, give her a positive outlook and improve the overall health outcomes of the mother and baby. Care at the facility optimizes biological, psychological, social and cultural well-being. Women are encouraged to adopt the position of their choice during labour, to walk around freely during the first stage and to eat and drink enough to ensure adequate nutrition and hydration. Women with complex emotional needs (e.g. previous newborn death, experience of gender- based violence, rape, mental health problems) are identified and supported. Grief support is provided to families if the mother or baby dies. Quality measures Input 2. Health care staff in the labour and childbirth areas of the maternity unit were oriented in non- pharmacological and pharmacological pain relief and received in-service training or sessions at least once in the preceding 12 months*. (87.07) 3. The health facility has a written, up-to-date protocol, which is explained to women and their families, to minimize unnecessary interventions, support normal labour and strengthen the woman’s capability, so that she feels in control of her childbirth experience. (83.21) 4. Health care staff in the labour and childbirth areas of the maternity unit were oriented and received in-service training or refresher sessions at least once in the preceding 12 months to strengthen their interpersonal and cultural competence in providing emotional support. (82.34) 5. The health facility has a referral mechanism for women and families with complex emotional needs, and refers them for specialist care. (79.71) Output/process 1. The proportion of all women who gave birth in the health facility who did so in the labour position of their choice. (82.02) 2. The proportion of all women undergoing bereavement or an adverse outcome who received additional emotional support from health facility staff. (80.64) 3. The proportion of all women who gave birth in the health facility who reported having sufficient food and drink during labour. (80.10) 4. The proportion of all women who gave birth in the health facility who were ambulatory during the first stage of labour. (77.30) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services*. (84.69) 2. The proportion of all women who gave birth in the health facility who would recommend childbirth in that facility*. (84.46) 3. The proportion of all women who gave birth in the health facility who reported a positive birth experience. (83.23) 4. The proportion of all women who gave birth in the health facility who were satisfied that their choices and preferences were respected. (82.36) 53 References used in setting standard 6 Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;7: CD003766. International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99. National Institute for Health Care Excellence. Using organisational change to enhance the experience of women giving birth by focusing on normalising births. London; 2013 (https://www.nice.org.uk/ sharedlearning/using-organisational-change-to-enhance-the-experience-of-women-giving-birth- by-focusing-on-normalising-births). National Institute for Health Care Excellence. NICE guidelines on routine intrapartum care (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Renfrew MJ. Optimising the contribution of midwifery to preventing stillbirths and improving the overall quality of care: co-ordinated global action needed. Midwifery 2016;36:99–101. Royal College of Midwives. Maternal emotional wellbeing and infant development, a good practice guide for midwives, London; 2012 (https://www.rcm.org.uk/sites/default/files/Emotional%2. Wellbeing_Guide_WEB.pdf). Sandall J. Soltani H, Gates S, Shennan, A, Devane, D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013;8: CD004667. World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/). World Health Organization. WHO recommendations for augmentation of labour. Geneva; 2014 (http:// www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation-labour/en/). Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Quality statement 7.1: Every woman and child has access at all times to at least one skilled birth attendant and support staff for routine care and management of complications. Rationale: The availability of health care staff around the clock is essential for optimal routine and emergency care of patients and timely management of complications. A health facility staffing policy is in place, reviewed regularly and updated as necessary, which specifies the number, types and necessary competence of staff to ensure an adequate number and skill mix of health care staff for the volume of work, 24 h a day, 7 days a week. Clinical and nonclinical staff are oriented to their specific roles and responsibilities in the facility or unit to which they are assigned. A staff roster listing duties and the times staff will be on duty is always updated and on display. Written information is available on how to access services, and signs indicate key service areas (e.g. emergency department) and what to do in case of an emergency. Women are triaged to prioritize emergency conditions. 54 Quality measures Input 1. The health facility has skilled birth attendants available at all times, in sufficient numbers to meet the anticipated work load*. (89.50) 2. The health facility has a written, up-to-date staffing policy, listing the numbers, types and competence of staff, that is reviewed continuously according to the work load*. (89.05) 3. The health facility has a roster that is displayed in all areas, giving the names of staff on duty, the times of their shifts and their specific roles and responsibilities. (86.43) 4. The health facility has a written, up-to-date policy on triage and waiting times for emergency and non-emergency consultations and treatment. (86.32) 5. The health facility has clear communication channels to reach staff on duty at all times. (82.87) Output/process 1. The proportion of available posts in the health facility that were filled by staff with the necessary competence for the job description to allow the facility to provide 24-h service. (80.72) 2. The proportion of staff who have been oriented to their functions, roles and responsibilities in the facility or unit to which they are assigned. (78.79) 3. The proportion of women who attended the health facility who reported receiving attention within the appropriate time for their condition as per facility policy on triage and waiting time. (73.08) Outcome 1. The proportion of women and their newborns in the health facility who were attended by a skilled birth attendant (as per the definition) during and after childbirth*. (90.11) 2. The proportion of all women who gave birth at the health facility who reported having been informed about danger signs for her and her baby and emergency preparedness. (84.27) 3. The proportion of women who attended the health facility who were satisfied with the health care they received. (80.87) Quality statement 7.2: The skilled birth attendants and support staff have appropriate competence and skills to meet requirements during labour, childbirth and the early postnatal period. Rationale: Qualification, training and orientation of staff improve their performance of their roles and responsibilities. All staff have a job description that lists the necessary competence, roles and responsibilities, supported by the desired qualifications and other requirements. The education, licensure or registration and other credentials required by law or regulation are verified for all health care staff and kept current. There are established programmes for recruitment, retention, professional development and continuing education of all staff. All staff receive continuing orientation on protocols and responsibilities, supportive supervision and professional development activities, with an annual performance appraisal and recognition of good performance. Effective, efficient case management systems are in place to ensure that patients receive adequate, safe, timely care, and health care staff can demonstrate appropriate competence in providing routine care and managing complications for mothers and newborns. 55 Quality measures Input 4. The health facility has a programme for continuing professional development and skills development for all skilled birth attendants and other support staff and conducts regular training*. (86.62) 5. The health facility has standard procedures and plans for recruitment, deployment, motivation (recognition and reward scheme) and retention of all staff*. (84.21) 6. The health facility periodically appraises all staff and has a mechanism for recognizing good performance. (82.76) 7. The health facility has sufficient numbers of educated, competent, licensed, motivated, regulated skilled birth attendants with an appropriate skills mix, working in multidisciplinary teams. (81.83) 8. The health facility provides an enabling, supportive environment for professional staff development, with regular supportive supervision and mentoring. (79.24) 9. The health facility facilitates inter-professional collaborative practice, with clear roles and responsibilities based on the professional scope of practice and care needs during labour, childbirth and the early postnatal period. (75.82) Output/process 1. The proportion of skilled birth staff at the health facility who received a written job description on deployment to the facility*. (85.81) 2. The proportion of skilled birth attendants at the health facility who received in-service training, a refresher session or mentoring within the past 12 months. (81.80) 3. The number of supervisory visits to support clinical competence and performance improvement (in the past three months). (80.85) 4. The proportion of staff at the health facility who were assessed at least once in the preceding 12 months. (77.54) 5. The number of team meetings held per month to review competence and quality improvement activities. (76.33) 6. The number of interactions per month with professional mentors to ensure clinical competence and improve performance. (75.17) 7. The proportion of all staff at the health facility who were engaged in at least two active quality improvement team meetings and participated in quality improvement activities in the preceding six months. (74.70) Outcome 1. The proportion of all women who gave birth at the health facility who were satisfied with the care and support from facility staff. (82.51) 2. The proportion of skilled birth attendants and support staff at the health facility whose preceding performance appraisal was satisfactory. 3. The proportion of all staff at the health facility who reported being “highly satisfied” with their job. (76.35) 4. The proportion of all staff at the health facility who could identify and report on at least one clinical improvement activity in which they were personally involved in the past six months. (75.97) 5. The proportion of all staff at the health facility who were actively considering looking for a new job. (64.26) 56 Quality statement 7.3: The managerial and clinical leadership of every health facility is collectively responsible for creating and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Rationale: Good managerial and clinical leadership improve performance by showing direction and inspiring employees and create an environment of support for staff in undertaking continuous quality improvement. There is managerial and clinical leadership, collective responsibility, appropriate government policies and procedures and an environment that supports staff in undertaking continuous quality improvement. There is a defined leadership structure and authority, lines of accountability and a defined quality improvement team with resources. Staff collectively develop and implement quality improvement and patient safety programmes and receive support, supervision and mentoring. A policy and plan are in place to manage financial risks, and the facility undertakes regular audits (maternal and perinatal deaths and near-misses), with recommendations for improving quality. A system is in place for regular review of the data collected and reporting and communication of quality management matters to guide decision-making and monitor performance. Patient care and satisfaction are reviewed regularly, and the status of quality improvement is documented. Quality measures Inputs 1. The health facility has a written, up-to-date plan for improving the quality of care and a patient safety programme*. (88.08) 2. The health facility has a written, up-to-date leadership structure, with defined roles and responsibilities and lines of accountability for reporting*. (87.19) 3. The health facility has a designated quality improvement team and responsible personnel*. (85.38) 4. The health facility has a mechanism for regular collection of information on patient and provider satisfaction. (84.98) 5. The health facility holds at least one monthly meeting to review data, monitor quality improvement performance, make recommendations to address any identified problems, honour those who have performed well and encourage staff who are struggling to improve. (83.19) 6. All standard governing procedures (policies and protocols) are in place and accessible to all relevant staff. (82.61) 7. The proportion of all health facility leaders who were trained in quality improvement and leading change (use of information, enabling behaviour, continuous learning). (81.07) 8. The health facility holds at least two annual meetings with stakeholders (e.g. the community, service users, partners) to review its performance, identify problems and make recommendations for joint actions to improve quality. 9. The proportion of all health facility leaders who were trained in leadership and management skills. (80.89) 10. A policy is in place for staff to provide feedback to the facility management on quality improvement and their performance. (80.82) 57 OutputProcess 1. Health facility leaders communicated the performance of the facility through established mechanisms for monitoring (e.g. a dashboard of key metrics) to all relevant staff. (79.75) 2. The proportion of monthly meetings on the quality of care that were actually held in the preceding 12 months. (78.69) Outcome 1. The proportion of all women who gave birth at the health facility who were satisfied with the care and support from facility staff. (83.95) 2. Evidence for improved performance of the system (according to the facility dashboard). (82.50) References used in setting standard 7 Gülmezoglu MA, Lawrie TA. Impact of training on emergency resuscitation skills: impact on Millennium Development Goals (MDGs) 4 and 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10.1016/j. bpobgyn.2015.03.018. ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014;384:1226–1235. International Confederation of Midwives. Essential competencies for basic midwifery practice. The Hague; 2011 (http://www.internationalmidwives.org). Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129–1145. The Lancet. Midwifery. An executive summary for The Lancet’s series. London; 2014 (http://www. thelancet.com/pb/assets/raw/Lancet/stories/series/midwifery/midwifery_exec_summ.pdf). United Nations Population Fund. The state of the world’s midwifery: delivering health, saving lives. New York; 2011. Whittaker S, Shaw C, Spieker N, Linegar A. Quality standards for healthcare establishments in South Africa. In: Padarath A, English R, editors. South African Health Review. Pretoria: National Department of Health; 2011:59–68 (http://www.cohsasa.co.za/sites/cohsasa.co.za/files/ publication_pdfs/ chap_5_quality_standards_pgs_59-_68_0.pdf). World Health Organization. Making pregnancy safer: the critical role of the skilled attendant – a joint statement by WHO, ICM and FIGO. Geneva; 2004 (http://www.who.int/maternal_child_adolescent/ documents/9241591692/en/). World Health Organization. World health report 2005. Make every mother and child count. Geneva; 2005 (http://www.who.int/whr/2005/whr2005_en.pdf). World Health Organization. World health report 2006. Working together for health. Geneva; 2006 (http://www.who.int/whr/2006/en/). World Health Organization. District planning tool for maternal and newborn health strategy implementation: a practical tool for strengthening health management system. Geneva; 2011. World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines-recommendations- newborn-health.pdf). World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/2014/hospital-care-for- mothers-and-newborn-babies-quality-assessment-andimprovement-tool.pdf?ua=1). 58 Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Quality statement 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functioning, reliable, safe and sufficient for the needs of staff, women and their families. Rationale: A safe, clean, hygienic environment with continuous supplies of clean water and electricity, good sanitation and safe waste disposal are the basis of appropriate care of patients, for carrying out all procedures and interventions and for controlling infection. A consistent supply of safe water is available on site at all times for drinking, cleaning and hand-washing in all clinical areas, including labour, childbirth and newborn areas and operating theatres. Sanitation services are available, clearly separated by gender and accessible to all women, their families and staff. The health facility and its ancillary facilities (e.g. staff quarters) have reliable access to a source of electricity (e.g. solar, generator or grid) at all times. A mechanism for the segregation, collection, transport, treatment and safe disposal of waste is in place. The facility has a budget and protocol for the operation and maintenance of energy, safe water and sanitation services. Quality measures Input 1. The health facility has a functioning source of safe water located on the premises that is adequate to meet all demands for drinking, personal hygiene, medical interventions, cleaning, laundry and cooking for use by staff, women, newborns and their families*. (90.90) 2. The health facility has leak-proof, covered, labelled waste bins and impermeable sharps containers available in every treatment area, to allow segregation of waste into four categories: sharps, non- sharps infectious waste, general non-infectious waste (e.g. food, packaging) and anatomical waste (e.g. placenta)*. (90.88) 3. The health facility has at least one functioning hand hygiene station per 10 beds, with soap and water or alcohol-based hand rubs, in all wards*. (89.53) 4. The health facility has energy infrastructure (e.g. solar, generator, grid) that can meet all the electricity demands of the facility and associated infrastructure at all times, with a back-up power source. (89.41) 5. The health facility has written, up-to-date protocols and awareness-raising materials (posters) on cleaning and disinfection, hand hygiene, operating and maintaining water, sanitation and hygiene facilities and safe waste management; these are posted in the areas in which the activities are conducted. (88.05) 6. The health facility has sanitation facilities on premises that are usable, appropriately illuminated at night, accessible to people with limited mobility and separated by gender for staff and patients; they include at least one toilet that meets the needs for menstrual hygiene management, with hand- washing stations and soap and water (at least 1 latrine per 20 users for inpatient settings). (87.46) 7. The health facility has sufficient trained, competent staff on site when needed, with clear descriptions of their responsibilities for cleaning, operating and maintaining water, sanitation, hygiene and health care waste facilities. (86.44) 8. The health facility has sufficient funds for rehabilitation, improvement and continuous operation and maintenance of water, sanitation, hygiene and health care waste services. (83.13) 59 9. The heath facility has a fuel management plan and a local buffer stock, supported by an adequate budget for all the fuel needs for vehicles, cooking and heating, as relevant and as required, at all times. (83.02) 10. The health facility has a preventive risk plan for managing and improving water, sanitation and hygiene services, including for infection prevention and control. (81.34) 11. The heath facility has an energy management plan supported by an adequate budget, maintained by appropriately trained staff and regulated by a competent authority. (77.26) Outcome 1. The proportion of women and their families who attended the health facility who were satisfied with the water, sanitation and energy services and would recommend the health facility to friends and family. (76.75) 2. The proportion of all health care staff at the health facility who were satisfied with the water, sanitation and energy services and considered that these services contribute positively to providing high-quality care. (76.23) 3. The proportion of women and their families who attended the health facility who were satisfied with the power and lighting source and would recommend the health facility to friends and family. (74.20) Quality statement 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. Rationale: The infrastructure of the health facility should be adequate and well maintained, with basic services, good ventilation, a power source and hygiene. The general infrastructure is organized into dedicated service areas close to the labour and childbirth areas or rooms (reception, triage and assessment area, immediate postnatal high- care area, rooming-in postnatal wards or rooms, newborn corners, sick newborn ward, kangaroo mother care ward, neonatal intensive care unit, theatre for performing caesarean sections) and adequately equipped for effective, consistent provision of optimal care. The service areas are clean, well ventilated and illuminated, particularly at night, and conducive to privacy (e.g. curtain, wall); adequate, safe, clean, well-maintained basic facilities (beds, mattresses, bed linen, washing and bathing facilities, toilet) are in place. Quality measures Input 1. The health facility has a dedicated area in the labour and childbirth area for resuscitation of newborns, which is adequately equipped with a table or resuscitaire, radiant warmer, light and appropriate resuscitation equipment and supplies*. (94.67) 2. The health facility has a labour ward and an adequate number of birthing rooms or areas for the estimated number of births in the service area*. (90.12) 3. The health facility has clean, appropriately illuminated, well-ventilated labour, childbirth and neonatal areas and surroundings that allow for privacy and are adequately equipped, regularly cleaned and maintained*. (89.52) 4. The health facility practises and enables rooming-in for all women to allow mothers and babies to remain together 24 h a day. (86.57) 5. The health facility has a labour and childbirth area or room with a functional, clean and accessible bathroom or shower room and toilet for use only by women in labour. (88.94) 60 6. A facility offering surgical services has an adequately equipped operating theatre located close to and easily accessible from the labour and childbirth areas. (88.84) 7. The facility has a dedicated recovery room or area for care of women with complications. (86.54) 8. The health facility has a dedicated ward for admitting sick and unstable small babies. (86.37) Output/process 1. The proportion of all pregnant women who attended the health facility who reported that it has a clean physical environment conducive for childbirth. (82.65) Outcome 1. The proportion of all women who gave birth in the health facility who were satisfied with the environment of the labour and childbirth area, including the cleanliness, proximity to a toilet, general lighting, level of crowding and privacy. (81.81) Quality statement 8.3: Adequate stocks of medicines, supplies and equipment are available for routine care and management of complications. Rationale: Available, adequate essential medicines, equipment and other supplies are critical for provision of optimal quality care. There is a list of essential medicines and supplies (e.g. laboratory reagents) and their uses and orderly, clean, secure storage for these items, with an efficient system to avoid stock-outs. All suitable medicines are available in the clinical areas (e.g. magnesium sulfate in the labour and childbirth areas). Essential equipment is available in the right places, at all times, with a system for regular maintenance and guidelines for appropriate use of the equipment. Laboratory tests are available (e.g. haemoglobin, blood group, urine protein) for routine use and management of complications. Blood is available for transfusion services, and an uninterrupted supply of oxygen is available in the labour and neonatal areas. Quality measures Input 1. The health facility has supplies of antihypertensive agents and magnesium sulfate in sufficient quantities, available at all times, in antenatal, labour, childbirth and postnatal areas for the management of women with pre-eclampsia*. (92.81) 2. The health facility has uterotonic drugs and supplies for intravenous infusion (syringes, needles, infusion sets, intravenous fluid solutions and blood) available in sufficient quantities at all times in the childbirth and postnatal care areas for the management of women with postpartum haemorrhage*. (92.31) 3. The health facility has supplies of antenatal corticosteroids (dexamethasone or betamethasone), antibiotics and magnesium sulfate available in sufficient quantities at all times to manage preterm births*. (92.15) 4. The health facility has functioning essential equipment and supplies for the detection of complications (e.g. thermometers, sphygmomanometers, foetal stethoscopes, urine dipsticks, pulse oximeter) in sufficient quantities at all times in the labour and childbirth areas of the maternity unit. (91.63) 5. The health facility has supplies of first- and second-line injectable antibiotics and other essential medicines available at all times for the management of women and newborns with, or at risk for, infections during labour, childbirth and the early postnatal period. (91.48) 61 6. The health facility has essential laboratory supplies and tests (blood glucose, haemoglobin or packed cell volume, blood group and cross-matching, bilirubin, urine protein, full blood count, blood culture, electrolytes, renal and liver function tests, syphilis, HIV and malaria rapid diagnostic tests) to support the management of women and newborns. (91.12) 7. The health facility has essential supplies and functioning equipment (including childbirth beds, vacuum, forceps, incubators, weighing machine, sterile gloves) available in sufficient quantities at all times in the labour and childbirth areas. (90.88) 8. The health facility has supplies and functioning equipment for the emergency care and resuscitation of women (well-stocked resuscitation trolley, suction device, pulse oximeter, airways, laryngoscope, endotracheal tubes, adult bag valve masks, infusion sets, intravenous fluids) available in sufficient quantities all times in areas designated for labour, childbirth and postnatal care. (89.70) 9. The health facility has a safe, uninterrupted oxygen source and delivery supplies (nasal prongs, catheters and masks), including nasal continuous positive airway pressure, available at all times in labour, childbirth and neonatal areas and the operating theatre (when available). (89.37) 10. The health facility has supplies and functioning equipment for emergency care and resuscitation of newborns (resuscitation table, well-stocked neonatal resuscitation trolley, warmer, suction device, pulse oximeter, laryngoscope) available all times in areas designated for labour, childbirth and neonatal care. (89.02) 11. The health facility has an on-site pharmacy and a medicine and supplies stock management system managed by a trained pharmacist or dispenser. (88.44) 12. The health facility has a dedicated budget for essential medicines, equipment (and its maintenance) and medical supplies for maternal and newborn care. (84.94) 13. The health facility has a functioning diagnostic ultrasound machine and trained health staff who can conduct a basic obstetric ultrasound examination to determine the number of fetuses present, gestational age, prenatal diagnosis of foetal anomalies or early diagnosis of placental insufficiency. (84.83) Output/process 1. Availability of essential life-saving medicines (oxytocin, magnesium sulfate, dexamethasone, vitamin K, injectable and oral amoxicillin, benzyl penicillin, gentamicin, ceftriaxone, metronidazole, antimalarial drugs, antiretroviral drugs and vaccines against tuberculosis, hepatitis B, poliomyelitis) in the past three months. (88.84) 2. The proportion of all women who had severe pre-eclampsia or eclampsia in the health facility who did not receive the full dose of magnesium sulfate because of a stock-out. (79.38) 3. The proportion of all women who gave birth in the health facility who purchased gloves and other necessary items. (70.62) Outcome 1. The proportion of all nulliparous women with a singleton cephalic foetus at ≥ 37 weeks of gestation who underwent caesarean section during spontaneous labour (Robson group 1). (82.54) 2. The proportion of unmet need for caesarean section as a result of lack of supplies or staff trained to conduct caesarean section. (74.81) References used in setting standard 8 Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Safe management of wastes from health-care activities. Geneva: World Health Organization; 2014 (http://www.who.int/ water_sanitation_health/publications/wastemanag/en/). 62 Water Supply and Sanitation Collaborative Council. WASH targets and indicators post-2015: recommendations from international consultations. Geneva; 2014 (http://www.wssinfo.org/ fileadmin/user_upload/resources/post-2015-WASH-targets-factsheet-12pp.pdf). World Health Organization. Essential elements of obstetric care at first referral level. Geneva; 1991 (http://apps.who.int/iris/bitstream/10665/41740/1/9241544244.pdf). World Health Organization. Essential environmental health standards in health care. Geneva; 2008 (http://www.who.int/water_sanitation_health/hygiene/settings/ehs_health_care.pdf.pdf). World Health Organization. Systems thinking for health systems strengthening. Geneva; 2009 (http:// www.who.int/alliance-hpsr/resources/9789241563895/en/). World Health Organization. Evaluating household water treatment options: health based targets and microbiological performance specifications. Geneva; 2011 (http://www.who.int/ water_sanitation_health/publications/household_water/en/). World Health Organization. Service availability and readiness assessment. Geneva; 2014 (http://apps. who.int/iris/bitstream/10665/149025/1/WHO_HIS_HSI_2014.5_eng.pdf). World Health Organization, UNICEF. Progress on drinking-water and sanitation: Joint Monitoring Programme update 2014. Geneva; 2014 (http://www.who.int/water_sanitation_health/ publications/jmp-report-2014/en/). World Health Organization, UNICEF. Water, sanitation and hygiene in health care facilities. Status in low- and middle-income countries and way forward. Geneva; 2015 (http://apps.who.int/iris/ bitstream/10665/154588/1/9789241508476_eng.pdf). 63 6. Operationalization Evidence-based, effective, respectful, high-quality care and the elements of health systems that support optimal care for women and newborns described in the WHO quality of care framework are to be operationalized by applying the standards of care and quality statements. The standards should be adapted to the context of each country to ensure detailed processes of evidence-based clinical care (standard 1), information systems (2), referral systems (3) experience of care (4–6), an enabled, motivated work force (7) and adequate resources (8). The standards are accompanied by evidence-based quality statements, which include measures of inputs, outputs and outcomes. These will improve quality and ensure high-quality care for mothers and newborns. Ideas for implementing the standards should be based on the county’s experience and on adaptive learning within and between countries. 6.1 Dissemination The framework, standards of care and quality measures are published in a technical reference document, which can be incorporated into strategic documents at country level. They are part of a package of normative tools for supporting improvement of the quality of maternal and newborn care. They will be translated into Arabic, French, Russian and Spanish in collaboration with the WHO regional offices, for wider circulation. The publication will be available for downloading from the websites of WHO headquarters, the regional and country offices, WHO collaborating centres and partner agencies involved in maternal and newborn quality of care. Hard copies of the publication will be disseminated to all WHO country offices and will be available for sale from WHO bookshop and its distribution network to all medical libraries and individuals. 6.2 Implementation approach To increase access to and use of the standards of care and quality measures, orientation and capacity-building workshops will be conducted in all the WHO regions in collaboration with the regional offices. Targeted support will be provided to countries, and a learning platform will be created for sharing best practices within and among countries by an innovative approach (Fig. 3), which is an adaptation of the “Plan Do Study Act” model (22) based on synthesis of evidence, best practice and experience. It provides a plan for continuous quality improvement by setting aims and building teams to achieve desired outcomes through use of change packages (individual, multi-faceted or complex interventions, depending on the context and needs), capacity-building and other strategies to maximize the chances for sustaining implementation. 64 Fig. 3. Implementation approach In addition, step-by-step guidance will be provided on establishing a system for improving the quality of maternal and newborn health within the national quality of care strategy and operational plan. The guidance will be accompanied by the necessary tools and targeted capacity-building for strong country leadership. 1. Establish leadership structures and function 5. Build capability & implement interventions 6. Continuously measure quality of care & outcomes 7. Refine strategies for scale up PLAN DO STUDY ACT 2. Adapt standards of care 3. Conduct situation analysis/assessment 4. Ensure essential infrastructure to get started 65 7. Monitoring and evaluation Implementation of these standards will be accompanied by an internal and external monitoring and evaluation plan. Internal monitoring and evaluation will be integrated into the guidance and linked to the output of the learning platform. External monitoring and evaluation will be conducted for rigorous evaluation of implementation by various methods, sources and study designs to ensure effectiveness (pragmatic and quasi-experimental designs), process (quantitative and qualitative designs) and economic efficiency. The results of both the internal and external monitoring and evaluations will be used to improve the implementation guidance and learning platform. 66 8. Updating the standards The best practices reported on the learning platform and the evaluations of implementation will be collated and used to review and update the standards of care and quality measures as appropriate. 67 References 1. Raven JH, Tolhurst RJ, Tang S, van den Broek N. What is quality in maternal and neonatal health care? Midwifery 2012;28:e676–e683. 2. Tuncalp Ö, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al, Quality of care for pregnant women and newborns – the WHO vision. Br J Obstet Gynaecol 2015;122:1045–1049. 3. World Health Organization. Strategies toward ending preventable maternal mortality. Geneva; 2015 (http://who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/, accessed 22 March 2015). 4. World Health Organization. Every newborn: an action plan to end preventable deaths. Geneva; 2014 (www.who.int/maternal_child_adolescent/topics/newborn/enap_ consultation/en/, accessed 19 January 2015). 5. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health 2014;2: e323–e333. 6. WHO Global Health Observatory. 2014 (http://apps.who.int/gho/data/?theme=main, accessed 12 January 2015). 7. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347–370. 8. United Nations. Global strategy for women’s and children’s health. New York; 2010. 9. Campbell OM, Graham WJ. Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284–1299. 10. Global Health Group. Where women go to deliver: overview of the project and review of preliminary findings. San Francisco, California: University of California at San Francisco, Global Health Sciences; 2014. 11. World Health Organization. WHO multicountry survey on maternal and newborn health 2010–2012. Geneva; 2011 (http://www.who.int/reproductivehealth/topics/ maternal_perinatal/nearmiss/en/). 12. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gulmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health 2014;11:71. 13. World Health Organization. The second report of the independent expert review group (iERG) in information and accountability for women’s and children’s health. Geneva; 2013. 14. Wilson L, Goldsmith P. Quality and its measurements. In: Wilson L, Goldsmith P, Editors. Quality management in health care. Sydney: McGraw-Hill; 1995;229–258. 68 15. Roemer MI, Montoya-Aguilar C. Quality assessment and assurance in primary health-care. Geneva: World Health Organization; 1988. 16. Institute of Medicine. A strategy for quality assurance. Washington DC: National Academy Press; 1990. 17. World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva; 2006. 18. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260:1743–1748. 19. Maxwell RJ. Dimensions of quality revisited: from thought to action. Qual Health Care 1992; 1:171–177. 20. Ovretveit J, Bate P, Cleary P, Cretin S, Gustafson D, McInnes K, et al. Health service quality. An introduction to quality methods for health services. Oxford: Blackwell Scientific Publications; 1992. 21. Hulton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Southampton: University of Southampton; 2000. 22. International Organization for Standardization. Geneva (http://www.iso.org/iso/home/ standards.htm accessed 24 June 2016) 23. The Joint Commission. Oakbrook Terrace, Illinois http://www.jointcommission.org/ standards_information/jcfaq.aspx accessed 24 June 2016. 24. The Council for Health Service Accreditation of Southern Africa (COHSASA) accreditation standards. Pretoria (http://www.cohsasa.co.za/ accessed 24 June 2016). 25. National Institute for Health and Care Excellence. London (https://www.nice.org.uk/ standards-and-indicators accessed 24 June 2016). 26. Pharmaccess group. Safe care basic healthcare standards. The Hague (http://www.safe- care.org/index.php?page=safecare-standards accessed 24 June 2016). 27. World Health Organization. Standards for maternal and neonatal care. Group 1: General standards of care for healthy pregnancy and childbirth. Geneva; 2007 (http://www.who. int/reproductivehealth/publications/maternal_perinatal_health/a91272/en/) 69 Annex 1. Participants in the meeting of the guideline development group, Geneva, 3–4 June 2015 Dr Pierre Barker, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA Mrs Sheena Currie, Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA Dr Kim Dickson, UNICEF, New York City (NY), USA Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden Dr Kathleen Hill, JHPIEGO, Washington DC, USA Dr Asia Kassim Hussein, UNICEF, Dar-es-Salaam, United Republic of Tanzania Dr Theopista John, WHO Country Office, Dar-es- Salaam, United Republic of Tanzania Dr Lily Kak, Global Partnerships and Newborn Health, Washington DC, USA Dr Senait Kebede, Emory University, Atlanta, Georgia, USA Professor Joy Lawn, London School of Hygiene and Tropical Medicine, London, United Kingdom Dr Tess Lawrie, Evidence-based Medicine Consultancy Ltd, Bath, United Kingdom Mr Norman Lufesi, Ministry of Health, Lilongwe, Malawi Dr Carolyn Maclennan, Alice Springs Hospital, Alice Springs, NT, Australia Dr Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Md. Ziaul Matin, UNICEF, Dakka, Bangladesh Dr Goldy Mazia, Maternal and Child Survival Program, PATH, Seattle, Washington, USA Dr Georgina Msemo, Ministry of Health and Social Welfare, Dar-es-Salaam, United Republic of Tanzania Dr Jim Neilson, Professor of Obstetrics & Gynaecology, University of Liverpool, United Kingdom Mr Lee Pyne-Mercier, Bill & Melinda Gates Foundation, Seattle, Washington, USA Dr Isabella Sagoe-Moses, Ministry of Health, Accra, Ghana Dr Memuna Tanko, Acting Director, Quality Assurance, National Health Insurance Authority, Accra, Ghana Professor Nynke van den Broek, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, United Kingdom Ms Donna Vivio, Senior Newborn Health Advisor, United States Agency for International Development, Washington DC, USA Dr Nabila Zaka, Senior Advisor Health, UNICEF, Geneva, Switzerland 70 Annex 2. List of participants in the Delphi study Joel Adze, Kaduna State University, Kaduna, Nigeria Anna Afugglas, United Nations Population Fund, Phnom Penh, Cambodia Dr Elnahas Amir, Sidra Medical and Research Center, Doha, Qatar Professor Surasak Angsuwathana, Faculty of Medicine, Mahidol University, Bangkok, Thailand Sir Sabaratnam Arulkumaran, FIGO, London, United Kingdom Dr Deorari Ashok, All-India Institute of Medical Sciences, New Delhi, India Ms Joanne Ashton, Joint Commission International, Oakbrook Terrace, Illinois, USA Professor Nabhan Ashraf, Ain Shams University, Cairo, Egypt Dr Alberta Bacci, Independent consultant, Lisbon, Portugal Dr Solange Balaga, , Independent Consultant, Kinshasa, Democratic Republic of the Congo Dr Cyprien Baribwira, Maryland Global Initiative Corporation (MGIC), Kigali, Rwanda Dr Suppawat Boonkasidecha, Queen Sirikit National Institute of Child Health, Bangkok Thailand Dr Betzabe Butron, WHO Regional Office for the Americas, Washington DC, USA Dr Romano Byaruhanga, Kampala Medical Chambers Hospital, Kampala, Uganda Ms Anna Coates, WHO Regional Office for the Americas, Washington DC, USA Dr Jeanine Umutesi Condo, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda Dr Dilberth Cordero, WHO Country Office, Tegucigalpa, Honduras Ms Sheena Currie, JHIEGO and Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA Dr Louise Day, LAMB Integrated Rural Health and Development, Dakka, Bangladesh Professor Soo Downe, Research in Childbirth and Health Group, London, United Kingdom Atf Gherissi, El Manar University, Tunis, Tunisia Professor Michael English, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya Professor Jan Jaap Erwich, University of Groningen, Groningen, Netherlands Professor Vicki Flenady, University of Queensland, Herston, Australia Mr Fabrice Fotso, UNICEF West and Central Africa Regional Office, Dakar, Senegal Dr Sabine Gabrysch, Heidelberg University, Heidelberg, Germany Dr Karima Gholzbhouri, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt Dr Gathari Gichuhi, Ministry of Health, Nairobi, Kenya 71 Dr Aparajita Gogoi, Whiteribbon Alliance, New Delhi, India Dr Rogelio Gonzalez, Centre for Perinatal Diagnosis, Catholic University of Chile, Santiago, Chile Professor Malik Goone wardene, Faculty of Medicine, University of Ruhuna, Sri Lanka Ms Ana Guerreiro, independent consultant, Lisbon, Portugal Privat Guie, Polyclinic Internationale sainte Anne Marie, Abidjan, Cote d’Ivoire Ms Gill Gyte, University of Liverpool, Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom Ms Fransisca Handy, Apotek Puri Satu Kembangan, Jakarta, Indonesia Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden Dr Jim Heiby, United States Agency for International Development, Washington DC, USA Dr Jorge Hermida, Assist/University Research Co., Quito, Ecuador Dr Kathleen Hill, United States Agency for International Development, ASSIST Project, Washington, DC, USA Dr Stephen Hodgins, Save the Children, Washington DC, USA Dr Caroline Homer, University of Technology, Sydney, Australia Ms Petra Hoope-Bender, Instituto de Cooperación Social – Integrare, Barcelona, Spain Dr Grace Irimu, Kenyatta University, Nairobi, Kenya Ms Rima Jolivet, White Ribbon Alliance for Safe Motherhood, Washington, DC, USA Dr Theopista Kabuteni-John, WHO Country Office, Dar-es-Salaam, United Republic of Tanzania Dr Lily Kak, United States Agency for International Development, Washington DC, USA Dr Ariel Karolinski, WHO Country Office, Buenos Aires, Argentina Professor Holly Kennedy, Yale University, Boston (MA), USA Dr Neena Khadka, Maternal and Child Survival Program, Washington DC, USA Prof Zulfiya Khodjaeva, Federal Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation Dr Tamar Khomasuridze, United Nations Population Fund, European Regional Office, Ankara, Turkey Dr Andre Lalonde, The Society of Obstetricians and Gynaecologists of Canada (SOGC), Ottawa, Canada Dr Marzia Lazzerin, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Italy Dr Li Wenying, Aviation General Hospital of China Medical University, Beijing, China Dr Jerker Liljestrand, Bill and Melinda Gates Foundation, Seattle, USA Dr Liu Cheng, Beijing Armed Police Corps Hospital, Beijing, China Dr Nigel Livesley, University Research Co., Bethesda, USA Mr Norman Lufesi, ARI/Community Health Service, Ministry of Health, Lilongwe, Malawi Ms Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Kuhu Maitra, Abt Associates, Cambridge (MA), USA Prof Zoe Matthews, University of Southampton, Southampton, United Kingdom Dr Goldy Mazia, PATH, Seattle (WA), USA Dr Alison McFadden, University of Liverpool, Liverpool, United Kingdom Ms Alison Mcintyre, WaterAid, East Melbourne, Australia 72 Prof Tarek Meguid, Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania Dr Tanko Memuna, National Health Insurance Authority, Accra, Ghana Dr Abraham Mengistu, Ministry of Health, Addis Ababa, Ethiopia Dr Raul Mercer, Universidad Nacional de La Plata, Buenos Aires, Argentina Dr Allisyn Moran, United States Agency for International Development, Washington DC, USA Dr Rintaro Mori, National Centre for Child Health and Development, Tokyo, Japan Dr Georgina Msemo, Ministry of Health, Dar-es- Salaam, United Republic of Tanzania Dr Bremen de Mucio, WHO Country Office, Montevideo, Uruguay Dr Christine Muzel, Philips Healthcare, Amsterdam, Netherlands Dr Victoria Nakibuka, Nsambya Hospital, Kampala, Uganda Dr James Neilson, University of Liverpool, Liverpool, United Kingdom Dr Hiromi Obara, Bureau of International Medical Cooperation, Tokyo, Japan Dr Dwiana Ocviyanti, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia Dr Jeanne Odette, Université du Burundi, Bujumbura, Burundi Prof Pius Okong, Health Service Commission, Kampala, Uganda Dr Eduardo Ortiz-Panozo, Centro de Investigaciones Regionales, Mérida, Mexico Prof Ouadraogo Charlemagne, Centre Hospitalier Universitaire Yalgado, Ouagdougou, Burkina Faso Dr Duran Pablo, WHO Country Office, Montevideo, Uruguay Dr Imran Pambudi, Ministry of Health Indonesia, Jakarta, Indonesia Dr Robert Pattinson, Maternal and Infant Health Care, South Africa Medical Research Council, Kalafong Hospital, Pretoria, South Africa Dr Loveday Penn-Kekana, University of the Witwatersrand, Johannesburg, South Africa Dr Emily Peterson, Centers for Disease Control and Prevention, Atlanta (GA), USA Dr Cynthia Pileggi, Ribeiro Preto Medical School, University of São Paulo, São Paulo, Brazil Dr Neil Prose, Duke University, Durham (NC), USA Ms Pamela Putney, Options Consultancy Services Limited, London, United Kingdom Dr Neena Raina, WHO Regional Office for South- East Asia, New Delhi, India Prof Kathryn Ramsey, Columbia University Medical Center, New York, USA Prof Mary Renfrew, Scottish Improvement Science Collaborating Centre, Dundee, United Kingdom Dr Alexander Rowe, Centers for Disease Control and Prevention, Atlanta (GA), USA Prof Irina Ryumina, Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation Dr Harshad Sanghvi, JHPIEGO, Baltimore, MD, USA Prof Ola Saugstad, University of Oslo, Oslo, Norway Dr Kerri Schuiling, International Confederation of Midwives, Rochester (MI), USA Ms Gloria Seguranyes, University of Barcelona, Barcelona, Spain Ms Priti Dave Sen, Children’s Investment Foundation, London, United Kingdom Dr Hemantha Senanayake, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka Prof Shi Qi, North Sichuan Medical College, Obstetrics and Gynaecology, Nanchong, China Dr Miannes Silvestre, University of the Philippines College of Medicine, Manila, Philippines 73 Dr Jeffrey Smith, JHPIEGO, Baltimore, MD, USA Dr Howard Sobel, WHO Regional Office for the Western Pacific, Manila, Philippines Prof Williams Stones, FIGO, London, United Kingdom Dr Tang Zengjun, Hebei Provincial People’s Hospital, Shijiazhuang, China Ms Nicole Thiele, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Paul Vinod, All-India Institute for Medical Sciences, New Delhi, India Ms Donna Vivio, United States Agency for International Development, Washington DC, USA Dr Gijs Walraven, Aga Khan Development Network, Paris, France Dr Wang Yeping, Wenzhou City People’s Hospital, Wenzhou, China Dr Martin Weber, WHO Regional Office for Europe, Copenhagen, Denmark Prof Zhang Hongyu, Hainan Medical, Haikou, China Dr Zhang Jim, Shanghai Jiao Tong University School of Medicine, Shanghai, China Dr Zhou Wei, Chongqing medical university, Chongqing, China Dr Nabila Zaka, UNICEF Headquarters, New York, USA Professor Zhang Huixin, Fourth Hospital of Hebei Medical University, Shijiazhuang, China

ISBN 978 92 4 151121 6Department of Maternal, Newborn, Child and Adolescent Health World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4853 E-mail: mach@who.int www.who.int Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth For more information, please contact:

STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES

STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES WHO Library Cataloguing-in-Publication Data: Standards for improving quality of maternal and newborn care in health facilities. 1.Maternal Health Services. 2.Maternal Welfare. 3.Infant, Newborn. 4.Child Health Services. 5.Delivery of Health Care – standards. 6.Perinatal Care. I.World Health Organization. ISBN 978 92 4 151121 6 (NLM classification: WA 310) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non- commercial distribution– should be addressed to WHO Press through the WHO website (http://www. who.int/about/licensing/copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by the WHO Document Production Services, Geneva, Switzerland. Design by Inís Communication – www.iniscommunication.com Acronyms and abbreviations iv Acknowledgements v Executive summary 1 1. Background 5 1.1 Introduction 5 1.2 Priorities for reducing maternal and perinatal mortality 6 1.3 Rationale 6 1.4 Target audience 7 2. Method and process 8 2.1 Overview 8 2.2 Scope 8 2.3 Development of the framework and standards of care 9 2.4 Development of quality measures 10 3. Definition and framework of quality of care 14 3.1 Evidence and summary of findings 14 3.2 Definition of quality of care 14 3.3 Quality of care framework 15 3.4 Strategic areas of work 17 4. Standards of care 18 4.1 Evidence and summary of findings 18 4.2 Definition and structure of standards 18 4.3 Scope and use of standards and quality statements 19 4.4 List of standards and quality statements 20 5. Quality statements and measures 24 5.1 Outcome of the Delphi process 24 5.2 Using quality measures 24 5.3 Measures for quality statements 25 6. Operationalization 63 6.1 Dissemination 63 6.2 Implementation approach 63 7. Monitoring and evaluation 65 8. Updating the standards 66 References 67 Annex 1. Participants in the meeting of the guideline development group, Geneva, 3–4 June 2015 69 Annex 2. List of participants in the Delphi study 70 Contents iv Acronyms and abbreviations ICD International Classification of Diseases NICE National Institute for Health and Care Excellence UNICEF United Nations Children’s Emergency Fund vAcknowledgements The WHO departments of Maternal, Newborn, Child and Adolescent Health and of Reproductive Health and Research gratefully acknowledge the contributions of many individuals to preparation of this document. Special thanks go to the experts who participated in and contributed to the framework for the quality of maternal and newborn care, standards of care and quality statements at a meeting in June 2015: Pierre Barker, Institute for Healthcare Improvement, USA; Nynke van den Broek, Liverpool School of Tropical Medicine, United Kingdom; Sheena Currie, Maternal and Child Health Integrated Program, USA; Kim Dickson, UNICEF, USA; Claudia Hanson, Karolinska Institute, Sweden; Kathleen Hill, JHPIEGO, USA; Asia Kassim Hussein, UNICEF, United Republic of Tanzania; Lily Kak, United States Agency for International Development, USA; Joy Lawn, London School of Hygiene and Tropical Medicine, United Kingdom; Tess Lawrie, Evidence- based Medicine Consultancy Ltd, United Kingdom; Norman Lufesi, Ministry of Health, Malawi; Silke Mader, European Foundation on the Care of Newborn Infants, Germany; Ziaul Matin, UNICEF, Bangladesh; Goldy Mazia, Maternal and Child Survival Program, USA; Georgina Msemo, Ministry of Health and Social Welfare, United Republic of Tanzania; Jim Neilson, University of Liverpool, United Kingdom; Lee Pyne-Mercier, Bill & Melinda Gates Foundation; USA; Isabella Sagoe-Moses, Ministry of Health, Ghana; Memuna Tanko, National Health Insurance Authority, Ghana; Donna Vivio, United States Agency for International Development, USA; and Nabila Zaka, UNICEF, USA. We acknowledge the contributions of the 116 experts in 46 countries who participated in the Delphi study to build consensus on the quality measures (listed in Annex 2). External consultants who supported the work at various stages are Carolyn MacLennan, Rashmi Mathur, Senait Kebede and Tess Lowrie. Staff members in the WHO Interdepartmental Guidelines Steering Group were Rajiv Bahl, Bernadette Daelmans, Matthews Mathai, Fran McConville, Annie Portela, Severin von Xylander and Wilson Were, Maternal, Newborn, Child and Adolescent Health; Metin Gülmezoglu, Olufemi Oladapo, Özge Tuncalp, and Joshua Vogel, Reproductive Health and Research; Neelam Dhingra, Shamsuzzoha Syed, Service Delivery and Safety; Margaret Montgomery and Michaela Pfeiffer, Public Health and Environment; Mwansa Nkowane, Health Workforce; and Gerardo Zamora and Lisa Rogers, Nutrition for Health and Development. This Publication was coordinated by staff members in the Maternal and Newborn Quality of care Core Working Group: Bernadette Daelmans, Olufemi Oladapo, Özge Tuncalp, Wilson Were and Severin von Xylander. We also acknowledge and thank all WHO staff in regions and countries who participated in the meetings, reviewed the text and provided input. We acknowledge and thank the Bill & Melinda Gates Foundation, which provided financial support for this work.

1Executive summary Much progress has been made during the past two decades in coverage of births in health facilities; however, reductions in maternal and neonatal mortality remain slow. With increasing numbers of births in health facilities, attention has shifted to the quality of care, as poor quality of care contributes to morbidity and mortality. The period around childbirth is the most critical for saving the maximum number of maternal and newborn lives and preventing stillbirths. WHO sees a future in which “Every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth and the postnatal period”. To realize this vision, WHO has defined “quality of care” and has prepared a framework for improving the quality of care for mothers and newborns around the time of childbirth. The framework contains eight domains of quality of care that should be assessed, improved and monitored within the health system. The health system provides the structure for access to high-quality care in the two important, inter-linked dimensions of provision and experience of care. Within this framework and in line with the Organization’s mandate, WHO will work towards realization of its vision in six strategic areas, which will be the basis for a systematic, evidence-based approach to providing guidance for improving the quality of maternal and newborn care. The six areas are: clinical guidelines, standards of care, effective interventions, measures of quality of care, relevant research and capacity-building Standards of care and measures of quality were prioritized because there is currently no substantive guidance, although it is the key to ensuring the quality of care. Standards explicitly define what is required in order to achieve high-quality care around the time of childbirth. In the first phase, a rigorous approach was used to identify existing resources, conduct an extensive literature search and map the standards of care of various organizations in order to define and determine their structure. It was proposed that broad standards be set, underpinned by specific quality statements and a number of input, output or process and outcome measures. Eight standards were formulated, one for each of the eight domains of the quality of care framework. To ensure that the standards are specific and focused, 2–13 quality statements were formulated for each standard to drive measurable improvements in the quality of care around childbirth. A WHO interdepartmental steering group and a core working group were established to review and synthesize the evidence. Between January 2015 and February 2016, the working group reviewed published studies to define “quality of care” and to formulate the framework for ensuring the quality of maternal and newborn care. The framework was presented to the guideline development group at a consultation held in Geneva on 3–4 June 2015, where the group reviewed and discussed the definition of “quality of care”, the proposed framework, standards of care, quality statements and criteria for defining measures of quality. Agreement on the definition, the domains of the framework, standards of care and the quality statements 2was reached by consensus. The guideline development group also discussed the criteria for defining the measures that would be used to assess, measure and monitor the quality of care. In the second phase, the interdepartmental guidelines steering group collated, reviewed and formulated input, output and outcome measures for each quality statement. These measures were derived from indicators used by WHO and other internationally recognized organizations in the public domain. Measures were then drafted by the relevant technical department and refined by consultation in the guidelines steering group. The resulting list was reviewed in two rounds of a Delphi process to ensure wider geographical (46 countries) and stakeholder (116 experts) consensus. Health facility teams can use the measures to identify gaps in the quality of care and improve the provision and experience of care according to the standards and quality statements. They are for use by health facility leaders, planners, managers and providers to assess and monitor the availability of resources, performance, areas for improvement and the impact of interventions, leading to better quality. The eight standards of care and 31 quality statements are listed below. Standards of care and quality statements Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Quality statements 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. 1.1b: Newborns receive routine care immediately after birth. 1.1c: Mothers and newborns receive routine postnatal care. 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines. 1.3: Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO guidelines. 1.4: Women with delay in labour or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. 1.7a: Women with or at risk for infection during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. 1.8: All women and newborns receive care according to standard precautions for preventing hospital-acquired infections. 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. 3Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Quality statements 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period. 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Quality statements 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Quality statements 4.1: All women and their families receive information about the care and have effective interactions with staff. 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals. Standard 5: Women and newborns receive care with respect and preservation of their dignity. Quality statements 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. 5.3: All women have informed choices in the services they receive, and the reasons for interventions or outcomes are clearly explained. Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability. Quality statements 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. 6.2: Every woman receives support to strengthens her capability during childbirth. 4Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Quality statements 7.1: Every woman and child has access at all times to at least one skilled birth attendant and support staff for routine care and management of complications. 7.2: The skilled birth attendants and support staff have appropriate competence and skills mix to meet the requirements of labour, childbirth and the early postnatal period. 7.3: Every health facility has managerial and clinical leadership that is collectively responsible for developing and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Quality statements 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functional, reliable, safe and sufficient to meet the needs of staff, women and their families. 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. 8.3: An adequate stock of medicines, supplies and equipment is available for routine care and management of complications. 51. Background 1.1 Introduction During the past two decades, considerable efforts have been made to ensure skilled birth attendance, with the aim of reducing morbidity and mortality among mothers and newborns. These efforts have substantially improved the number of births in health facilities, the proportion of deliveries attended by skilled health personnel in developing countries having increased from 56% in 1990 to 68% in 2012. Despite this increased coverage, 800 women and 7700 newborns still die each day from complications during pregnancy and childbirth and in the postnatal period; an additional 7300 women experience a stillbirth. With increasing numbers of births in health facilities, more avoidable maternal and perinatal mortality and morbidity are occurring in those facilities. The outcome of the care for women and newborns around the time of birth in health facilities reflects the evidence-based practices used and the overall quality of services provided. The quality of care depends on the physical infrastructure, human resources, knowledge, skills and capacity to deal with both normal pregnancies and complications that require prompt, life-saving interventions. Improving the quality of care in health facilities is thus increasingly recognized as an important focus in the quest to end preventable mortality and morbidity among mothers and newborns. Research has shown that maximizing coverage of essential interventions is insufficient to reduce maternal mortality and severe morbidity. Additionally, there is a complex interplay between experience of care and pregnancy outcomes. To end preventable maternal and newborn morbidity and mortality, every pregnant woman and newborn should have skilled care at birth with evidence-based practices delivered in a humane, respectful, supportive environment. Good-quality care requires appropriate use of effective clinical and non-clinical interventions, strengthened health infrastructure, optimum skills and a positive attitude of health providers. These will improve health outcomes and give women, their families and the health care providers a positive experience. High-quality care is integral to the right to health and the route to equity and the preservation of dignity for women and children. Ensuring access to skilled birth attendance and essential obstetric care that is effective and of good quality help reduce maternal and newborn mortality and morbidity (1). The WHO standards for the quality of maternal and newborn care are based on prioritized, evidence- based interventions during critical periods of care. WHO envisions a world in which “every pregnant woman and newborn receives quality care throughout pregnancy, childbirth and the immediate postnatal period” (2) This statement is aligned with two complementary global action agendas: “Strategies toward ending preventable maternal mortality” (3) and the “Every newborn: an action plan to end preventable deaths” (4). 61.2 Priorities for reducing maternal and perinatal mortality Globally, over 70% of maternal deaths are due to complications of pregnancy and childbirth such as haemorrhage, hypertensive disorders, sepsis and abortion (5). Complications of preterm birth, asphyxia, intra-partum perinatal death and neonatal infections account for more than 85% of newborn deaths (6). Studies show that effective, high-quality care to prevent and manage complications during this critical period is likely to reduce the numbers of maternal deaths, stillbirths and early neonatal deaths significantly (7). Hence, the time of childbirth and the period immediately after are particularly critical for maternal, foetal and neonatal survival and represent an opportunity to increase the return on investments to improve care. Effective prevention and management of conditions in late pregnancy, childbirth and the early newborn period are likely to reduce the numbers of maternal deaths, antepartum and intrapartum-related stillbirths and early neonatal deaths significantly. Therefore, improvement of the quality of preventive and curative care during this critical period could have the greatest impact on maternal, foetal and newborn survival. On the basis of the current evidence on burden and impact, the following thematic areas are considered high priorities for evidence- based practices in routine and emergency care (2). • routine care during childbirth, including monitoring of labour and newborn care at birth and during the first week; • management of pre-eclampsia, eclampsia and its complications; • management of difficult labour with safe, appropriate medical techniques; • management of postpartum haemorrhage; • newborn resuscitation; • management of preterm labour, birth and appropriate care for preterm and small babies; and • management of maternal and newborn infections. 1.3 Rationale Quality of care is increasingly recognized internationally as a critical aspect of the unfinished maternal and newborn health agenda, mainly with respect to care around labour and delivery and in the immediate postnatal period (8). It is recognized that high coverage alone is not enough to reduce mortality. To reduce maternal and neonatal mortality substantially and move towards elimination of preventable causes of maternal and newborn death, increased coverage should be accompanied by improved quality throughout the continuum of care (9, 10). The WHO Multicounty Survey on Maternal and Newborn Health (11), with data on more than 300 000 women attending 359 health care facilities in 29 countries, showed a poor correlation between coverage of “essential interventions” (e.g. the proportion of the population who had received an indicated intervention, such as women with eclampsia who received magnesium sulfate) and maternal mortality in health facilities. Studies also show that high-quality care requires appropriate use of the available infrastructure, staff and commodities to ensure effective case management (12). High-quality care requires appropriate use of evidence-based clinical practices and non-clinical interventions, strengthened health infrastructure and optimum skills and a positive attitude of health providers. 7Providing high-quality antenatal, intrapartum and postnatal care must be integral to any quality improvement strategy. Human rights norms, medical ethics and technical standards encourage integration of these services, directly or through effective referral, as a fundamental element of the quality of care.1 The right to health is a fundamental human right that is central to accelerating reductions in maternal, neonatal and child mortality and morbidity and is the route to equity and preservation of the dignity of women and children (13). 1.4 Target audience The quality of care framework, standards of care and quality measures may be used to guide the preparation of national standards of care and measures for improving, assessing and monitoring the quality of care provided to mothers and newborns in health facilities. The framework can also be used as a basis for quality improvement strategies and activities and for incorporating quality into existing national programmes. The framework, standards of care and quality measures are intended primarily for use by policy-makers, programme managers, health planners at national, subnational, district and facility levels, maternal and newborn health care professionals, and professional bodies or technical partners involved in quality of care or which advise ministries of health. They can also be used as a resource in medical training institutions. In recognition of the differences between countries with regard to the organizational structure of health facilities and the health workers who provide maternal and neonatal care, the document focuses on the standards of care, competence, services and physical resources necessary to ensure that maternal and neonatal health conditions are appropriately assessed, managed or referred within a functioning health system in order to provide the optimal care. The standards of care and quality measures should be adapted to the local context to ensure their applicability and to obtain the desired outcomes for mothers and newborns. 1 Germain A. Meeting human rights norms for the quality of sexual and reproductive health information and services. Commissioned discussion paper presented at the international conference on population and development beyond 2014. International conference on human rights, Noordwijk, 7–10 July 2013. 82. Method and process 2.1 Overview The vision of the quality of care, the framework, the standards of care and the measures of quality were defined in three phases. In the first, consensus was reached on the WHO vision, and the quality of maternal and newborn care was defined. In the second phase, agreement was reached on a conceptual framework for quality of care, a strategic approach to implementation and strategic areas for improving the quality of care. In the third phase, the group addressed gaps identified in strategic work areas and defined standards of care and measures for monitoring improvement in the quality of care in health facilities. These phases included a literature review, expert consultations and consensus-building in a Delphi process. 2.2 Scope The scope of the work was such as to provide comprehensive guidance to international and national stakeholders to meet the WHO global vision of improving the quality of care for mothers and newborns. This required a framework to define the domains of measurement, the means by which interventions can be expected to achieve the desired health outcomes and the measures required for assessment. A consultation was initiated in 2015 under the guidance of the Assistant Director-General of the Family, Women and Children cluster. An interdepartmental guidelines steering group was set up, consisting initially of members from the two departments directly responsible for maternal and newborn health: the Department of Maternal, Newborn, Child and Adolescent Health and the Department of Reproductive Health and Research. Once the vision had been defined, the steering group was expanded to include the departments of Public Health, Environmental and Social Determinants of Health, Service Delivery and Safety, Health Workforce and Nutrition for Health and Development. A core working group with members from the departments of Maternal, Newborn, Child and Adolescent Health and Reproductive Health and Research led evidence retrieval and synthesis and ensured coordination. The guidelines steering group met every two weeks to achieve consensus on the WHO vision of maternal and newborn quality of care and to define the scope of their work. Three categories of review were identified: • of definitions of quality of care in the context of maternal and newborn health; • of existing models of quality of care and the design of a systematic framework of important domains of maternal and newborn quality of care; and 9• of the literature and definition of an effective strategy for clinical and health service interventions to improve the quality of care at country level. These areas were addressed during the first and second phases as the basis for defining quality of care and the quality of care framework and identifying strategic work areas. Definition of standards of care was identified as a major gap. 2.3 Development of the framework and standards of care The core working group reviewed published and unpublished literature that reported definitions of quality of care, models of care, quality of care frameworks and strategic approaches that have been used to improve the quality of care in general and specifically for maternal and newborn health. The findings were presented to the interdepartmental guidelines steering group for review and discussion, and consensus was reached on a definition of quality of care, the conceptual framework and the strategic implementation approach (2). Standards represent benchmarks against which improvements can be measured and should therefore be measurable. Defining standards of care was identified as a priority, because there was little guidance available, except for evidence-based clinical practice guidelines. In a first step, a definition, taxonomy and structure were devised, and then standards of care were formulated. Consensus was reached on the definition, draft framework, and standards of care, which were then presented to a meeting of the guideline development group in June 2015 (Annex 1). 2.3.1 Evidence retrieval and synthesis MEDLINE, WHO publications and other databases were searched for relevant publications that provided definitions and models of quality of care, with the search terms “standard [definition] [criteria], [service delivery], [clinical or guidelines], [standard operating procedures]”. Additional searches were conducted by adding ‘maternal and newborn’ to the key words. Publications were located on organizations’ websites by utilizing the site’s search box or a specific section of their site dedicated to publications. Organizations that were likely to have developed standards in general and for maternal and newborns in particular including international quality and safety organizations, government agencies, nongovernment and professional organizations were identified. Box 1 lists the organizations the publications of which were used as the main sources for the definition, taxonomy and structure of standards of care. A general internet search with the Google search engine and the same key words was also conducted. The documents were then reviewed and analysed to identify a standard in terms of definition, description, format, measurement and taxonomy. The group also reviewed experience in improving the quality of care in various projects completed by WHO departments. 10 Box 1. Resources reviewed to define standards • International Organization for Standardization • International Society for Quality in Health Care • The Joint Commission (USA) • National Institute for Health and Care Excellence (NICE), United Kingdom • Council for Health Service Accreditation of Southern Africa • National Department of Health: National Core Standards for Health Establishment in South Africa (2011) • Safecare Basic Health Care Standards (PharmAccess Foundation of the Netherlands, the Joint Commission International of the USA and the Council for Health Service Accreditation of Southern Africa) • Australian Commission on Safety and Quality in Health Care: National safety and quality health service standards (2012) • WHO standards for maternal and newborn health. Group 1: General standards of care for healthy pregnancy and childbirth (2007) • WHO Regional Office for South-East Asia: Standards of Midwifery Care (1999) 2.3.2 Expert review and consensus-building In order to reflect the diversity of expert opinion and technical perspectives appropriately, the quality of care framework and standards of care were defined in a participatory process. The draft was reviewed by relevant WHO departments to ensure technical accuracy and consistency and with WHO regional offices and country representatives to assess their applicability in different contexts. The consultation was conducted electronically and at face-to-face meetings, followed by a one-day meeting of the members of the interdepartmental guideline development group to review, finalize and draft the framework and standards of care for presentation and discussion by the guideline development group. In June 2015, an expert meeting (Annex 1) was held to review the WHO vision and framework and to achieve consensus on the WHO approach and the draft standards of care. The experts reviewed the background information and drafts to determine the comprehensiveness of the review and whether the proposed definition of quality of care, framework and standards of care reflected current knowledge and understanding of quality of care, their applicability to values in low-resource settings and the feasibility of implementation. Consensus was reached on most items and by a show of hands only exceptionally. The drafts were finalized on the basis of the outcome of the meeting. 2.4 Development of quality measures Measures of quality are a fundamental component of standards of care. They are required to measure inputs, the process of care or service provision and, if appropriate, the outcome of care and thus to monitor progress towards achievement of a particular standard of care. Defining measures of quality is challenging, however, in view of variations in definitions, complex interactions among the factors responsible for outcomes and the context of their use and application. 11 The group sought realistic parameters and a balanced approach to measuring interventions in health facilities. They sought both appropriate direct measures and measures that reflect the combined effect of interventions The initial step was to identify the elements of interventions that define the standards of care, on the basis of WHO guidelines and other relevant sources. A list of quality measures was then collated, and the relevant WHO technical unit formulated a quality statement. These were reviewed by the interdepartmental guidelines steering group before a Delphi process for consensus-building. 2.4.1 Collating and drafting quality measures WHO technical departments drafted the quality measures for each statement in collaboration with the core working group. The group mapped and collated existing measures from WHO guidelines, several WHO tools for assessing health facilities and collecting data and from national and international partners. When no measures were found in these sources, new measures were formulated on the basis of current guidelines and discussed within the relevant WHO units. The measures were collated, and the interdepartmental guidelines steering group drafted a list of 318 measures for the 31 quality statements, to be reviewed in the wider consultation. 2.4.2 Consensus-building on quality measures To build consensus on the quality measures, a wider consultation was undertaken, initially within WHO technical units and regional and country offices and then globally in a Delphi process. Prospective participants in the global consultation were identified who had a wide spectrum of expertise, from the provision of care to the experience of care. They included experts in quality of care, professionals (e.g. obstetricians, a neonatologist, paediatricians, midwives, nurses, communication specialists, lawyers), researchers, academics, users and implementers at various levels and representatives of consumer organizations, professional societies and international and bilateral agencies. Invitations were sent to 215 prospective participants in 60 countries to gauge their interest and obtain consent to participate. The aim was to recruit approximately equal numbers of participants in the various sectors of health and social care, with global representation. Of 215 invitees, 130 (60%) in 48 low-, middle- and high-income countries agreed to participate. The quality measures were sent to those who consented to participate in the consultation, which was conducted in two rounds over 14 weeks. Online software (SurveyMonkey®) allowed participants to submit their comments and rankings of measures in two rounds. In the first round, participants were asked to review the list of 318 quality measures for validation and completeness, provide comments and propose any additional measures. In the second round, participants were asked to prioritize the measures on the basis of the criteria agreed at the guideline development group expert meeting. Round one of the Delphi survey In the first round, the 130 participants were sent the list of quality measures divided into three sections, the first covering provision of care (standards 1–3), the second covering experience of care (standards 4–6) and the third on cross-cutting areas (standards 7 and 8). Participants could choose to address either provision or experience of care plus cross-cutting areas or all three sections, depending on their expertise. They were asked to provide general comments on the validity and completeness of the measures for each quality statement and, if necessary, 12 to propose additional measures. The survey was open for two weeks, during which time three reminder e-mails were sent. The participants were encouraged to complete the survey at their own pace and to review their answers before submitting them. The core working group analysed the text comments and the quality measures proposed by the respondents and grouped them for each quality statement. Text comments were analysed and organized into categories, which were refined and clustered by the aspects of care covered by the quality statements. The categories included comments that provided insight into areas that were not covered but considered important, those that suggested reformulation of a measure and those that extended a statement in some way. The proposed additional quality measures were also grouped into themes. The relevant technical units then reviewed the grouped comments and additional measures and compiled a list for round 2 of the Delphi process. Round two of the Delphi survey The second round was conducted six weeks after the first, when the list was sent to 116 respondents who had expressed preferences in the first round. Three surveys were designed: one on the provision of care plus the cross-cutting areas (standards 1–3, 7 and 8), a second on experience of care plus cross-cutting areas (standards 4–6, 7 and 8) and the third on all the quality statements. The online survey was open for four weeks, and four reminder e-mails were sent during this period. In this round, respondents were asked to score the quality measures on the basis of the following five criteria, agreed upon by the guideline development group: • Importance: The topic of the measure is significant and strategically important to stakeholders (e.g. patients, clinicians, purchasers, public health officials, policy-makers). Health importance: The aspect of health that the measure addresses is important, as indicated by high prevalence or incidence and/or a significant effect on the burden of illness (i.e. effect on mortality and morbidity in a population). • Measurability: The requirements for data collection for the measure are understandable and feasible. The data source required for implementing the measure is available and accessible within the timeframe for measurement. • Reliability: The results of the measurement are reproducible for a fixed set of conditions, irrespective of who makes the measurement or when it is made. • Validity: The measure truly measures what it purports to measure. • Usefulness: The measure provides a meaningful measure of change over time, for decision-making. For each of the above criteria, participants had six graded options, from which to choose one: • No: This quality measure does not fulfil this criterion. • Probably no: This quality measure probably does not fulfil this criterion. • Not sure: I am not sure whether this quality measure fulfils this criterion. • Probably yes: This quality measure probably fulfils this criterion. • Yes: This quality measure fulfils this criterion. • No expertise: I don’t have expertise in this area. 13 Ranking of quality measures The ratings given in round 2 by the survey respondents were used to estimate a mean score for each quality measure, as follows: • No: This quality measure does not fulfil this criterion. = 0 points • Probably no: This quality measure probably does not fulfil this criterion. = 0.25 point • Not sure: I am not sure whether this quality measure fulfils this criterion. = 0.5 point • Probably yes: This quality measure probably fulfils this criterion. = 0.75 point • Yes: This quality measure fulfils this criterion. = 1 point • No expertise: I don’t have expertise in this area. = Blank “Blank” responses were not included in calculation of the mean scores. Calculation of mean scores A mean score was calculated for each quality measure on each criterion and termed the “intermediate” score, calculated as equal to the sum of all the scores for a particular criterion divided by the number of respondents (excluding blanks). The intermediate score for a quality measure for one criterion = mean score (C) for that quality measure by the number of participants. “C” is equal to the sum of the scores for that criterion divided by the total number of respondents (excluding blanks). As there were five criteria, the mean of the five intermediate score was calculated to obtain the final priority score for each quality measure. The final priority score for each quality measure was calculated by adding the intermediate scores for that measure on the five criteria, divided by 5. Final score for a quality measure = Mean of the intermediate scores for the five criteria = (C1+C2+C3+C4+C5)/5. The input, output and outcome quality measures were then ranked for each quality statement, according to the final priority score. 14 3. Definition and framework of quality of care 3.1 Evidence and summary of findings No one, universally accepted definition of quality of care was found in the literature (14–18). Quality of care was found to be multi-faceted and described from different perspectives and dimensions, including by health care providers, managers or patients and the health care system; on the basis of quality characteristics such as safety, effectiveness, timeliness, efficiency, equity and patient-centredness; and as the provision and experience of care (Box 2). A number of models of quality of care have been proposed since that of Donabedian in 1988 (18): Maxwell (19), Ovretveit et al. (20), Hulton et al. (21), the Institute of Medicine (16) and WHO (17). The three models most commonly used and most clearly defined were perspective, characteristics and systems models, which have been used to operationalize the characteristics of quality of care on the basis of various elements. The most compelling was the WHO model (17), which advanced health systems thinking by identifying six building blocks – service delivery; health workforce; information, medical products, vaccines and technology; financing, leadership and governance; and a structure for establishing health systems analysis and points of intervention. The health system creates the structure that enables access to high-quality care. These models were used to design a conceptual framework for defining, assessing and monitoring the quality of maternal and newborn care. The definition and framework of maternal and newborn quality of care described below were based on the above analysis and the consensus reached at the guideline development group expert meeting. 3.2 Definition of quality of care On the basis of several definitions in the literature, the WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred” (2). 15 Box 2. Operational definitions of the characteristics of quality of care • Safe – delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors • Effective – providing services based on scientific knowledge and evidence-based guidelines • Timely – reducing delays in providing and receiving health care • Efficient – delivering health care in a manner that maximizes resource use and avoids waste • Equitable – delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status • People-centred – providing care that takes into account the preferences and aspirations of individual service users and the culture of their community The quality of care for women and newborns is therefore the degree to which maternal and newborn health services (for individuals and populations) increase the likelihood of timely, appropriate care for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and take into account the preferences and aspirations of individual women and their families. This definition takes into consideration the characteristics of quality of care and two important components of care: the quality of the provision of care and the quality of care as experienced by women, newborns and their families. 3.3 Quality of care framework As quality of care is multidimensional, various models were used to prepare a conceptual framework to guide health care providers, managers and policy-makers in improving the quality of health services for mothers and newborns. Building on these models and the WHO health systems approach, a quality of care framework (Fig. 1) was designed by identifying domains that should be targeted to assess, improve and monitor care in health facilities in the context of the health system (2). The framework has eight domains of quality of care within the overall health system. Although it focuses on the care provided in facilities, it also accounts for the critical role of communities and service users in identifying their needs and preferences and in managing their own health. The perspectives of women, their families and their communities on the quality of maternity care services influence their decision to seek care and are essential components in creating a demand for and access to high-quality maternal and newborn services (12). Community engagement is therefore an important aspect to be considered, beyond health facilities, and should be an integral component of improving the quality of care for women and newborns. 16 Fig. 1. WHO framework for the quality of maternal and newborn health care Health system St ru ct ur e Quality of Care O ut co m e Pr oc es s Individual and facility-level outcomes Coverage of key practices People-centred outcomes Health outcomes PROVISION OF CARE EXPERIENCE OF CARE 7. Competent, motivated human resources 8. Essential physical resources available 1. Evidence based practices for routine care and management of complications 2. Actionable information systems 3. Functional referral systems 4. Effective communication 5. Respect and preservation of dignity 6. Emotional support The framework of eight domains of quality of care for pregnant women and newborns in facilities increases the likelihood that the desired individual and facility outcomes will be achieved. The health system approach provides the structure for quality improvement in the two linked dimensions of provision and experience of care. Provision of care includes use of evidence-based practices for routine and emergency care, information systems in which record- keeping allows review and auditing and functioning systems for referral between different levels of care. Experience of care consists of effective communication with women and their families about the care provided, their expectations and their rights; care with respect and preservation of dignity; and access to the social and emotional support of their choice. The cross-cutting areas of the framework include the availability of competent, motivated human resources and of the physical resources that are prerequisites for good quality of care in health facilities. This framework can be used to assess the characteristics or dimensions of quality of care in various sectors of the health system, from the perspectives of service users, service providers and managers. On the basis of this framework and in line with the organizational mandate, six strategic areas of work were identified for improving the quality of maternal and newborn care. These six areas were used as the basis for a systematic, evidence-based approach to preparing guidelines, standards of care, effective interventions, indicators of quality of care and research and capacity-building for improving the quality of maternal and newborn care. 17 3.4 Strategic areas of work The six strategic areas for improving the quality of care and ending preventable mortality and morbidity among mothers and newborns are research, guidelines, standards of care, effective intervention strategies, indicators for monitoring at global, national and facility levels and strengthening capacity for quality improvement, measurement and programming (2). Guided by the framework, work in these strategic areas will support improvement of the quality of maternal and newborn care, with targeted national capacity strengthening and technical support. A review indicated, however, that, whereas evidence-based clinical practice guidelines are generally available, there was no guidance on expected standards of care and appropriate measures of quality. Therefore, standards of care and quality measures were prioritized as the first normative products. 18 4. Standards of care 4.1 Evidence and summary of findings The search for definitions, taxonomy and the structure of standards of care resulted in no consistent “definition” or specific, standardized “structure”. The majority of the sources identified were from non-health related areas that defined a standard as a statement that provides guidance to ensure consistency in processes and products (22). Health related standards were predominantly from high-income settings (23, 24). The National Centre for Health and Care Excellence (NICE) provided examples of maternal and newborn standards, including standards for antibiotics for neonatal infection, hypertension in pregnancy, induction of labour, caesarean section, postnatal care and antenatal care (25). The PharmAccess Foundation in the Netherlands (26), the Joint Commission International in the USA (23) and the Council for Health Service Accreditation of Southern Africa (24) have issued standards for low- and middle-income countries. In 2007, WHO published a limited number of standards for maternal and newborn care (27), none of which were specific to the time around childbirth. These health-related sources defined standards primarily for “accreditation”, although a few were for “quality improvement”, providing “criteria” for meeting standards in “prioritized areas”, with recognized gaps in quality and safety. While most recommended the need for “measurement criteria”, few provided such measurements. 4.2 Definition and structure of standards On the basis of these findings, for maternal and newborn care, a “standard” is defined as “a description of what is expected to be provided to achieve high-quality care around the time of childbirth”. The standard of care has two main components: the quality statement and the quality measure (Fig. 2). A quality statement sets out the requirements to achieve compliance with the standard and quality measures provide objective evidence for determining whether or not the requirements have been met. Quality statements are concise statements of priorities for measurably improving quality of care around childbirth (adapted from NICE quality standards (25). They define the markers of quality derived from evidence on the thematic area and the resources required. Quality measures are criteria for assessing, measuring and monitoring the quality of care as specified in the quality statement. They are of three types: • input: what must be in place for the desired care to be provided (e.g. physical resources, human resources, policies, guidelines), 19 • output: whether the desired process of care was provided as expected and • outcome: the effect of the provision and experience of care on health and people-centred outcomes. Fig. 2. Structure of standards In line with the eight domains in the WHO quality of care framework, eight standards have been formulated to define the priorities for quality improvement: 1. evidence-based practices for routine care and management of complications; 2. actionable information systems; 3. functioning referral systems; 4. effective communication; 5. respect and preservation of dignity; 6. emotional support; 7. competent, motivated personnel; and 8. availability of essential physical resources. The standards are accompanied by two or three quality statements; the exception is standard 1 on evidence-based practices for routine care and management of complications, for which there are 13 quality statements to reflect specific priorities for intervention. There are a total of 31 quality statements. For standard 1, some are annotated with ‘a’ if they cover only the woman, ‘b’ if they cover the baby and ‘c’ if they cover both the mother and the baby. Each of the 31 quality statements has 6–18 measures of input, output and outcome. 4.3 Scope and use of standards and quality statements The standards of care cover the routine care and management of complications occurring for women and their babies during labour, childbirth and the early postnatal period, including those of small babies during the first week of life. They are centred on the woman, the newborn and the family and are applicable to all health facilities that offer maternity services. They are in line with WHO guidelines and designed to address the specific priorities identified in section 1.2. The standards of care provide a basis for what is expected and required, support the monitoring and measurement of performance against measures of best practice in order to identify priorities for improvement and provide information on how best practice can be used to support high- quality care or service delivery. They define priorities for improving the quality of maternal and newborn care for use by planners, managers and health care providers to: Quality measures (input, output and outcome) Two or three quality statements per standard Eight standards, one for each WHO quality of care framework domain 20 • prepare evidence-based national and subnational standards of care to ensure high-quality, effective maternal and neonatal health services around the time of childbirth; • introduce the expected standards of care and delivery in order to identify the components of care that require improvement to ensure high-quality service; • use available resources to achieve optimal health care outcomes and improve the use by and satisfaction of individuals, families and communities with maternal and neonatal health services; • monitor service improvements, show that high-quality maternal and newborn care or services are being provided and highlight areas for improvement; and • provide a benchmark for national health facility audits, accreditation and rewards for provider performance. They should be adopted and streamlined within national quality of care strategies and frameworks for the delivery of maternal and newborn health services to ensure that the services provided are of high quality. 4.4 List of standards and quality statements Evidence-based practices for routine care and management of complications Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Aim: The aim of this standard is to ensure the expected evidence-based management of labour, childbirth and the immediate postnatal period to mothers and to newborns in the first few days of life. It includes routine care, early diagnosis of complications and their appropriate management. Many conditions require attention during this period; the standard has therefore been limited to those associated with high morbidity and mortality. Managing these conditions appropriately will drastically reduce the number of deaths and improve outcomes of women and newborns during this period. Quality statements Quality statement 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. Quality statement 1.1b: Newborns receive routine care immediately after birth. Quality statement 1.1c: Mothers and newborns receive routine postnatal care. Quality statement 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.3: Women with postpartum haemorrhage promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.4: Women with delay in labour or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. Quality statement 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. 21 Quality statement 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. Quality statement 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. Quality statement 1.7a: Women with or at risk for infection during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. Quality statement 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. Quality statement 1.8: All women and newborns receive care according to standard precautions for preventing hospital-acquired infections. Quality statement 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. Actionable information systems Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Aim: The aim of this standard is to record all information in the health facility accurately and to use it appropriately to improve the care of women and newborns. This will require the availability of standard forms for collecting information on all patients throughout their stay in the facility and trained, skilled staff for data collection, analysis and use of the results to provide feedback to monitor and improve performance at all levels of the health care system, including the performance of health care staff. Quality statements Quality statement 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period Quality statement 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Functional referral systems Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Aim: The aim of this standard is to ensure timely, appropriate referral of all patients who need care that cannot be provided in the health facility. The decision to refer a patient should be made as soon as a condition that cannot be treated in the health facility is diagnosed, once the required pre-referral treatment has been given. Communication should be made with the centre to which the referral is made before transfer of the patient, so that appropriate arrangements can be made to receive the patient. A complete hand-over should be given to the receiving health facility, and feedback on the condition of the patient should be sought periodically to improve care in both the referring and referral health facility. 22 Quality statements Quality statement 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. Quality statement 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. Quality statement 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Effective communication Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Aim: The aim of this standard is effective communication, which is an essential component of the experience of care received by the patient and her family. The patient should receive all information about her care and should feel involved in all decisions taken regarding her treatment. Effective communication between the health care provider and the patient can reduce unnecessary anxiety and make childbirth a positive experience for the woman. Quality statements Quality statement 4.1: All women and their families receive information about the care and have effective interactions with staff. Quality statement 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals Respect and preservation of dignity Standard 5: Women and newborns receive care with respect and can maintain their dignity. Aim: The aim of this standard is to give total respect and to preserve the dignity of all women throughout their stay in the health facility. Their privacy and confidentiality should be respected at all times, and any kind of mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services, should be avoided. Quality statements Quality statement 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected. Quality statement 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. Quality statement 5.3: All women can make informed choices about the services they receive, and the reasons for interventions or outcomes are clearly explained. Emotional support Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability. 23 Aim: Emotional support is an essential component of the experience of care. Having the birth companion of her choice helps a woman to go through childbirth more confidently. Every woman receives support that strengthens her own capability during childbirth. Quality statements Quality statement 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. Quality statement 6.2: Every woman receives support to strengthen her capability during childbirth. Competent, motivated human resources Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Aim: All labour and childbirth areas of the health facility should have competent, well-trained staff and skilled birth attendants present 24 h a day in sufficient numbers for the expected work load. Good leadership and management in the health facility are essential to provide support and ensure continuous quality improvement. Quality statements Quality statement 7.1: Every woman and child has access at all times to at least one skilled birth attendant and to support staff for routine care and management of complications. Quality statement 7.2: The skilled birth attendants and support staff have appropriate competence and skills mix to meet the requirements of labour, childbirth and the early postnatal period. Quality statement 7.3: Every health facility has managerial and clinical leadership that is collectively responsible for developing and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Essential physical resources available Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Aim: Every health facility should have basic infrastructure and amenities, including water, sanitation, hygiene and electricity, waste disposal, a stock of essential medicines, supplies and equipment to meet the health care needs of the women and newborns in the facility. Areas for labour, childbirth and postnatal care should be hygienic, comfortable and logically designed and organized to maintain continuity of care. Quality statements Quality statement 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functioning, reliable, safe and sufficient to meet the needs of staff, women and their families. Quality statement 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. Quality statement 8.3: Adequate stocks of medicines, supplies and equipment are available for routine care and management of complications. 24 5. Quality statements and measures 5.1 Outcome of the Delphi process Most of the 318 measures drafted for the online Delphi consultation were input and output measures, as outcome measures are not necessarily covered by a single quality statement. Outcomes measures are mainly those that could be used at local level to reliably assess the quality of care and allow comparisons between facilities or changes over time. In round 1, 116 of the 130 participants who received the survey (89%) responded. In general, they agreed that the quality measures considered covered the inputs, process and outcomes of the quality of the care that women and newborns receive around the time of birth. Of the comments received, some indicated important areas that had not been covered, proposed reformulation of some measures or extended the reflection beyond the quality statements. Some were not directly related to the quality statements but reflected participants’ general views on the quality of care. A number of quality statements were clarified on the basis of the comments, 10 were deleted, and 41 new measures were added, resulting in a total of 350 quality measures for consideration in round 2. In round 2, a total of 81 participants in 46 high-, middle- and low-income countries completed one of the three surveys, for a response rate of 70% (81/116). Sixty-one of 83 respondents commented on the provision of care and 48 of 74 on the experience of care. Most of the quality measures were ranked highly, from a high of 94.8 to a low of 64.3; only three measures were ranked below 70. For provision of care, the mean score was > 90 for 35 measures, 80–90 for 116 measures and < 80 for 45 measures. For experience of care, the mean score was > 90 for nine measures, 80–90 for 47 measures and < 80 for 16 measures. For cross- cutting measures, the mean score was ≥ 90 for 12 measures, 80–90 for 50 measures and ≤ 80 for 16 measures. Thus, 56 quality measures received a ranking of > 90. Most of the most highly ranked quality statements were input measures. 5.2 Using quality measures Health facility teams can use the quality measures to identify gaps in the quality of care and to improve the provision and experience of care according to the standard and the relevant quality statement. Health facility leaders, planners, managers and providers can use them to assess and monitor the availability of resources, the performance of processes, areas that require improvement and the impact of interventions, hence driving quality improvement. The 25 measures should be adapted to each context, but standards must be implemented consistently to ensure quality improvement. The quality measures include input, output/process and outcome measures. Input measures include physical resources, human resources, policies, protocols and guidelines. Output measures include coverage of key practices and most are expressed as proportions, such as “The proportion of all women who gave birth in the health facility whose urinalysis result was appropriately recorded during labour, childbirth and the early postpartum period.” The outcome measures include people centred and health outcomes. Most quality statements are followed by measures that are highly specific to that statement; however, some measures might be relevant to more than one statement, especially with regard to physical resources (standard 8). The numbering of the quality measures reflects the order in which they were listed in the survey. The score received by each measure is given in brackets, and the three most highly ranked quality measures for each statement are marked with an asterisk. 5.3 Measures for quality statements Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines. Quality statement 1.1a: Women are assessed routinely on admission and during labour and childbirth and are given timely, appropriate care. Rationale: Assessment of women and regular monitoring on admission and during labour and birth are critical to ensure essential care that is appropriate to the woman’s case, to prevent the onset of complications and to identify risks or complications that require urgent action or referral for better outcomes of pregnancy and labour for both the mother and the newborn. On admission, women undergo a full review of their antenatal care records, pregnancy and labour history, a vaginal examination and confirmation of labour. Fetal heart rate, fetal lie, position and presentation, blood pressure, pulse and temperature are determined and recorded. Blood group and Rhesus typing, haemoglobin, urine protein and glucose, and HIV status, if appropriate, are tested and recorded. The progress of labour is monitored with a partograph; blood pressure, pulse, temperature and fetal heart rate are assessed regularly and at a 4-h action line. Pain relief is offered, and the mother’s choice is respected. Spontaneous vaginal birth is supported and guided by the mother’s urge to push. The third stage of labour is managed actively, with intravenous or intramuscular oxytocin given immediately after the birth. Any complications at admission and during labour and birth are rapidly identified and appropriately managed (see quality statements 1.2, 1.3, 1.4, 1.5, 1.6a and b, 1.7a and b). 26 Quality measures Input measures 1. The health facility has the basic essential equipment and supplies for routine care and detection of complications (thermometers, sphygmomanometers, fetal stethoscopes, urine dipsticks) available in sufficient quantities at all times in the areas of the maternity unit for labour and childbirth*. (93.38) 2. The health facility has written, up-to-date clinical protocols for assessing intrapartum care and action in the labour and childbirth areas of the maternity unit that are consistent with WHO guidelines*. (89.37) 3. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training and regular refresher sessions at least once every 12 months in the identification and management of obstetric emergencies during labour and childbirth. (83.42) 4. Health-care staff in labour and childbirth areas receive at least monthly drills or simulation exercises and supportive supervision in routine care and detection of obstetric complications during labour and childbirth. (78.65) Output/process measures 1. The proportion of all women who gave birth in the health facility whose blood pressure, pulse and temperature were appropriately recorded during labour, childbirth and the early postpartum period (and acted on if appropriate). (87.25) 2. The proportion of all women who gave birth in the health facility who received oxytocin within 1 min of the birth of their baby. (86.18) 3. The proportion of all women who gave birth in the health facility whose progress in labour was correctly monitored and documented with a partograph and a 4-h action line. (84.56) 4. The proportion of all women who gave birth in the health facility whose urinalysis result was appropriately recorded during labour, childbirth and the early postpartum period (and acted on if appropriate). (78.45) 5. The proportion of all women who gave birth in the health facility who received any option for pain relief during labour and childbirth. (73.04) Outcome measures 1. The health facility perinatal mortality rate [number of foetal death (stillbirths) or early neonatal deaths / the total number of births of babies weighing at least 1000 g or of 28 weeks’ gestation (stillbirths + live births) x 1000] *. (91.39) 2. Intrapartum stillbirth rate (number of stillbirths occurring during the intrapartum period per 1000 births). (88.42) 3. The proportion of all women admitted to the health facility in active labour who gave birth within 12 h. (72.83) Quality statement 1.1b: Newborns receive routine care immediately after birth. Rationale: Routine care of newborns immediately after birth facilitates adaptation of the newborn to the new environment, meets his or her immediate needs in the best possible way and avoids preventable complications. Immediately after birth, newborns are dried thoroughly and placed in skin-to-skin contact with the mother for at least 1 h. Clamping of the umbilical cord is delayed until 1–3 min after birth, and breastfeeding is supported in the first hour after birth. Any complications are identified and managed appropriately. 27 Quality measures Input 1. The health facility has written, up-to-date, clinical protocols for essential newborn care that are consistent with WHO guidelines and are available in the labour and childbirth areas of the maternity unit*. (91.09) 2. The health facility has supplies of sterile cord ties (or clamps) and scissors (or blades), available in sufficient quantities at all times for the expected number of births*. (89.86) 3. The health facility has supplies of clean towels in the labour and childbirth areas for immediate drying of newborns, available in sufficient quantities at all times for the expected number of births. (84.83) 4. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training or regular refresher sessions in essential newborn care and breastfeeding support at least once every 12 months. (83.94) 5. The health facility has local arrangements and a mechanism to maintain a documented room temperature in the labour and childbirth areas at or above 25 °C and free of draughts. (77.9) 6. Health-care staff in the labour and childbirth areas receive at least monthly drills or simulation exercises and supportive supervision in essential newborn care and supporting breastfeeding. (77.82) Output/process 1. The proportion of all newborns who were breastfed within 1 h of birth*. (86.42) 2. The proportion of all newborns who were kept in skin-to-skin contact (with body and head covered) with their mothers for at least 1 h after birth. (83.34) 3. The proportion of all newborns who received all four elements of essential newborn care: immediate and thorough drying, immediate skin-to-skin contact, delayed cord clamping and initiation of breastfeeding in the first hour. (78.93) 4. The proportion of all newborns whose umbilical cord was clamped 1–3 min after birth. (76.56) 5. The proportion of all newborns who were dried immediately and thoroughly at birth. (76.53) Outcome 1. The proportion of all newborns who had a normal body temperature (36.5–37.5 °C) at the first complete examination (60–120 min after birth). (85.37) Quality statement 1.1c: Mothers and newborns receive routine postnatal care. Rationale: Routine postnatal care represents the use of best practices for prevention, early detection and treatment of complications in the mother and baby and counselling of mothers on how best to take care of themselves and their newborns. Postnatal care, the individualized care provided to a mother and her baby after childbirth should address any variation from the expected normal recovery after birth. Blood pressure, temperature, bleeding and urine voiding are monitored frequently during the first 48 h after childbirth. Complications are identified and managed, and exclusive breastfeeding is supported. Mothers are counselled on danger signs in themselves and their babies and on birth spacing and family planning methods. Newborns receive a complete physical assessment, are kept in skin-to-skin contact with the mother and given eye and umbilical cord care. Bathing is delayed for 24 h, vitamin K and vaccines are given as per the national guidelines, temperature is monitored, and complications are identified and managed. Low-birth-weight and small babies are given additional care as needed (see Quality statement 1.6b). 28 Quality measures Input 1. The health facility has written, up-to-date clinical protocols for postnatal care in the maternity and/ or postnatal care areas of the maternity unit that are consistent with WHO guidelines*. (90.10) 2. The health facility practises and enables rooming-in to allow mothers and babies to remain together 24 h a day*. (86.57) 3. The health facility has a written breastfeeding policy that is routinely communicated to all health care and support staff. (83.18) 4. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in routine postnatal care and breastfeeding at least every 12 months. (83.04) 5. The health facility has local arrangements to ensure that every mother knows when and where postnatal care for herself and her newborn will be provided after discharge from the hospital. (79.98) 6. The health facility has local arrangements for alternative feeding methods, including cup or cup-and- spoon feeding, and avoids bottle-feeding. (78.97) 7. The health facility has local arrangement to inform pregnant women and their families about the benefits and management of breastfeeding. (74.49) 8. The health facility ensures that feeding of infant formula is demonstrated to mothers and family members of newborns only when needed, with a full explanation of the hazards of improper use. (71.85) Output/process 1. The proportion of all newborns on postnatal care wards or areas in the health facility who received vitamin K and full vaccination as per national guidelines*. (91.23) 2. The proportion of all stable newborns in the health facility who are fed exclusively on breast milk from birth to discharge. (84.37) 3. The proportion of all women in postnatal care wards or areas in the health facility who have documented problems of blood pressure, pulse rate, vaginal bleeding, lochia or breastfeeding. (84.02) 4. The proportion of all newborns in the health facility who received a full clinical examination before discharge. (83.13) 5. The proportion of all healthy mothers and newborns who received care for at least 24 h after an uncomplicated vaginal birth in a health facility. (82.50) 6. The proportion of all newborns on postnatal care wards or areas in the health facility for whom there is documented information on the newborn body temperature, respiratory rate, feeding behaviour and the absence or presence of danger signs. (82.41) 7. The proportion of all healthy mothers on postnatal wards or areas in the health facility who received breastfeeding counselling and support from a skilled health care provider. (82.14) 8. The proportion of all women who gave birth in the health facility who were allowed to room-in with their newborn 24 h a day. (78.90) 9. The proportion of all postpartum women in the health facility who were offered counselling on birth spacing and family planning methods before discharge. (77.84) Outcome 1. The proportion of all newborns in the health facility who were exclusively breastfed at the time of discharge from hospital. (85.55) 2. The proportion of all postpartum women in the health facility who received contraception counselling on birth spacing and family planning before discharge. (84.03) 29 Quality statement 1.2: Women with pre-eclampsia or eclampsia promptly receive appropriate interventions. Rationale: Pregnancy-induced hypertension, pre-eclampsia and eclampsia are major causes of maternal mortality, stillbirth and neonatal mortality. Prevention, early diagnosis and timely, appropriate treatment can drastically reduce the associated mortality and morbidity. Women with severe pre-eclampsia are immediately given intravenous or intramuscular magnesium sulfate and an antihypertensive, as appropriate. A pre-referral loading dose of magnesium sulfate should be given if the woman is to be transferred. Signs of organ dysfunction and other danger signs (blood pressure, respiratory rate, fluid balance, urine output, tendon reflexes and foetal heart rate) are monitored. Laboratory testing of urea and electrolytes determines the progression of disease. If the woman is at term or the foetus is nonviable, labour is induced with instrumental intervention or caesarean section, as appropriate. For preterm pregnancies, proactive management with corticosteroids is undertaken if the condition is stable. Quality measures Input 1. The health facility has supplies of oral and intravenous antihypertensive agents and magnesium sulfate available in sufficient quantities at all times in the antenatal, labour and childbirth areas of the maternity unit*. (91.8) 2. The health facility has written, up-to-date clinical protocols on the management of pre-eclampsia that are available in the labour, childbirth and postnatal areas of the maternity unit and are consistent with WHO guidelines. (90.59) 3. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in the use of antihypertensive agents, intravenous infusion and magnesium sulfate for treating pre- eclampsia and eclampsia at least once every 12 months. (84.54) Output/process 1. The proportion of all women with severe pre-eclampsia or eclampsia in the health facility who received the full dose of magnesium sulfate*. (91.37) 2. The proportion of all women with severe pregnancy-induced hypertension in the health facility who received the recommended antihypertensives. (88.02) 3. The proportion of all women with pre-eclampsia in the health facility whose condition progressed to eclampsia. (81.9) Outcome 1. The proportion of all women with pre-eclampsia or eclampsia in the health facility who died as a result of pre-eclampsia or eclampsia*. (91.22) 2. The proportion of all women with pre-eclampsia or eclampsia who arrived at the health facility with a live foetus whose baby died in the perinatal period (stillbirths or early neonatal deaths). (86.55) 3. The proportion of all women with pre-eclampsia or eclampsia in the health facility who experienced maternal near-misses due to pre-eclampsia or eclampsia. (76.88) 30 Quality statement 1.3: Women with post-partum haemorrhage promptly receive appropriate interventions. Rationale: Post-partum haemorrhage is the leading cause of preventable maternal mortality, most deaths occurring in the first 24–48 h of delivery. Early diagnosis and timely, adequate management are the basis for effectively reducing mortality. Postpartum bleeding is monitored routinely. If haemorrhage occurs, it should be promptly managed with intravenous oxytocin, uterine massage, manual removal of retained placenta as appropriate, temporizing measures or surgical interventions when indicated. Continued blood loss, pulse and blood pressure are closely monitored, and shock is managed with immediate resuscitation with intravenous fluid and blood transfusion, if indicated. Quality measures Input 4. The health facility has written, up-to-date clinical protocols for post-partum haemorrhage management that are available in the childbirth and postnatal care areas and are consistent with WHO guidelines*. (90.76)) 5. The health facility has uterotonic drugs and supplies for intravenous fluid and blood administration (syringes, needles, intravenous cannulas, intravenous fluid solutions, blood) available in sufficient quantities at all times in the childbirth and postnatal care areas. (89.55) 6. A functional blood transfusion service is available in the health facility at all times. (86.82) 7. Health-care staff in the labour, childbirth and postnatal care areas of the maternity unit receive in-service training and regular refresher sessions in management of post-partum haemorrhage at least once every 12 months. (84.25) Output/process 1. The proportion of all women with post-partum haemorrhage in the health facility who received therapeutic uterotonic drugs*. (89.75) 2. The proportion of all women in the health facility with post-partum haemorrhage due to a retained placenta for whom manual removal of the placenta was performed by a skilled birth attendant. (80.48) Outcome 1. The proportion of all women who had post-partum haemorrhage in the health facility who died as a result of post-partum haemorrhage*. (92.98) 2. The proportion of all women who gave birth in the health facility by caesarean section who received a blood transfusion. (85.80) 3. The proportion of all women who gave birth vaginally in the health facility who received a blood transfusion. (85.58) 4. The proportion of all women who gave birth in the health facility who had severe post-partum haemorrhage (abnormal bleeding of >1000 mL or any bleeding with hypotension or requiring blood transfusion). (83.69) 5. The proportion of all women who had post-partum haemorrhage in the health facility who experienced maternal near-misses due to post-partum haemorrhage. (77.97) 31 Quality statement 1.4: Women whose progress in labour is delayed or whose labour is obstructed receive appropriate interventions, according to WHO guidelines. Rationale: Obstructed labour is a major cause of both maternal and newborn morbidity and mortality. Undiagnosed obstructed labour can lead to a ruptured uterus, vesico- vaginal fistula or recto-vaginal fistula in the mother and higher risks for stillbirth, neonatal asphyxia, meconium aspiration syndrome and other conditions. Proper monitoring of labour to avoid prolongation and its complications and early detection and timely management of obstructed labour can decrease the incidence of these complications. Interventions for delayed labour include digital vaginal examination at intervals of 4 h and prompt confirmation of the delay in labour with a partograph with a 4-h action line, checking for cephalopelvic disproportion and assessing and managing the woman’s hydration. Labour augmentation with intravenous oxytocin (and with amniotomy if the membrane is not ruptured) is used if there is delay in the first stage with no cephalopelvic disproportion. Delay in the second stage of labour is treated by appropriate use of instrumental delivery (vacuum or forceps) or by caesarean section if there is evidence of foetal compromise or signs of obstruction of labour. Note: Augmentation should be used only in confirmed delay of labour after exclusion of cephalopelvic disproportion and in facilities capable of close, regular monitoring of the foetal heart rate and the pattern of uterine contraction and can manage any adverse effects. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for preventing and managing prolonged labour, which are available in the labour and childbirth areas and are consistent with WHO guidelines*. (90.88) 2. The health facility has the essential supplies and equipment for vacuum or forceps-assisted delivery, including newborn resuscitation equipment, available in sufficient quantities at all times in the childbirth area of the maternity unit*. (90.33) 3. The health facility has an adequately equipped operating theatre close to the childbirth area of the maternity unit*. (90.13) 4. The health facility has an adequate number of staff skilled in performing caesarean section, 24 h a day. (87.93) 5. Health-care staff in the labour and childbirth areas of the maternity unit receive in-service training and regular refresher sessions (every 6 months) in managing prolonged and obstructed labour. (82.19) Output/process 1. The proportion of all nulliparous women in the health facility with a singleton cephalic foetus at ≥ 37 weeks’ gestation who underwent caesarean section during spontaneous labour (Robson group 1). (87.27) 2. The proportion of all women in the health facility with prolonged and/or obstructed labour who gave birth by caesarean section. (86.03) 3. The proportion of all women who gave birth in the health facility who underwent instrumental vaginal birth for delayed second stage of labour. (83.21) 4. The proportion of women with prolonged or obstructed labour who underwent emergency caesarean section within 30 min of the decision to perform caesarean section. (79.9) 5. The proportion of all women in the health facility with confirmed delay in progress of the first stage of labour who received oxytocin for augmentation. (79.06) 32 6. The proportion of all women who gave birth in the health facility whose active phase of first stage of labour exceeded 12 h. (76.79) 7. The proportion of all women who gave birth in the health facility who had a prolonged second stage of labour. (74.82) Outcome 1. The proportion of all women who gave birth in the health facility whose uterus ruptured during labour. (89.35) 2. The proportion of all perinatal deaths that occurred in the health facility after prolonged or obstructed labour. (85.23) 3. The proportion of all newborns born in the health facility who had birth injuries (brachial palsy, fractures, cephalhaematoma). (83.75) 4. The proportion of women with prolonged and/or obstructed labour in the health facility who experienced maternal near-misses due to prolonged and/or obstructed labour. (78.0) Quality statement 1.5: Newborns who are not breathing spontaneously receive appropriate stimulation and resuscitation with a bag-and-mask within 1 min of birth, according to WHO guidelines. Rationale: Birth asphyxia is one of the leading causes of neonatal deaths within the first week of life and is also responsible for long-term neurological disability and impairment. It can be prevented by appropriate, effective resuscitation of newborns who are not breathing at birth. Newborns who are not breathing spontaneously after thorough drying are rubbed two to three times on the back for extra stimulation. Suction is used only if the newborn had meconium- stained liquor or if secretions are present in the mouth or nose. Positive-pressure ventilation with a self-inflating bag-and-mask is initiated within 1 min of birth, with air for newborns > 32 weeks’ gestation and with 30% oxygen for preterm babies at < 32 weeks’ gestation. The adequacy of ventilation is monitored by measuring the heart rate, chest movement and pulse oximetry (if available). A higher oxygen concentration is given only if the heart rate is < 60/min after 60 s of resuscitation. Quality measures Input 1. The health facility has a suction device, at least two sizes of neonatal mask and a self-inflating bag in the childbirth and neonatal areas of the maternity unit*. (93.83) 2. The health facility has written, up-to-date clinical protocols for managing newborns who are not breathing spontaneously in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.86) 3. All health-care workers providing care for pregnant and postpartum women and newborns in the health facility are skilled in basic newborn resuscitation, as demonstrated by simulating positive- pressure ventilation with a bag-and-mask on a manikin. (89.64) 4. Health care staff in the childbirth and neonatal areas of the maternity unit receive in-service training and regular refresher sessions s in basic newborn resuscitation at least once every 12 month. (87.06) 5. Health care staff in the childbirth and neonatal areas of the maternity unit receive monthly drills or simulation exercises and supportive supervision in basic newborn resuscitation. (83.91) 33 Output/process 1. The proportion of all newborns who were not breathing spontaneously after additional stimulation at the health facility who were resuscitated with a bag-and-mask. (81.10) 2. The proportion of all newborns who were not breathing spontaneously after additional stimulation at the health facility who were resuscitated with a bag-and-mask within 1 min of birth. (75.56) Outcome 1. The proportion of all live babies born at term (≥ 37 weeks) with no major congenital malformations in the health facility who died within 7 days of birth (early neonatal mortality) *. (91.14) 2. The proportion of all live babies born at term (≥ 37 weeks) in the health facility who were not breathing spontaneously but were breathing spontaneously 5 min after resuscitation. (77.92) Quality statement 1.6a: Women in preterm labour receive appropriate interventions for both themselves and their babies, according to WHO guidelines. Rationale: Preterm labour (before 37 completed weeks of pregnancy) can result in numerous health risks to the baby, which increase the earlier the baby is delivered. Prevention of preterm labour and appropriate management of imminent preterm labour are imperative to reduce the associated risks to the baby, prevent avoidable complications and improve the outcome and survival of preterm babies. Women in preterm labour are admitted to a facility that has the capacity to manage preterm babies and their complications, conduct a thorough assessment and evaluation to confirm gestational age by ultrasound or date of the last menstrual period, assess them for signs and symptoms of infection and evaluate whether birth is imminent or can be delayed. Antenatal corticosteroids are given, after ruling out chorioamnionitis, for imminent risk of preterm birth at 24–34 weeks of gestation, with tocolysis as appropriate. Antenatal magnesium sulfate is given for preterm labour at < 32 weeks of gestation to protect the foetus from neurological complications. Women with confirmed preterm pre-labour rupture of membranes are routinely given antibiotics. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for management of preterm labour in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.46) 2. The health facility has supplies of antenatal corticosteroids (dexamethasone or betamethasone), antibiotics and magnesium sulfate available in sufficient quantities at all times to manage preterm birth in accordance with WHO guidelines*. (90.06) 3. Health-care staff in the maternity unit receive in-service training and regular refresher sessions in the management of preterm labour at least once every 12 months. (85.52) 4. Health-care staff in the maternity unit receive monthly drills or simulation exercises and supportive supervision in the management of preterm labour. (79.18) 34 Output/process 1. The proportion of all preterm newborns born between 24 and 34 weeks of gestation in the health facility whose mothers received at least one dose of antenatal corticosteroids when indicated. (86.11) 2. The proportion of all preterm newborns born before 32 weeks of gestation in the health facility whose mothers received magnesium sulfate to protect their baby from foetal neurological complications. (78.52) 3. The proportion of all women with preterm pre-labour rupture of membranes who gave birth in the health facility who received prophylactic antibiotics. (87.60) Outcome 1. The proportion of all women with preterm pre-labour rupture of membranes who gave birth in the health facility who received prophylactic antibiotics*. (87.60) 2. The proportion of all babies at risk for birth in the health facility at 24 to < 34 weeks of gestation who were exposed to antenatal corticosteroids. (73.61) 3. The proportion of all babies at risk for birth in the health facility at ≥ 34 weeks of gestation who were exposed to antenatal corticosteroids. (72.43) Quality statement 1.6b: Preterm and small babies receive appropriate care, according to WHO guidelines. Rationale: Preterm and small babies are at much greater risk for death during the neonatal period and for long-term health problems and lifelong disabilities. They should be cared for in well-equipped neonatal units with well-trained staff present round the clock. Preterm and low-birth-weight babies (< 2500 g) are kept warm at all times and closely monitored for complications; their mothers are given support in providing exclusive breastfeeding or alternative feeding (expressed breast milk, donor breast milk or formula). Clinically stable preterm newborns weighing ≤ 2000 g are given kangaroo mother care. Those who are unstable are cared for in a clean incubator or under a radiant warmer, and their temperature is closely monitored. The risks for common complications (hypothermia, feeding problems, apnoea, respiratory distress syndrome and infections) are assessed, monitored, recognized early and appropriately managed. Antibiotics, safe oxygen therapy, continuous positive airway pressure and surfactant replacement are given as appropriate. Quality measures Input 1. The health facility has written, up-to-date clinical protocols for the care of small and preterm babies in the childbirth areas of the maternity unit that are consistent with WHO guidelines*. (91.41) 2. The health facility has supplies and materials to provide optimal thermal care to stable and unstable preterm babies, including kangaroo mother care (support binders, baby hats, socks), clean incubators and radiant warmers*. (89.14) 3. The health facility has the supplies and materials to provide optimal feeding to preterm babies and support for breastfeeding or alternative feeding (feeding cups and spoons, infant formula, breast pumps, milk-storage facilities, pasteurizers, milk banks if possible, nasogastric tubes, syringe drivers, intravenous fluids and tubing). (86.56) 4. Health care staff in the health facility who work with pregnant and postpartum women and newborns receive in-service training and regular refresher sessions in appropriate care of preterm and low- birth-weight babies at least once every 12 months. (85.82) 35 Output/process 1. The proportion of all low-birth-weight newborns born in the health facility with a birth weight ≤ 2000 g who received near-continuous kangaroo mother care in the first week of life. (83.35) 2. The proportion of all unstable low-birth-weight newborns weighing ≤ 2000 g who cannot receive kangaroo mother care in the health facility who were cared for in a thermo-neutral environment, either under radiant warmers or in incubators, as appropriate. (79.29) 3. The proportion of all low-birth-weight newborns born in the health facility whose mothers received additional support to establish breastfeeding. (77.13) Outcome 1. The proportion of all preterm babies (< 28 weeks, 28–32 weeks and 32–37 weeks of gestational age) born in the health facility who died within the first 7 days of life*. (90.15) 2. The proportion of all low-birth-weight newborns born in the health facility who were exclusively fed on their mother’s milk during their stay in the health facility. (84.57) 3. The proportion of all live preterm babies born in the health facility who had severe neonatal morbidity (respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis). (81.20) 4. The proportion of low-birth-weight baby deaths in the facility attributed to possible serious bacterial infection or sepsis. (80.30) Quality statement 1.7a: Women with or at risk for infections during labour, childbirth or the early postnatal period promptly receive appropriate interventions, according to WHO guidelines. Rationale: Puerperal sepsis is one of the leading causes of maternal mortality and can also cause early-onset sepsis in newborns. The prevention of predisposing factors, aseptic precautions in all interventions and procedures, early, accurate diagnosis and use of appropriate antibiotics for treatment of maternal infection will reduce the occurrence of both maternal and neonatal sepsis and the associated morbidity and mortality. Women at risk for infection are given prophylactic antibiotics if they are undergoing elective or emergency caesarean section, in protracted labour with pre-labour rupture of membranes, in cases of retained placental products, with third- or fourth-degree perineal tears or before manual removal of the placenta. Specimens are obtained for culture and sensitivity before starting antibiotic treatment. Women with signs and symptoms of infection (fever > 38 °C before delivery or during labour, membranes ruptured ≥18 h before birth, foul-smelling or purulent amniotic fluid and abdominal pain and/or offensive vaginal discharge in the postnatal period) are treated with antibiotics and monitored closely, and their management is assessed regularly. Quality measures Input 1. The health facility has supplies of oral and injectable first- and second-line antibiotics (ampicillin or penicillin and gentamicin, clindamycin, cephalosporin and metronidazole) available in sufficient quantities at all times for the expected case load*. (92.15) 2. The health facility has written, up-to-date clinical protocols for treatment of women with, or at risk for, infections during labour, childbirth and the early postnatal period in the childbirth and postnatal care areas of the maternity unit that are consistent with WHO guidelines*. (91.75) 3. Health care staff in the health facility who deal with pregnant and postpartum women receive in-service training and regular refresher sessions in the recognition and management of maternal peri-partum infections at least once every 12 months. (85.20) 36 Output/process 1. The proportion of all women who underwent caesarean section in the health facility who received prophylactic antibiotics before caesarean section*. (90.37) 2. The proportion of all women who gave birth in the health facility with preterm pre-labour rupture of membranes who received antibiotics. (87.44) 3. The proportion of all women in the health facility with third- or fourth-degree perineal tears who received antibiotics. (83.45) 4. The proportion of all birthing or postpartum women in the health facility with signs of infection who received injectable antibiotics. (83.39) 5. The proportion of all women who gave birth in the health facility who had a temperature of > 38 ˚C or other signs of infection (foul-smelling or purulent lochia) after childbirth. (82.87) Outcome 1. The proportion of all women who underwent caesarean section in the health facility who had severe systemic infection or sepsis after the caesarean section. (86.56) 2. The proportion of all women who gave birth in the health facility who had severe systemic infection or sepsis in the postpartum period. (86.15) Quality statement 1.7b: Newborns with suspected infection or risk factors for infection are promptly given antibiotic treatment, according to WHO guidelines. Rationale: Newborns are at higher risk for infection because of their immature immune system. Infections in newborns can lead to death or to long-term disabilities in survivors. Good hand hygiene, cord care and other appropriate aseptic precautions, screening of neonatal sepsis according to the presence of one or more risk factor, early diagnosis of signs and symptoms of neonatal sepsis and appropriate treatment with antibiotics are essential to prevent sepsis and the associated morbidity and mortality. Newborns with risk factors for infection or with signs of infection are given antibiotic treatment according to WHO guidelines. Risk factors for infection are maternal fever (> 38 °C) before delivery or during labour, membranes ruptured ≥ 18 h before birth and foul-smelling or purulent amniotic fluid. Newborns with signs of serious bacterial infection present with inability to feed (or have stopped feeding well), convulsions, fast breathing (> 60 breaths/min) severe chest in-drawing, fever (≥ 38 °C) or low body temperature (< 35 °C), lethargy, movement only when stimulated or no movement at all. A blood culture is obtained before initiation of antibiotics in newborns at risk or with signs of infection. They are treated with an empirical injectable antibiotic for sepsis or suspected sepsis and closely monitored for reassessment of their management. Culture reports are the basis for deciding any change in antibiotics and the duration of treatment. Quality measures Input 1. The health facility has supplies of injectable antibiotics (at least first- and second-line antibiotics for neonatal sepsis and meningitis) available in sufficient quantities at all times for the expected case load*. (92.14) 2. The health facility has a written, up-to-date clinical protocol for early diagnosis and management of neonatal infection in the childbirth areas of the maternity unit that is consistent with WHO guidelines*. (90.47) 37 3. Health care staff in the health facility who care for pregnant and postpartum women and newborns receive in-service training and regular refresher sessions in the recognition and management of suspected newborn infections at least once every 12 months. (85.95) 4. Health care staff in the health facility know the signs of newborn sepsis and how to treat it, according to WHO guidelines. (84.29) Output/process 1. The proportion of all newborns in the health facility with signs of infection who received injectable antibiotics. (86.94) 2. The proportion of all newborns of mothers with signs of infection in the health facility who received injectable antibiotics. (77.53) Outcome 1. The proportion of newborns treated for sepsis in the health facility who died (case fatality rate) *. (89.32) 2. The proportion of all neonatal deaths in the health facility that were due to sepsis. (86.96) 3. The proportion of all severe neonatal morbidity in the health facility that was due to neonatal sepsis. (77.53) Quality statement 1.8: All women and newborns receive care that includes standard precautions for preventing hospital-acquired infections. Rationale: Hospital-acquired infections increase morbidity and mortality, the cost of care and the duration of stay in hospital. Standard precautions are essential to prevent hospital-acquired infections. Standard precautions are observed at all times, including hand hygiene with soap and water or alcohol-based hand rub before and after examining a woman or newborn and appropriate use of gloves; safe storage and disposal of infectious waste and sharps; safe handling of equipment for patient care and soiled linen; and sterilization and disinfection of instruments and the childbirth surface. Quality measures Input 1. The health facility has a reliable water source on site and soap and towels (preferably disposable) or alcohol-based hand rub for hand hygiene*. (94.27) 2. The health facility ensures safe handling, storage and final disposal of infectious waste*. (94.08) 3. The health facility ensures safe handling, storage (puncture resistant) and final disposal of sharps waste*. (93.36) 4. The health facility has appropriate sterilizing facilities and disinfectants for instruments. (92.99) 5. The health facility has a functioning incinerator or other appropriate method for treatment of infectious waste and used instruments. (92.56) 6. The health facility has written, up-to-date guidelines for standard infection control and precautions for transmission. (92.35) 7. Health care staff in the childbirth and neonatal areas of the maternity unit receive training in standard infection control and precautions for transmission at least once every 12 months. (87.27) 38 Output/process 1. The percentage of health care staff in the health facility who clean their hands correctly as per the WHO “5 moments for hand hygiene” audit tool. (87.78) 2. The proportion of newborns with suspected severe bacterial infection who received appropriate antibiotic therapy. (84.76) 3. Safe management of health care waste, from the point of generation to the point of disposal. (82.73) 4. The percentage of staff members in the health facility who meet biosafety standards when administering parenteral drugs. (81.85) Outcome 1. The proportion of all women who gave birth in the health facility who had a severe systemic infection or sepsis in the postnatal period, including at readmission after delivery in the facility. (81.41) 2. The proportion of all women who gave birth in the health facility who had proven hospital-acquired infections. (78.43) 3. The proportion of all neonates born in the health facility who had hospital-acquired infections. (78.00) Quality statement 1.9: No woman or newborn is subjected to unnecessary or harmful practices during labour, childbirth and the early postnatal period. Rationale: Unnecessary and harmful practices can lead to complications and harm mothers and their newborns. They should be avoided and replaced with evidence-based health practices. Unnecessary or harmful practices are not used or practised. These practices include: routine enemas and pubic or perineal shaving before vaginal birth; fundal pressure to facilitate the second stage of labour; augmentation of labour with oxytocin before confirmation of delayed labour; episiotomy (unless indicated); uterine packing to control bleeding (unless indicated); instrumental vaginal childbirth (unless indicated); caesarean section (unless indicated) and suctioning of a newborn (unless indicated); immediate bathing of the baby, keeping well babies in the nursery away from the mother, advertising and promotion of breastfeeding substitutes and bottle-feeding, and applying substances to the cord. Quality measures Input 1. The health facility has written, up-to-date guidance on harmful practices and unnecessary interventions during labour, childbirth and the early postnatal period*. (89.03) 2. The health facility does not display infant formula or bottles and teats, including on posters or placards*. (88.98) 3. The health facility does not give newborns food or drink other than breast milk, unless medically indicated, and does not give pacifiers (also called “dummies” or “soothers”) to breastfeeding babies. (85.13) 4. Health care staff in the facility receive in-service training and regular refresher sessions on harmful practices and unnecessary interventions at least once every 12 months. (83.00) 5. The health facility does not promote infant formula on the wards, and samples are not distributed to mothers or staff. (82.93) 6. Health-care staff in the health facility receive monthly supportive supervision and mentoring on harmful practices and unnecessary interventions. (75.38) 39 Output/process 1. The proportion of all uncomplicated, spontaneous vaginal births in the health facility in which an episiotomy was performed*. (86.01) 2. The proportion of women undergoing caesarean section in the health facility according to Robson classification groups. (83.2) 3. The proportion of all women who gave birth in the health facility who received augmentation of labour with no indication of delay in progress of labour. (80.01) 4. The proportion of all babies born in the health facility who received early bathing and removal of the vernix within 6 h of birth. (79.30) 5. The proportion of all women who gave birth in the health facility who received routine pubic or perineal shaving before a vaginal birth. (77.59) 6. The proportion of all babies born through clear amniotic fluid in the health facility who received routine suctioning. (77.35) 7. The proportion of all women who gave birth in the health facility who received routine enemas at any time before vaginal birth. (76.02) References used in setting standard 1 Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347–370. Boulkedid R, Sibony O, Goffinet F, Fauconnier A, Branger B, Alberti C. Quality indicators for continuous monitoring to improve maternal and infant health in maternity departments: a modified Delphi survey of an international multidisciplinary panel. PLoS One 2013;8:e60663. Gülmezoglu MA, Lawrie TA. Impact of training on emergency resuscitation skills: impact on Millennium Development Goals (MDGs) 4 and 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10.1016/j. bpobgyn.2015.03.018. Hussein J, Mavalankar DV, Sharma S, D’Ambruoso L. A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality. Globalization Health 2011;7:14. Khaskheli MN, Baloch S, Sheeba A. Risk factors and complications of puerperal sepsis at a tertiary healthcare centre. Pak J Med Sci 2013;29:972–976. National Institute for Health Care Excellence. NICE guidelines on routine intrapartum care (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Polin RA, Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Paediatrics 2012;129:1006 –1015. Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011;114:4–9. Schuchat A, Zywicki SS, Dinsmoor MJ, Mercer B, Romaguera J, O’Sullivan MJ, et al. Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicentre case-control study. Pediatrics. 2000;105:21–26. Sibanda T, Fox R, Draycott TJ, Mahmood T, Richmond D, Simms RA. Intrapartum care quality indicators: a systematic approach for achieving consensus. Eur J Obstet Gynecol Reprod Biol 2013;166:23–29. Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, et al. Improving quality of care for maternal and newborn health: prospective pilot study of the WHO safe childbirth checklist program. PLoS One 2012;7:e35151. Tietjen L, Bossemeyer D, McIntosh N. Infection prevention guidelines for healthcare facilities with limited resources. Baltimore, Maryland: JHPIEGO; 2003. 40 World Health Organization. International code of marketing of breast-milk substitutes. Geneva; 1981 (http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/). World Health Organization. Standard precautions in health care: aide-memoire. Geneva; 2007 (http:// www.who.int/csr/resources/publications/EPR_AM2_E7.pdf). World Health Organization. WHO guidelines on hand hygiene in health care. Geneva; 2009 (http:// www.who.int/gpsc/information_centre/hand-hygiene-2009/en/). World Health Organization. Evaluating the quality of care for severe pregnancy complications. The WHO near-miss approach for maternal health. Geneva; 2011 (http://whqlibdoc.who.int/ publications/2011/9789241502221_eng.pdf). World Health Organization. WHO recommendations for the prevention and treatment of pre-eclampsia/eclampsia. Geneva; 2011 (http://apps.who.int/iris/ bitstream/10665/44703/1/9789241548335_eng.pdf). World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva; 2012 (http://www.who.int/reproductivehealth/publications/ maternal_perinatal_health/9789241548502/en/). World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines-recommendations- newborn-health.pdf). World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on maternal and perinatal health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines- recommendations-maternal-health.pdf?ua=1). World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva, 2013 (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/). World Health Organization. Safe management of wastes from health-care activities Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1). World Health Organization. WHO recommendations for augmentation of labour. Geneva; 2014 (http:// www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation-labour/en/). World Health Organization. The role of WHO in public health. Geneva; 2015 (http://www.who.int/ about/role/en/). World Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. Geneva; 2015 (http://who.int/reproductivehealth/publications/ maternal_perinatal_health/preterm-birth-guideline/en/). World Health Organization, Partnership for Maternal, Newborn and Child Health. Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities. Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf). World Health Organization, UNICEF. Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva; 2009 (http://www.who.int/nutrition/publications/infantfeeding/ bfhi_trainingcourse/en/). World Health Organization, UNICEF. Indicators for assessing health facility practices that affect breastfeeding. Geneva; 1993 (http://apps.who.int/iris/handle/10665/62140). World Health Organization Regional Office for Europe. Making pregnancy safer: assessment tool for the quality of hospital care for mothers and newborn babies. Copenhagen; 2009 (http://www. euro.who.int/__data/assets/pdf_file/0008/98792/E93128.pdf). World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/2014/hospital-care-for- mothers-and-newborn-babies-quality-assessment-andimprovement-tool.pdf?ua=1). 41 Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn. Quality statement 2.1: Every woman and newborn has a complete, accurate, standardized medical record during labour, childbirth and the early postnatal period. Rationale: Complete, accurate medical recording during labour is important for documenting care, clinical follow-up, accurate hand-over, early detection of complications and health outcomes and provides information for identifying areas for improvement. Standardized patient care registers and clinical records for mothers and newborns from admission to discharge are in place and are accurate, complete and legible. Continuity of care records are available (e.g. referral notes, records of antenatal and intrapartum care). Demographic data, times of admission, childbirth and discharge, progress of labour, actions taken and the outcome of childbirth, including stillbirths, are appropriately recorded. Details of newborns, including identification, gestational age, birth weight and examination findings, are recorded in a system that allows linkage of women and their newborns in all records. The International Classification of Diseases (ICD) is used to code diagnoses. Quality measures Input 1. The health facility has registers, data collection forms, clinical and observation charts in place at all time for routine recording and monitoring of all care processes for women and newborns*. (90.34) 2. The health facility has a birth and death registration system in place that is linked to the national vital registration system at all times*. (89.44) 3. The health facility has a system for classifying diseases and birth outcomes, including death, which is aligned with the ICD. (86.33) Output/process 1. The proportion of all newborns currently in the health facility who have a patient identifier and individual clinical medical record*. (89.15) 2. The proportion of all newborns discharged from the health facility within the past 24 h who had an accurately completed record of processes of care, treatments, outcomes and diagnoses (with ICD code). (83.28) 3. The proportion of all women discharged postpartum within the past 24 h who had an accurately completed record of processes of care, treatments, outcomes and diagnoses (with ICD code). (82.88) Quality statement 2.2: Every health facility has a mechanism for data collection, analysis and feedback as part of its activities for monitoring and improving performance around the time of childbirth. Rationale: The purpose of data collection is to provide information that can be analysed and used appropriately to provide feedback and improve health outcomes. Data are collected, verified, analysed and used routinely to make clinical and management decisions for planning and improving clinical services. They are available to, and used by, facility staff for continuous improvement of processes of care and used by physicians, midwives, nurses, supervisors and mentors to plan and improve activities and clinical services. Accurate, complete data are submitted to the appropriate levels in a timely manner and are used for periodic reviews of mortality and morbidity in order to improve quality. 42 Quality measures Input 1. The health facility has conducted reviews of maternal and perinatal deaths and near-misses at least once a month within the past six months and has a mechanism for implementing the recommendations of reviews*. (88.20) 2. The health facility has standard operating procedures and protocols in place at all times for checking, validating and reporting data. (86.35) 3. The health facility has a data system for collecting and analysing relevant indicators and can produce visual outputs and timely reporting on paper or digitally at all times. (85.74) 4. Managers and health care workers in the health facility met at least once a month within the past six months to review process and outcome data. (85.12) 5. Managers and health care workers in the health facility used the recommendations in reviews of data for decision-making and for mentoring improved performance within the past six months. (80.10) Output/process 1. The proportion of all perinatal deaths occurring in the health facility that were reviewed with standard audit tools*. (90.26) 2. The proportion of all maternal deaths and near-misses occurring in the health facility that were reviewed with standard audit tools*. (88.24) 3. The proportion of all maternal deaths and near-misses occurring in the health facility that were notified. (86.84) Outcome 1. Data are collected routinely in the health facility during labour, childbirth and the postnatal period and used regularly to make decisions on quality improvement. (83.08) 2. The proportion of all recommendations in perinatal death reviews at the health facility that have been fully implemented. (81.51) 3. The proportion of all recommendations in maternal death reviews at the health facility that have been fully implemented. (81.37) References used in setting standard 2 Brien ES, Lorenzetti LD, Lewis S, Kennedy J, Ghali AW. Overview of a formal scoping review on health system report cards. Implementation Sci 2010;5:2. Graham WJ, Campbell OM. Maternal health and the measurement trap. Soc Sci Med 1992;35:967–977. Lippeveld T, Sauerborn R, Bodart C. Design and implementation of health information systems. Geneva: World Health Organization; 2000. Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan 2001;16:353–361. UNICEF. The state of the world’s children 2009. Geneva (http://www.unicef.org/sowc09/docs/SOWC09- FullReport-EN.pdf). World Health Organization. Service availability and readiness assessment (SARA). An annual monitoring system for service delivery. Reference manual, version 2.2 Geneva; 2015 (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). World Health Organization, United Nations Population Fund, UNICEF, World Bank. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. Geneva: World Health Organization; 2015. 43 Standard 3: Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred. Quality statement 3.1: Every woman and newborn is appropriately assessed on admission, during labour and in the early postnatal period to determine whether referral is required, and the decision to refer is made without delay. Rationale: It is vital to recognize cases that require referral rapidly in order to ensure that every patient receives timely, appropriate care and to avoid unnecessary complications. Up-to-date referral protocols and guidelines are in place, are accessible and reflect the health facility’s capacity and resources. There is a triage system at admission, and a mechanism on the wards to assess, identify and respond to emergencies immediately. Facilities are available to provide pre-referral stabilization care and treatment. Quality measures Input 1. The health facility has written, up-to-date clinical protocols and guidelines for the identification, management (including pre-referral care) and referral of women with complications related to pregnancy and childbirth and in newborns*. (89.94) 2. The health facility is equipped with appropriate medicines and medical supplies for stabilization and pre-referral treatment for referred women and newborns*. (89.20) 3. Health care staff in the maternity unit receive in-service training and regular refresher sessions in referral protocols and guidelines at least once every 12 months*. (85.33) Output/Process 1. The proportion of women and newborns seen in the health facility in the past three months who fulfilled the facility’s criteria for referral who were actually referred. (81.79) 2. The proportion of all pregnant or postpartum women who could not be managed at the health facility who were transferred to a higher-level facility for childbirth or further management without delay, accompanied by a health care professional and a completed standardized referral note. (81.47) 3. The proportion of all sick, preterm or small newborns who could not be managed at the health facility who were transferred to an appropriate level of care within 1 h of a decision, accompanied by a health care professional and a completed standardized referral note. (79.90) Outcome 1. The proportion of all women admitted to the labour ward who reported receiving immediate attention on arrival at the health facility. (82.83) Quality statement 3.2: For every woman and newborn who requires referral, the referral follows a pre-established plan that can be implemented without delay at any time. Rationale: A pre-established plan for referral expedites the process, prevents unnecessary delay and results in better, more timely care for patients. Availability of adequately equipped transport services that operate 24 h a day, 7 days a week, to transport women and newborns as necessary. A list of known network facilities and their telephone numbers is in place. The referral system is supervised and accountable, with a policy that protects women from financial barriers to referral, and there is a procedure to monitor and evaluate the system. 44 Quality measures Input 1. The health facility has ready access to a functioning ambulance or other vehicle for emergency transport of women and newborns to referral facilities*. (90.35) 2. There is an up-to-date list of network facilities in the same geographical area that provide referral care for women and children*. (89.20) 3. The health facility has local arrangements to ensure that women and newborns who cannot be managed at the health facility are referred to an appropriate level of care without delay, 24 h a day, 7 days a week. (87.11) Output/process 1. The proportion of all newborns who died before or during transfer to a higher-level facility for further management*. (87.74) 2. The proportion of all pregnant or postpartum women who died before or during transfer to a higher- level facility for childbirth for further management. (87.04) 3. The proportion of pregnant and postpartum women and newborns who were referred without appropriate emergency transport. (75.62) 4. The proportion of all women referred from the health facility who contributed financially to communication or to transport. (68.93) Outcome 1. The proportion of all women referred from the health facility who completed their referral. (80.97) 2. The proportion of all newborns referred from the health facility who completed their referral. (80.95) 3. The proportion of newborns referred from the facility who reached the referral facility without hypothermia. (76.34) Quality statement 3.3: For every woman and newborn referred within or between health facilities, there is appropriate information exchange and feedback to relevant health care staff. Rationale: Appropriate information exchange and feedback within and between health facilities improves patient care, increases the motivation of health care workers, helps learning from experience and leads to improved patient care. A functioning communication system (e.g. radio, telephone) within the referral network operates at all times, and formal agreements and arrangements for communication and consultations are in place. Information exchange and feedback protocols on referral and standardized referral and counter-referral forms are available when needed. Quality measures Input 1. The health facility has a standardized referral form to document relevant demographic and clinical information, which includes clinical findings, diagnosis, pre-referral interventions or treatment given and reason for referral*. (89.13) 2. The health facility has reliable communication methods, including a mobile phone, land line or radio, which is functioning at all times, for referrals and consultation on complicated cases*. (87.14) 3. Evidence that the health facility has formal agreements, communication arrangements and a feedback system with referral centre(s) *. (85.55) 45 Output/process 1. The proportion of all referred women seen at the referring facility for whom there was complete counter-referral feedback information. (80.65) 2. The proportion of all referred newborns seen at the referring facility for whom there was complete counter-referral feedback information. (80.12) 3. The proportion of all referred women and newborns seen at the referring facility who received timely care at the referral facility. (79.57) References used in setting standard 3 Lawn J, McCarthy BJ, Ross R. The healthy newborn: a reference manual for program managers. Atlanta, Georgia: Centers for Disease Control, CARE International; 2001. Maine D, Ward V, Eitahir AH. Meeting the community halfway: programming guidelines for the reduction of maternal mortality. New York City, New York: UNICEF; 1993. Murray SF, Pearson S. Maternity referral systems in developing countries: current knowledge and future research needs. Soc Sci Med 2006;62:2205–2215. Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan 2001;16:353–361. World Health Organization. Essential elements of obstetric care at first referral level. Geneva: 1991. World Health Organization. Service availability and readiness assessment (SARA). An annual monitoring system for service delivery. Reference manual, version 2.2. Geneva; 2015 (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). World Health Organization Regional Office for the Western Pacific. District health facilities: Guidelines for development and operations. Manila; 1998. Standard 4: Communication with women and their families is effective and responds to their needs and preferences. Quality statement 4.1: All women and their families receive information about the care and have effective interactions with staff. Rationale: Effective communication with women and their families helps them feel more involved in their care, avoids unnecessary anxiety, misunderstanding and wrong expectations and gives them control of their condition, which contribute to a positive experience. Health care staff have interpersonal communication and counselling skills and are readily approachable. They have a positive attitude, use simple, clear language that women and their families can understand and recognize the communication needs and preferences of all women under their care. Quality measures Input 1. Easily understood health education materials, in an accessible written or pictorial format, are available in the languages of the communities served by the health facility*. (91.01) 2. Health care staff in the maternity unit are oriented and receive in-service training at least once every 12 months to improve their interpersonal communication and counselling skills and cultural competence*. (85.74) 46 3. The health facility has a written, up-to-date policy that outlines clear goals, operational plans and monitoring mechanisms to promote the interpersonal communication and counselling skills of health care staff. (84.69) 4. Health care staff in the maternity unit receive supportive supervision in interpersonal communication, counselling and cultural competence every three months. (80.12) Output/process 1. The proportion of all women discharged from the labour and childbirth area of the facility who received written and verbal information and counselling on the following elements before discharge: nutrition and hygiene, birth spacing and family planning, exclusive breastfeeding and maintaining lactation, keeping their baby warm and clean, communication and play with the baby, danger signs for the mother and newborn and where to go in case of complications*. (85.83) 2. The proportion of all women who gave birth in the health facility who reported that they were given the opportunity to discuss their concerns and preferences. (82.79) 3. The proportion of health care staff in the health facility who demonstrated the following skills: active listening, asking questions, responding to questions, verifying the understanding of women and their families and supporting women in problem-solving. (76.67) Outcome 1. The proportion of all women who gave birth in the health facility who felt they were adequately informed by the care provider(s) about the examinations, actions and decisions taken for their care. (83.58) 2. The proportion of all women who gave birth in the health facility who reported that their needs and preferences were taken into account during labour, childbirth and postnatal care. (80.67) 3. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (80.66) 4. The proportion of all women who gave birth in the health facility who reported that they were satisfied with the health education and information they received from care providers. (76.25) Quality statement 4.2: All women and their families experience coordinated care, with clear, accurate information exchange between relevant health and social care professionals. Rationale: Coordinated care and accurate hand-over of information among health care providers is essential to maintain continuity in patient care and to avoid unnecessary delays in treatment. A standard format is used for information exchange between care providers (e.g. during staff shift changes and referrals, with social care services, sending laboratory results), and effective verbal and/or telephone communication is used among caregivers involved in the hand-over of care. There is timely reporting of the results of critical diagnostic tests. Quality measures Input 1. The health facility has a standard form for clinical progress notes and monitoring events during labour (partograph), birth and after birth to facilitate written hand-over*. (91.75) 2. The health facility has written, up-to-date protocols for verbal and written hand-over of women and newborns at shift changes, during intra-facility transfer, on referral to other facilities and at discharge*. (89.14) 47 3. Health-care staff in the maternity unit are oriented and receive in-service training and regular refresher sessions at least once every 12 months in the clinical hand-over policy and communication of important information for hand-over, referral or discharge. (81.53) 4. The health facility has a functioning, reliable communication system for information exchange among relevant service providers. (78.26) Output/process 1. The proportion of women attended during labour and childbirth for whom a partograph has been completed. (81.87) 2. The proportion of all women who gave birth in the health facility who reported that health care staff introduced themselves and showed good knowledge of the women’s history and the care that had been given to date. (73.47) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services*. (83.53) 2. The proportion of health care staff, by cadre, and social professionals who were satisfied with the communication during clinical hand-over among members of the health care team in the health facility. (68.98) References used in setting standard 4 de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Anderson L, Scrimshaw S, Fullilove M, Fielding J, Normand H. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003;24:68–79. Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267. Fealy G, Riordan F. Communication and clinical handover practices: a systematic review. Dublin: University College Dublin and Health Service Executive; 2014. Iedema R, Manidis M. Patient–clinician communication: an overview of relevant research and policy literatures. In: Communication (clinical handover) in maternity services. Sydney: Australian Commission on Safety and Quality in Health Care and UTS Centre for Health Communication; 2014 (National clinical guideline No. 5) (http://health.gov.ie/wp-content/uploads/2015/01/ National-Clinical-Guideline-No.-5-Clinical-Handover-Nov2014.pdf). Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003;4:CD003716. Kongnyu E, van den Broek N. Criteria for clinical audit of women friendly care and providers’ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28. National Institute for Health Care Excellence. Patient experience in adult NHS services. London; 2012 (https://www.nice.org.uk/guidance/qs15/chapter/ quality-statement-2-demonstrated-competency-in-communication-skills#quality-statement-2). The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. Oakbrook Terrace, Illinois; 2010 (http://www. jointcommission.org). 48 Standard 5: Women and newborns receive care with respect and preservation of their dignity. Quality statement 5.1: All women and newborns have privacy around the time of labour and childbirth, and their confidentiality is respected. Rationale: Privacy and confidentiality of information make women and families feel respected at all times, protect them from any stigma associated with their problems and build trust in health care providers. Health care staff respect the privacy and confidentiality of care and information. Linen, curtains and screens are available to ensure privacy, and verbal and written records of women’s and newborns’ conditions are kept confidential. Quality measures Input 3. The physical environment of the health facility allows privacy and the provision of respectful, confidential care, including the availability of curtains, screens, partitions and sufficient bed capacity*. (94.80) 4. The health facility has written, up-to-date protocols to ensure privacy and confidentiality for all women and newborns in all aspects of care*. (89.27) 5. The health facility has accountability mechanisms for redress in the event of violations of privacy, confidentiality or consent. (85.16) Output/process 1. The proportion of procedures in the health facility that require written consent for which there is an associated record of the woman’s consent*. (86.90) 2. The proportion of all women undergoing examinations or procedures in the health facility who reported that their permission was sought before the examination or procedures were performed. (84.41) Outcome 1. The proportion of all women who gave birth in the health facility who were satisfied with the degree of privacy during their stay in the labour and childbirth areas. (85.63) 2. The proportion of all women examined and treated in the health facility who expressed satisfaction with the degree of privacy during examinations and treatment. (85.48) 3. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (81.90) Quality statement 5.2: No woman or newborn is subjected to mistreatment, such as physical, sexual or verbal abuse, discrimination, neglect, detainment, extortion or denial of services. Rationale: Every woman has the basic human right to the highest attainable standard of health care without discrimination or maltreatment. Health care staff treat all women with kindness, compassion, courtesy, respect, understanding and honesty and preserve their dignity. Women are free to complain without fear of repercussions, and there is no restriction on their movement into or out of the health facility. 49 Quality measures Input 1. The health facility has written, up-to-date, zero-tolerance non-discriminatory policies with regard to mistreatment of women and newborns*. (91.19) 2. The health facility has a system whereby the mothers of small, sick newborns can be close to and nurse their babies*. (89.59) 3. The fee structures for maternity and newborn care are equitable, affordable and clearly displayed*. (89.07) 4. The health facility has written accountability mechanisms for redress in the event of mistreatment. (88.50) 5. The health facility has a written, up-to-date policy and protocols that outline women’s and families’ right to make a complaint about the care received and has an easily accessible mechanism (e.g. a box) for handing in complaints. (88.34) 6. Health care staff in the maternity unit receive in-service training and supportive supervision in respecting the rights of mothers and newborns, respectful care and accountability mechanisms. Orientation is provided for new staff. (87.36) 7. The health facility policy for payment specifically precludes detention of a woman or baby for non- payment. (86.00) 8. The health facility has a complaints box, which is easily accessible to women and their families, is periodically emptied and the contents reviewed. (77.22) Output/process 1. The proportion of all women who gave birth in the health facility who reported physical, verbal or sexual abuse, to themselves or their newborns, during labour or childbirth or after birth. (86.68) 2. The proportion of women who gave birth in the health facility who were satisfied that the facility met their religious and cultural needs. (78.15) 3. The proportion of women who attended the health facility who were refused care because of their inability to pay. (76.97) 4. The proportion of complaints received about respect and preservation of the dignity of women and their families. (74.37) 5. The proportion of women who gave birth in the health facility who were aware of the existence and location of a complaints box. (70.90) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (85.93) 2. The proportion of all women who gave birth in the health facility who reported having been treated with respect and their dignity preserved. (84.13) 3. The proportion of all women in the health facility who made a complaint whose complaints were acted upon without repercussions. (72.82) Quality statement 5.3: All women can make informed choices about the services they receive, and the reasons for interventions or outcomes are clearly explained. Rationale: It is essential that women feel involved in their treatment and care and can make informed choices in order to improve their compliance and satisfaction with the treatment. 50 Women are informed about their rights and options for care and encouraged to ask questions. They are supported in making decisions about all aspects of their care and treatment; their personal values and beliefs are respected, and their consent is obtained before procedures are carried out. Quality measures Input 1. The health facility has a written, up-to-date policy for obtaining informed consent from women before examinations and procedures*. (90.98) 2. The health facility has a standard informed consent form that helps health care staff to provide easily understandable information to women in order to obtain their fully informed consent*. (90.39) 3. Health care staff in the health facility receive in-service training and supportive supervision in effective informed consent procedures and in women’s right to choose care at childbirth. Orientation is provided for new staff*. (87.51) 4. The health facility has written accountability mechanisms for redress in the event that women are denied informed choice, and the mechanism is displayed. (81.41) Output/process 1. The proportion of procedures in the health facility that require written consent for which there is an associated record of consent signed by the woman or a family member. (84.32) 2. The proportion of all women who gave birth in the health facility who felt adequately informed by health care staff regarding decisions taken about their care. (80.82) 3. The proportion of women who received care in the health facility who were aware that they had the right to accept or refuse treatment. (78.55) Outcome 1. The proportion of women who gave birth in the health facility by caesarean section who were aware of the reason for the caesarean section. (87.13) 2. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (82.74) 3. The proportion of women who gave birth in the health facility who felt they had shared decisions about their labour, birth and postnatal care. (75.86) References used in setting standard 5 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015;12:e1001847. de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Dwamena F1, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267. International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99. Kongnyuy E, van den Broek N. Criteria for clinical audit of women friendly care and providers’ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28. Lothian JA. Do not disturb: the importance of privacy in labor, J Perinat Educ 2004;13:4–6. 51 National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. London; 2012 (http://www.nice.org. uk/guidance/cg138). Reader TW, Gillespie A. Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC Health Serv Res 2013;13:156. Valentine NB, de Silva A, Kawabata K, Darby C, Murray CJL, Evans DB. Health system responsiveness: concepts, domains and measurement. In: Murray CJL, Evans DB, editors, Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. World Health Organization. WHO statement on the prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva; 2015 (http://apps.who.int/iris/bitstream/10665/134588/1/ WHO_RHR_14.23_eng.pdf?ua=1&ua=1). Standard 6: Every woman and her family or the companion of her choice are given emotional support that is sensitive to their needs and strengthens the woman’s capability. Quality statement 6.1: Every woman is offered the option to experience labour and childbirth with the companion of her choice. Rationale: Birth companions provide physical, emotional and spiritual support to women during labour and deliver and thus have a positive impact on the women and improved birth outcomes. Women are allowed and encouraged to choose a companion to be present during her labour and childbirth. The companion is oriented in supporting the woman during labour and childbirth, and both the woman and her companion are encouraged to participate actively in the woman’s care. Quality measures Input 1. The labour and childbirth areas are organized in such a way as to allow a physical private space for the woman and her companion at the time of birth*. (91.59) 2. The health facility has a written, up-to-date protocol, which is explained to women and their families, to encourage all women to have at least one person of their choice, as culturally appropriate, with them during labour, childbirth and the immediate postnatal period*. (91.25) 3. Health care staff in the health facility are oriented and receive in-service refresher training sessions at least once every 12 months on the evidence for and positive impact of the presence of a chosen companion during labour and birth. (84.63) 4. Orientation sessions and information (written or pictorial) are available to orient the companion on his or her role in supporting the woman during labour and birth. (83.40) Output/process 1. The proportion of all women who gave birth in the health facility who had a companion of their choice during labour and childbirth*. (91.76) 2. The proportion of all companions who were satisfied with the orientation given on their role during labour and childbirth. (75.19) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services. (84.84) 52 Quality statement 6.2: Every woman receives support to strengthen her capability during childbirth. Rationale: Every woman should be given emotional support to improve her mental health, give her a positive outlook and improve the overall health outcomes of the mother and baby. Care at the facility optimizes biological, psychological, social and cultural well-being. Women are encouraged to adopt the position of their choice during labour, to walk around freely during the first stage and to eat and drink enough to ensure adequate nutrition and hydration. Women with complex emotional needs (e.g. previous newborn death, experience of gender- based violence, rape, mental health problems) are identified and supported. Grief support is provided to families if the mother or baby dies. Quality measures Input 2. Health care staff in the labour and childbirth areas of the maternity unit were oriented in non- pharmacological and pharmacological pain relief and received in-service training or sessions at least once in the preceding 12 months*. (87.07) 3. The health facility has a written, up-to-date protocol, which is explained to women and their families, to minimize unnecessary interventions, support normal labour and strengthen the woman’s capability, so that she feels in control of her childbirth experience. (83.21) 4. Health care staff in the labour and childbirth areas of the maternity unit were oriented and received in-service training or refresher sessions at least once in the preceding 12 months to strengthen their interpersonal and cultural competence in providing emotional support. (82.34) 5. The health facility has a referral mechanism for women and families with complex emotional needs, and refers them for specialist care. (79.71) Output/process 1. The proportion of all women who gave birth in the health facility who did so in the labour position of their choice. (82.02) 2. The proportion of all women undergoing bereavement or an adverse outcome who received additional emotional support from health facility staff. (80.64) 3. The proportion of all women who gave birth in the health facility who reported having sufficient food and drink during labour. (80.10) 4. The proportion of all women who gave birth in the health facility who were ambulatory during the first stage of labour. (77.30) Outcome 1. The proportion of all women who gave birth in the health facility who expressed satisfaction with the health services*. (84.69) 2. The proportion of all women who gave birth in the health facility who would recommend childbirth in that facility*. (84.46) 3. The proportion of all women who gave birth in the health facility who reported a positive birth experience. (83.23) 4. The proportion of all women who gave birth in the health facility who were satisfied that their choices and preferences were respected. (82.36) 53 References used in setting standard 6 Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;7: CD003766. International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99. National Institute for Health Care Excellence. Using organisational change to enhance the experience of women giving birth by focusing on normalising births. London; 2013 (https://www.nice.org.uk/ sharedlearning/using-organisational-change-to-enhance-the-experience-of-women-giving-birth- by-focusing-on-normalising-births). National Institute for Health Care Excellence. NICE guidelines on routine intrapartum care (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Renfrew MJ. Optimising the contribution of midwifery to preventing stillbirths and improving the overall quality of care: co-ordinated global action needed. Midwifery 2016;36:99–101. Royal College of Midwives. Maternal emotional wellbeing and infant development, a good practice guide for midwives, London; 2012 (https://www.rcm.org.uk/sites/default/files/Emotional%2. Wellbeing_Guide_WEB.pdf). Sandall J. Soltani H, Gates S, Shennan, A, Devane, D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013;8: CD004667. World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/). World Health Organization. WHO recommendations for augmentation of labour. Geneva; 2014 (http:// www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation-labour/en/). Standard 7: For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications. Quality statement 7.1: Every woman and child has access at all times to at least one skilled birth attendant and support staff for routine care and management of complications. Rationale: The availability of health care staff around the clock is essential for optimal routine and emergency care of patients and timely management of complications. A health facility staffing policy is in place, reviewed regularly and updated as necessary, which specifies the number, types and necessary competence of staff to ensure an adequate number and skill mix of health care staff for the volume of work, 24 h a day, 7 days a week. Clinical and nonclinical staff are oriented to their specific roles and responsibilities in the facility or unit to which they are assigned. A staff roster listing duties and the times staff will be on duty is always updated and on display. Written information is available on how to access services, and signs indicate key service areas (e.g. emergency department) and what to do in case of an emergency. Women are triaged to prioritize emergency conditions. 54 Quality measures Input 1. The health facility has skilled birth attendants available at all times, in sufficient numbers to meet the anticipated work load*. (89.50) 2. The health facility has a written, up-to-date staffing policy, listing the numbers, types and competence of staff, that is reviewed continuously according to the work load*. (89.05) 3. The health facility has a roster that is displayed in all areas, giving the names of staff on duty, the times of their shifts and their specific roles and responsibilities. (86.43) 4. The health facility has a written, up-to-date policy on triage and waiting times for emergency and non-emergency consultations and treatment. (86.32) 5. The health facility has clear communication channels to reach staff on duty at all times. (82.87) Output/process 1. The proportion of available posts in the health facility that were filled by staff with the necessary competence for the job description to allow the facility to provide 24-h service. (80.72) 2. The proportion of staff who have been oriented to their functions, roles and responsibilities in the facility or unit to which they are assigned. (78.79) 3. The proportion of women who attended the health facility who reported receiving attention within the appropriate time for their condition as per facility policy on triage and waiting time. (73.08) Outcome 1. The proportion of women and their newborns in the health facility who were attended by a skilled birth attendant (as per the definition) during and after childbirth*. (90.11) 2. The proportion of all women who gave birth at the health facility who reported having been informed about danger signs for her and her baby and emergency preparedness. (84.27) 3. The proportion of women who attended the health facility who were satisfied with the health care they received. (80.87) Quality statement 7.2: The skilled birth attendants and support staff have appropriate competence and skills to meet requirements during labour, childbirth and the early postnatal period. Rationale: Qualification, training and orientation of staff improve their performance of their roles and responsibilities. All staff have a job description that lists the necessary competence, roles and responsibilities, supported by the desired qualifications and other requirements. The education, licensure or registration and other credentials required by law or regulation are verified for all health care staff and kept current. There are established programmes for recruitment, retention, professional development and continuing education of all staff. All staff receive continuing orientation on protocols and responsibilities, supportive supervision and professional development activities, with an annual performance appraisal and recognition of good performance. Effective, efficient case management systems are in place to ensure that patients receive adequate, safe, timely care, and health care staff can demonstrate appropriate competence in providing routine care and managing complications for mothers and newborns. 55 Quality measures Input 4. The health facility has a programme for continuing professional development and skills development for all skilled birth attendants and other support staff and conducts regular training*. (86.62) 5. The health facility has standard procedures and plans for recruitment, deployment, motivation (recognition and reward scheme) and retention of all staff*. (84.21) 6. The health facility periodically appraises all staff and has a mechanism for recognizing good performance. (82.76) 7. The health facility has sufficient numbers of educated, competent, licensed, motivated, regulated skilled birth attendants with an appropriate skills mix, working in multidisciplinary teams. (81.83) 8. The health facility provides an enabling, supportive environment for professional staff development, with regular supportive supervision and mentoring. (79.24) 9. The health facility facilitates inter-professional collaborative practice, with clear roles and responsibilities based on the professional scope of practice and care needs during labour, childbirth and the early postnatal period. (75.82) Output/process 1. The proportion of skilled birth staff at the health facility who received a written job description on deployment to the facility*. (85.81) 2. The proportion of skilled birth attendants at the health facility who received in-service training, a refresher session or mentoring within the past 12 months. (81.80) 3. The number of supervisory visits to support clinical competence and performance improvement (in the past three months). (80.85) 4. The proportion of staff at the health facility who were assessed at least once in the preceding 12 months. (77.54) 5. The number of team meetings held per month to review competence and quality improvement activities. (76.33) 6. The number of interactions per month with professional mentors to ensure clinical competence and improve performance. (75.17) 7. The proportion of all staff at the health facility who were engaged in at least two active quality improvement team meetings and participated in quality improvement activities in the preceding six months. (74.70) Outcome 1. The proportion of all women who gave birth at the health facility who were satisfied with the care and support from facility staff. (82.51) 2. The proportion of skilled birth attendants and support staff at the health facility whose preceding performance appraisal was satisfactory. 3. The proportion of all staff at the health facility who reported being “highly satisfied” with their job. (76.35) 4. The proportion of all staff at the health facility who could identify and report on at least one clinical improvement activity in which they were personally involved in the past six months. (75.97) 5. The proportion of all staff at the health facility who were actively considering looking for a new job. (64.26) 56 Quality statement 7.3: The managerial and clinical leadership of every health facility is collectively responsible for creating and implementing appropriate policies and fosters an environment that supports facility staff in continuous quality improvement. Rationale: Good managerial and clinical leadership improve performance by showing direction and inspiring employees and create an environment of support for staff in undertaking continuous quality improvement. There is managerial and clinical leadership, collective responsibility, appropriate government policies and procedures and an environment that supports staff in undertaking continuous quality improvement. There is a defined leadership structure and authority, lines of accountability and a defined quality improvement team with resources. Staff collectively develop and implement quality improvement and patient safety programmes and receive support, supervision and mentoring. A policy and plan are in place to manage financial risks, and the facility undertakes regular audits (maternal and perinatal deaths and near-misses), with recommendations for improving quality. A system is in place for regular review of the data collected and reporting and communication of quality management matters to guide decision-making and monitor performance. Patient care and satisfaction are reviewed regularly, and the status of quality improvement is documented. Quality measures Inputs 1. The health facility has a written, up-to-date plan for improving the quality of care and a patient safety programme*. (88.08) 2. The health facility has a written, up-to-date leadership structure, with defined roles and responsibilities and lines of accountability for reporting*. (87.19) 3. The health facility has a designated quality improvement team and responsible personnel*. (85.38) 4. The health facility has a mechanism for regular collection of information on patient and provider satisfaction. (84.98) 5. The health facility holds at least one monthly meeting to review data, monitor quality improvement performance, make recommendations to address any identified problems, honour those who have performed well and encourage staff who are struggling to improve. (83.19) 6. All standard governing procedures (policies and protocols) are in place and accessible to all relevant staff. (82.61) 7. The proportion of all health facility leaders who were trained in quality improvement and leading change (use of information, enabling behaviour, continuous learning). (81.07) 8. The health facility holds at least two annual meetings with stakeholders (e.g. the community, service users, partners) to review its performance, identify problems and make recommendations for joint actions to improve quality. 9. The proportion of all health facility leaders who were trained in leadership and management skills. (80.89) 10. A policy is in place for staff to provide feedback to the facility management on quality improvement and their performance. (80.82) 57 OutputProcess 1. Health facility leaders communicated the performance of the facility through established mechanisms for monitoring (e.g. a dashboard of key metrics) to all relevant staff. (79.75) 2. The proportion of monthly meetings on the quality of care that were actually held in the preceding 12 months. (78.69) Outcome 1. The proportion of all women who gave birth at the health facility who were satisfied with the care and support from facility staff. (83.95) 2. Evidence for improved performance of the system (according to the facility dashboard). (82.50) References used in setting standard 7 Gülmezoglu MA, Lawrie TA. Impact of training on emergency resuscitation skills: impact on Millennium Development Goals (MDGs) 4 and 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10.1016/j. bpobgyn.2015.03.018. ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014;384:1226–1235. International Confederation of Midwives. Essential competencies for basic midwifery practice. The Hague; 2011 (http://www.internationalmidwives.org). Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129–1145. The Lancet. Midwifery. An executive summary for The Lancet’s series. London; 2014 (http://www. thelancet.com/pb/assets/raw/Lancet/stories/series/midwifery/midwifery_exec_summ.pdf). United Nations Population Fund. The state of the world’s midwifery: delivering health, saving lives. New York; 2011. Whittaker S, Shaw C, Spieker N, Linegar A. Quality standards for healthcare establishments in South Africa. In: Padarath A, English R, editors. South African Health Review. Pretoria: National Department of Health; 2011:59–68 (http://www.cohsasa.co.za/sites/cohsasa.co.za/files/ publication_pdfs/ chap_5_quality_standards_pgs_59-_68_0.pdf). World Health Organization. Making pregnancy safer: the critical role of the skilled attendant – a joint statement by WHO, ICM and FIGO. Geneva; 2004 (http://www.who.int/maternal_child_adolescent/ documents/9241591692/en/). World Health Organization. World health report 2005. Make every mother and child count. Geneva; 2005 (http://www.who.int/whr/2005/whr2005_en.pdf). World Health Organization. World health report 2006. Working together for health. Geneva; 2006 (http://www.who.int/whr/2006/en/). World Health Organization. District planning tool for maternal and newborn health strategy implementation: a practical tool for strengthening health management system. Geneva; 2011. World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines-recommendations- newborn-health.pdf). World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn-health/publications/2014/hospital-care-for- mothers-and-newborn-babies-quality-assessment-andimprovement-tool.pdf?ua=1). 58 Standard 8: The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications. Quality statement 8.1: Water, energy, sanitation, hand hygiene and waste disposal facilities are functioning, reliable, safe and sufficient for the needs of staff, women and their families. Rationale: A safe, clean, hygienic environment with continuous supplies of clean water and electricity, good sanitation and safe waste disposal are the basis of appropriate care of patients, for carrying out all procedures and interventions and for controlling infection. A consistent supply of safe water is available on site at all times for drinking, cleaning and hand-washing in all clinical areas, including labour, childbirth and newborn areas and operating theatres. Sanitation services are available, clearly separated by gender and accessible to all women, their families and staff. The health facility and its ancillary facilities (e.g. staff quarters) have reliable access to a source of electricity (e.g. solar, generator or grid) at all times. A mechanism for the segregation, collection, transport, treatment and safe disposal of waste is in place. The facility has a budget and protocol for the operation and maintenance of energy, safe water and sanitation services. Quality measures Input 1. The health facility has a functioning source of safe water located on the premises that is adequate to meet all demands for drinking, personal hygiene, medical interventions, cleaning, laundry and cooking for use by staff, women, newborns and their families*. (90.90) 2. The health facility has leak-proof, covered, labelled waste bins and impermeable sharps containers available in every treatment area, to allow segregation of waste into four categories: sharps, non- sharps infectious waste, general non-infectious waste (e.g. food, packaging) and anatomical waste (e.g. placenta)*. (90.88) 3. The health facility has at least one functioning hand hygiene station per 10 beds, with soap and water or alcohol-based hand rubs, in all wards*. (89.53) 4. The health facility has energy infrastructure (e.g. solar, generator, grid) that can meet all the electricity demands of the facility and associated infrastructure at all times, with a back-up power source. (89.41) 5. The health facility has written, up-to-date protocols and awareness-raising materials (posters) on cleaning and disinfection, hand hygiene, operating and maintaining water, sanitation and hygiene facilities and safe waste management; these are posted in the areas in which the activities are conducted. (88.05) 6. The health facility has sanitation facilities on premises that are usable, appropriately illuminated at night, accessible to people with limited mobility and separated by gender for staff and patients; they include at least one toilet that meets the needs for menstrual hygiene management, with hand- washing stations and soap and water (at least 1 latrine per 20 users for inpatient settings). (87.46) 7. The health facility has sufficient trained, competent staff on site when needed, with clear descriptions of their responsibilities for cleaning, operating and maintaining water, sanitation, hygiene and health care waste facilities. (86.44) 8. The health facility has sufficient funds for rehabilitation, improvement and continuous operation and maintenance of water, sanitation, hygiene and health care waste services. (83.13) 59 9. The heath facility has a fuel management plan and a local buffer stock, supported by an adequate budget for all the fuel needs for vehicles, cooking and heating, as relevant and as required, at all times. (83.02) 10. The health facility has a preventive risk plan for managing and improving water, sanitation and hygiene services, including for infection prevention and control. (81.34) 11. The heath facility has an energy management plan supported by an adequate budget, maintained by appropriately trained staff and regulated by a competent authority. (77.26) Outcome 1. The proportion of women and their families who attended the health facility who were satisfied with the water, sanitation and energy services and would recommend the health facility to friends and family. (76.75) 2. The proportion of all health care staff at the health facility who were satisfied with the water, sanitation and energy services and considered that these services contribute positively to providing high-quality care. (76.23) 3. The proportion of women and their families who attended the health facility who were satisfied with the power and lighting source and would recommend the health facility to friends and family. (74.20) Quality statement 8.2: Areas for labour, childbirth and postnatal care are designed, organized and maintained so that every woman and newborn can be cared for according to their needs in private, to facilitate the continuity of care. Rationale: The infrastructure of the health facility should be adequate and well maintained, with basic services, good ventilation, a power source and hygiene. The general infrastructure is organized into dedicated service areas close to the labour and childbirth areas or rooms (reception, triage and assessment area, immediate postnatal high- care area, rooming-in postnatal wards or rooms, newborn corners, sick newborn ward, kangaroo mother care ward, neonatal intensive care unit, theatre for performing caesarean sections) and adequately equipped for effective, consistent provision of optimal care. The service areas are clean, well ventilated and illuminated, particularly at night, and conducive to privacy (e.g. curtain, wall); adequate, safe, clean, well-maintained basic facilities (beds, mattresses, bed linen, washing and bathing facilities, toilet) are in place. Quality measures Input 1. The health facility has a dedicated area in the labour and childbirth area for resuscitation of newborns, which is adequately equipped with a table or resuscitaire, radiant warmer, light and appropriate resuscitation equipment and supplies*. (94.67) 2. The health facility has a labour ward and an adequate number of birthing rooms or areas for the estimated number of births in the service area*. (90.12) 3. The health facility has clean, appropriately illuminated, well-ventilated labour, childbirth and neonatal areas and surroundings that allow for privacy and are adequately equipped, regularly cleaned and maintained*. (89.52) 4. The health facility practises and enables rooming-in for all women to allow mothers and babies to remain together 24 h a day. (86.57) 5. The health facility has a labour and childbirth area or room with a functional, clean and accessible bathroom or shower room and toilet for use only by women in labour. (88.94) 60 6. A facility offering surgical services has an adequately equipped operating theatre located close to and easily accessible from the labour and childbirth areas. (88.84) 7. The facility has a dedicated recovery room or area for care of women with complications. (86.54) 8. The health facility has a dedicated ward for admitting sick and unstable small babies. (86.37) Output/process 1. The proportion of all pregnant women who attended the health facility who reported that it has a clean physical environment conducive for childbirth. (82.65) Outcome 1. The proportion of all women who gave birth in the health facility who were satisfied with the environment of the labour and childbirth area, including the cleanliness, proximity to a toilet, general lighting, level of crowding and privacy. (81.81) Quality statement 8.3: Adequate stocks of medicines, supplies and equipment are available for routine care and management of complications. Rationale: Available, adequate essential medicines, equipment and other supplies are critical for provision of optimal quality care. There is a list of essential medicines and supplies (e.g. laboratory reagents) and their uses and orderly, clean, secure storage for these items, with an efficient system to avoid stock-outs. All suitable medicines are available in the clinical areas (e.g. magnesium sulfate in the labour and childbirth areas). Essential equipment is available in the right places, at all times, with a system for regular maintenance and guidelines for appropriate use of the equipment. Laboratory tests are available (e.g. haemoglobin, blood group, urine protein) for routine use and management of complications. Blood is available for transfusion services, and an uninterrupted supply of oxygen is available in the labour and neonatal areas. Quality measures Input 1. The health facility has supplies of antihypertensive agents and magnesium sulfate in sufficient quantities, available at all times, in antenatal, labour, childbirth and postnatal areas for the management of women with pre-eclampsia*. (92.81) 2. The health facility has uterotonic drugs and supplies for intravenous infusion (syringes, needles, infusion sets, intravenous fluid solutions and blood) available in sufficient quantities at all times in the childbirth and postnatal care areas for the management of women with postpartum haemorrhage*. (92.31) 3. The health facility has supplies of antenatal corticosteroids (dexamethasone or betamethasone), antibiotics and magnesium sulfate available in sufficient quantities at all times to manage preterm births*. (92.15) 4. The health facility has functioning essential equipment and supplies for the detection of complications (e.g. thermometers, sphygmomanometers, foetal stethoscopes, urine dipsticks, pulse oximeter) in sufficient quantities at all times in the labour and childbirth areas of the maternity unit. (91.63) 5. The health facility has supplies of first- and second-line injectable antibiotics and other essential medicines available at all times for the management of women and newborns with, or at risk for, infections during labour, childbirth and the early postnatal period. (91.48) 61 6. The health facility has essential laboratory supplies and tests (blood glucose, haemoglobin or packed cell volume, blood group and cross-matching, bilirubin, urine protein, full blood count, blood culture, electrolytes, renal and liver function tests, syphilis, HIV and malaria rapid diagnostic tests) to support the management of women and newborns. (91.12) 7. The health facility has essential supplies and functioning equipment (including childbirth beds, vacuum, forceps, incubators, weighing machine, sterile gloves) available in sufficient quantities at all times in the labour and childbirth areas. (90.88) 8. The health facility has supplies and functioning equipment for the emergency care and resuscitation of women (well-stocked resuscitation trolley, suction device, pulse oximeter, airways, laryngoscope, endotracheal tubes, adult bag valve masks, infusion sets, intravenous fluids) available in sufficient quantities all times in areas designated for labour, childbirth and postnatal care. (89.70) 9. The health facility has a safe, uninterrupted oxygen source and delivery supplies (nasal prongs, catheters and masks), including nasal continuous positive airway pressure, available at all times in labour, childbirth and neonatal areas and the operating theatre (when available). (89.37) 10. The health facility has supplies and functioning equipment for emergency care and resuscitation of newborns (resuscitation table, well-stocked neonatal resuscitation trolley, warmer, suction device, pulse oximeter, laryngoscope) available all times in areas designated for labour, childbirth and neonatal care. (89.02) 11. The health facility has an on-site pharmacy and a medicine and supplies stock management system managed by a trained pharmacist or dispenser. (88.44) 12. The health facility has a dedicated budget for essential medicines, equipment (and its maintenance) and medical supplies for maternal and newborn care. (84.94) 13. The health facility has a functioning diagnostic ultrasound machine and trained health staff who can conduct a basic obstetric ultrasound examination to determine the number of fetuses present, gestational age, prenatal diagnosis of foetal anomalies or early diagnosis of placental insufficiency. (84.83) Output/process 1. Availability of essential life-saving medicines (oxytocin, magnesium sulfate, dexamethasone, vitamin K, injectable and oral amoxicillin, benzyl penicillin, gentamicin, ceftriaxone, metronidazole, antimalarial drugs, antiretroviral drugs and vaccines against tuberculosis, hepatitis B, poliomyelitis) in the past three months. (88.84) 2. The proportion of all women who had severe pre-eclampsia or eclampsia in the health facility who did not receive the full dose of magnesium sulfate because of a stock-out. (79.38) 3. The proportion of all women who gave birth in the health facility who purchased gloves and other necessary items. (70.62) Outcome 1. The proportion of all nulliparous women with a singleton cephalic foetus at ≥ 37 weeks of gestation who underwent caesarean section during spontaneous labour (Robson group 1). (82.54) 2. The proportion of unmet need for caesarean section as a result of lack of supplies or staff trained to conduct caesarean section. (74.81) References used in setting standard 8 Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Safe management of wastes from health-care activities. Geneva: World Health Organization; 2014 (http://www.who.int/ water_sanitation_health/publications/wastemanag/en/). 62 Water Supply and Sanitation Collaborative Council. WASH targets and indicators post-2015: recommendations from international consultations. Geneva; 2014 (http://www.wssinfo.org/ fileadmin/user_upload/resources/post-2015-WASH-targets-factsheet-12pp.pdf). World Health Organization. Essential elements of obstetric care at first referral level. Geneva; 1991 (http://apps.who.int/iris/bitstream/10665/41740/1/9241544244.pdf). World Health Organization. Essential environmental health standards in health care. Geneva; 2008 (http://www.who.int/water_sanitation_health/hygiene/settings/ehs_health_care.pdf.pdf). World Health Organization. Systems thinking for health systems strengthening. Geneva; 2009 (http:// www.who.int/alliance-hpsr/resources/9789241563895/en/). World Health Organization. Evaluating household water treatment options: health based targets and microbiological performance specifications. Geneva; 2011 (http://www.who.int/ water_sanitation_health/publications/household_water/en/). World Health Organization. Service availability and readiness assessment. Geneva; 2014 (http://apps. who.int/iris/bitstream/10665/149025/1/WHO_HIS_HSI_2014.5_eng.pdf). World Health Organization, UNICEF. Progress on drinking-water and sanitation: Joint Monitoring Programme update 2014. Geneva; 2014 (http://www.who.int/water_sanitation_health/ publications/jmp-report-2014/en/). World Health Organization, UNICEF. Water, sanitation and hygiene in health care facilities. Status in low- and middle-income countries and way forward. Geneva; 2015 (http://apps.who.int/iris/ bitstream/10665/154588/1/9789241508476_eng.pdf). 63 6. Operationalization Evidence-based, effective, respectful, high-quality care and the elements of health systems that support optimal care for women and newborns described in the WHO quality of care framework are to be operationalized by applying the standards of care and quality statements. The standards should be adapted to the context of each country to ensure detailed processes of evidence-based clinical care (standard 1), information systems (2), referral systems (3) experience of care (4–6), an enabled, motivated work force (7) and adequate resources (8). The standards are accompanied by evidence-based quality statements, which include measures of inputs, outputs and outcomes. These will improve quality and ensure high-quality care for mothers and newborns. Ideas for implementing the standards should be based on the county’s experience and on adaptive learning within and between countries. 6.1 Dissemination The framework, standards of care and quality measures are published in a technical reference document, which can be incorporated into strategic documents at country level. They are part of a package of normative tools for supporting improvement of the quality of maternal and newborn care. They will be translated into Arabic, French, Russian and Spanish in collaboration with the WHO regional offices, for wider circulation. The publication will be available for downloading from the websites of WHO headquarters, the regional and country offices, WHO collaborating centres and partner agencies involved in maternal and newborn quality of care. Hard copies of the publication will be disseminated to all WHO country offices and will be available for sale from WHO bookshop and its distribution network to all medical libraries and individuals. 6.2 Implementation approach To increase access to and use of the standards of care and quality measures, orientation and capacity-building workshops will be conducted in all the WHO regions in collaboration with the regional offices. Targeted support will be provided to countries, and a learning platform will be created for sharing best practices within and among countries by an innovative approach (Fig. 3), which is an adaptation of the “Plan Do Study Act” model (22) based on synthesis of evidence, best practice and experience. It provides a plan for continuous quality improvement by setting aims and building teams to achieve desired outcomes through use of change packages (individual, multi-faceted or complex interventions, depending on the context and needs), capacity-building and other strategies to maximize the chances for sustaining implementation. 64 Fig. 3. Implementation approach In addition, step-by-step guidance will be provided on establishing a system for improving the quality of maternal and newborn health within the national quality of care strategy and operational plan. The guidance will be accompanied by the necessary tools and targeted capacity-building for strong country leadership. 1. Establish leadership structures and function 5. Build capability & implement interventions 6. Continuously measure quality of care & outcomes 7. Refine strategies for scale up PLAN DO STUDY ACT 2. Adapt standards of care 3. Conduct situation analysis/assessment 4. Ensure essential infrastructure to get started 65 7. Monitoring and evaluation Implementation of these standards will be accompanied by an internal and external monitoring and evaluation plan. Internal monitoring and evaluation will be integrated into the guidance and linked to the output of the learning platform. External monitoring and evaluation will be conducted for rigorous evaluation of implementation by various methods, sources and study designs to ensure effectiveness (pragmatic and quasi-experimental designs), process (quantitative and qualitative designs) and economic efficiency. The results of both the internal and external monitoring and evaluations will be used to improve the implementation guidance and learning platform. 66 8. Updating the standards The best practices reported on the learning platform and the evaluations of implementation will be collated and used to review and update the standards of care and quality measures as appropriate. 67 References 1. Raven JH, Tolhurst RJ, Tang S, van den Broek N. What is quality in maternal and neonatal health care? Midwifery 2012;28:e676–e683. 2. Tuncalp Ö, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al, Quality of care for pregnant women and newborns – the WHO vision. Br J Obstet Gynaecol 2015;122:1045–1049. 3. World Health Organization. Strategies toward ending preventable maternal mortality. Geneva; 2015 (http://who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/, accessed 22 March 2015). 4. World Health Organization. Every newborn: an action plan to end preventable deaths. Geneva; 2014 (www.who.int/maternal_child_adolescent/topics/newborn/enap_ consultation/en/, accessed 19 January 2015). 5. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health 2014;2: e323–e333. 6. WHO Global Health Observatory. 2014 (http://apps.who.int/gho/data/?theme=main, accessed 12 January 2015). 7. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347–370. 8. United Nations. Global strategy for women’s and children’s health. New York; 2010. 9. Campbell OM, Graham WJ. Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284–1299. 10. Global Health Group. Where women go to deliver: overview of the project and review of preliminary findings. San Francisco, California: University of California at San Francisco, Global Health Sciences; 2014. 11. World Health Organization. WHO multicountry survey on maternal and newborn health 2010–2012. Geneva; 2011 (http://www.who.int/reproductivehealth/topics/ maternal_perinatal/nearmiss/en/). 12. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gulmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health 2014;11:71. 13. World Health Organization. The second report of the independent expert review group (iERG) in information and accountability for women’s and children’s health. Geneva; 2013. 14. Wilson L, Goldsmith P. Quality and its measurements. In: Wilson L, Goldsmith P, Editors. Quality management in health care. Sydney: McGraw-Hill; 1995;229–258. 68 15. Roemer MI, Montoya-Aguilar C. Quality assessment and assurance in primary health-care. Geneva: World Health Organization; 1988. 16. Institute of Medicine. A strategy for quality assurance. Washington DC: National Academy Press; 1990. 17. World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva; 2006. 18. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260:1743–1748. 19. Maxwell RJ. Dimensions of quality revisited: from thought to action. Qual Health Care 1992; 1:171–177. 20. Ovretveit J, Bate P, Cleary P, Cretin S, Gustafson D, McInnes K, et al. Health service quality. An introduction to quality methods for health services. Oxford: Blackwell Scientific Publications; 1992. 21. Hulton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Southampton: University of Southampton; 2000. 22. International Organization for Standardization. Geneva (http://www.iso.org/iso/home/ standards.htm accessed 24 June 2016) 23. The Joint Commission. Oakbrook Terrace, Illinois http://www.jointcommission.org/ standards_information/jcfaq.aspx accessed 24 June 2016. 24. The Council for Health Service Accreditation of Southern Africa (COHSASA) accreditation standards. Pretoria (http://www.cohsasa.co.za/ accessed 24 June 2016). 25. National Institute for Health and Care Excellence. London (https://www.nice.org.uk/ standards-and-indicators accessed 24 June 2016). 26. Pharmaccess group. Safe care basic healthcare standards. The Hague (http://www.safe- care.org/index.php?page=safecare-standards accessed 24 June 2016). 27. World Health Organization. Standards for maternal and neonatal care. Group 1: General standards of care for healthy pregnancy and childbirth. Geneva; 2007 (http://www.who. int/reproductivehealth/publications/maternal_perinatal_health/a91272/en/) 69 Annex 1. Participants in the meeting of the guideline development group, Geneva, 3–4 June 2015 Dr Pierre Barker, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA Mrs Sheena Currie, Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA Dr Kim Dickson, UNICEF, New York City (NY), USA Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden Dr Kathleen Hill, JHPIEGO, Washington DC, USA Dr Asia Kassim Hussein, UNICEF, Dar-es-Salaam, United Republic of Tanzania Dr Theopista John, WHO Country Office, Dar-es- Salaam, United Republic of Tanzania Dr Lily Kak, Global Partnerships and Newborn Health, Washington DC, USA Dr Senait Kebede, Emory University, Atlanta, Georgia, USA Professor Joy Lawn, London School of Hygiene and Tropical Medicine, London, United Kingdom Dr Tess Lawrie, Evidence-based Medicine Consultancy Ltd, Bath, United Kingdom Mr Norman Lufesi, Ministry of Health, Lilongwe, Malawi Dr Carolyn Maclennan, Alice Springs Hospital, Alice Springs, NT, Australia Dr Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Md. Ziaul Matin, UNICEF, Dakka, Bangladesh Dr Goldy Mazia, Maternal and Child Survival Program, PATH, Seattle, Washington, USA Dr Georgina Msemo, Ministry of Health and Social Welfare, Dar-es-Salaam, United Republic of Tanzania Dr Jim Neilson, Professor of Obstetrics & Gynaecology, University of Liverpool, United Kingdom Mr Lee Pyne-Mercier, Bill & Melinda Gates Foundation, Seattle, Washington, USA Dr Isabella Sagoe-Moses, Ministry of Health, Accra, Ghana Dr Memuna Tanko, Acting Director, Quality Assurance, National Health Insurance Authority, Accra, Ghana Professor Nynke van den Broek, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, United Kingdom Ms Donna Vivio, Senior Newborn Health Advisor, United States Agency for International Development, Washington DC, USA Dr Nabila Zaka, Senior Advisor Health, UNICEF, Geneva, Switzerland 70 Annex 2. List of participants in the Delphi study Joel Adze, Kaduna State University, Kaduna, Nigeria Anna Afugglas, United Nations Population Fund, Phnom Penh, Cambodia Dr Elnahas Amir, Sidra Medical and Research Center, Doha, Qatar Professor Surasak Angsuwathana, Faculty of Medicine, Mahidol University, Bangkok, Thailand Sir Sabaratnam Arulkumaran, FIGO, London, United Kingdom Dr Deorari Ashok, All-India Institute of Medical Sciences, New Delhi, India Ms Joanne Ashton, Joint Commission International, Oakbrook Terrace, Illinois, USA Professor Nabhan Ashraf, Ain Shams University, Cairo, Egypt Dr Alberta Bacci, Independent consultant, Lisbon, Portugal Dr Solange Balaga, , Independent Consultant, Kinshasa, Democratic Republic of the Congo Dr Cyprien Baribwira, Maryland Global Initiative Corporation (MGIC), Kigali, Rwanda Dr Suppawat Boonkasidecha, Queen Sirikit National Institute of Child Health, Bangkok Thailand Dr Betzabe Butron, WHO Regional Office for the Americas, Washington DC, USA Dr Romano Byaruhanga, Kampala Medical Chambers Hospital, Kampala, Uganda Ms Anna Coates, WHO Regional Office for the Americas, Washington DC, USA Dr Jeanine Umutesi Condo, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda Dr Dilberth Cordero, WHO Country Office, Tegucigalpa, Honduras Ms Sheena Currie, JHIEGO and Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA Dr Louise Day, LAMB Integrated Rural Health and Development, Dakka, Bangladesh Professor Soo Downe, Research in Childbirth and Health Group, London, United Kingdom Atf Gherissi, El Manar University, Tunis, Tunisia Professor Michael English, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya Professor Jan Jaap Erwich, University of Groningen, Groningen, Netherlands Professor Vicki Flenady, University of Queensland, Herston, Australia Mr Fabrice Fotso, UNICEF West and Central Africa Regional Office, Dakar, Senegal Dr Sabine Gabrysch, Heidelberg University, Heidelberg, Germany Dr Karima Gholzbhouri, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt Dr Gathari Gichuhi, Ministry of Health, Nairobi, Kenya 71 Dr Aparajita Gogoi, Whiteribbon Alliance, New Delhi, India Dr Rogelio Gonzalez, Centre for Perinatal Diagnosis, Catholic University of Chile, Santiago, Chile Professor Malik Goone wardene, Faculty of Medicine, University of Ruhuna, Sri Lanka Ms Ana Guerreiro, independent consultant, Lisbon, Portugal Privat Guie, Polyclinic Internationale sainte Anne Marie, Abidjan, Cote d’Ivoire Ms Gill Gyte, University of Liverpool, Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom Ms Fransisca Handy, Apotek Puri Satu Kembangan, Jakarta, Indonesia Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden Dr Jim Heiby, United States Agency for International Development, Washington DC, USA Dr Jorge Hermida, Assist/University Research Co., Quito, Ecuador Dr Kathleen Hill, United States Agency for International Development, ASSIST Project, Washington, DC, USA Dr Stephen Hodgins, Save the Children, Washington DC, USA Dr Caroline Homer, University of Technology, Sydney, Australia Ms Petra Hoope-Bender, Instituto de Cooperación Social – Integrare, Barcelona, Spain Dr Grace Irimu, Kenyatta University, Nairobi, Kenya Ms Rima Jolivet, White Ribbon Alliance for Safe Motherhood, Washington, DC, USA Dr Theopista Kabuteni-John, WHO Country Office, Dar-es-Salaam, United Republic of Tanzania Dr Lily Kak, United States Agency for International Development, Washington DC, USA Dr Ariel Karolinski, WHO Country Office, Buenos Aires, Argentina Professor Holly Kennedy, Yale University, Boston (MA), USA Dr Neena Khadka, Maternal and Child Survival Program, Washington DC, USA Prof Zulfiya Khodjaeva, Federal Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation Dr Tamar Khomasuridze, United Nations Population Fund, European Regional Office, Ankara, Turkey Dr Andre Lalonde, The Society of Obstetricians and Gynaecologists of Canada (SOGC), Ottawa, Canada Dr Marzia Lazzerin, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Italy Dr Li Wenying, Aviation General Hospital of China Medical University, Beijing, China Dr Jerker Liljestrand, Bill and Melinda Gates Foundation, Seattle, USA Dr Liu Cheng, Beijing Armed Police Corps Hospital, Beijing, China Dr Nigel Livesley, University Research Co., Bethesda, USA Mr Norman Lufesi, ARI/Community Health Service, Ministry of Health, Lilongwe, Malawi Ms Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Kuhu Maitra, Abt Associates, Cambridge (MA), USA Prof Zoe Matthews, University of Southampton, Southampton, United Kingdom Dr Goldy Mazia, PATH, Seattle (WA), USA Dr Alison McFadden, University of Liverpool, Liverpool, United Kingdom Ms Alison Mcintyre, WaterAid, East Melbourne, Australia 72 Prof Tarek Meguid, Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania Dr Tanko Memuna, National Health Insurance Authority, Accra, Ghana Dr Abraham Mengistu, Ministry of Health, Addis Ababa, Ethiopia Dr Raul Mercer, Universidad Nacional de La Plata, Buenos Aires, Argentina Dr Allisyn Moran, United States Agency for International Development, Washington DC, USA Dr Rintaro Mori, National Centre for Child Health and Development, Tokyo, Japan Dr Georgina Msemo, Ministry of Health, Dar-es- Salaam, United Republic of Tanzania Dr Bremen de Mucio, WHO Country Office, Montevideo, Uruguay Dr Christine Muzel, Philips Healthcare, Amsterdam, Netherlands Dr Victoria Nakibuka, Nsambya Hospital, Kampala, Uganda Dr James Neilson, University of Liverpool, Liverpool, United Kingdom Dr Hiromi Obara, Bureau of International Medical Cooperation, Tokyo, Japan Dr Dwiana Ocviyanti, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia Dr Jeanne Odette, Université du Burundi, Bujumbura, Burundi Prof Pius Okong, Health Service Commission, Kampala, Uganda Dr Eduardo Ortiz-Panozo, Centro de Investigaciones Regionales, Mérida, Mexico Prof Ouadraogo Charlemagne, Centre Hospitalier Universitaire Yalgado, Ouagdougou, Burkina Faso Dr Duran Pablo, WHO Country Office, Montevideo, Uruguay Dr Imran Pambudi, Ministry of Health Indonesia, Jakarta, Indonesia Dr Robert Pattinson, Maternal and Infant Health Care, South Africa Medical Research Council, Kalafong Hospital, Pretoria, South Africa Dr Loveday Penn-Kekana, University of the Witwatersrand, Johannesburg, South Africa Dr Emily Peterson, Centers for Disease Control and Prevention, Atlanta (GA), USA Dr Cynthia Pileggi, Ribeiro Preto Medical School, University of São Paulo, São Paulo, Brazil Dr Neil Prose, Duke University, Durham (NC), USA Ms Pamela Putney, Options Consultancy Services Limited, London, United Kingdom Dr Neena Raina, WHO Regional Office for South- East Asia, New Delhi, India Prof Kathryn Ramsey, Columbia University Medical Center, New York, USA Prof Mary Renfrew, Scottish Improvement Science Collaborating Centre, Dundee, United Kingdom Dr Alexander Rowe, Centers for Disease Control and Prevention, Atlanta (GA), USA Prof Irina Ryumina, Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation Dr Harshad Sanghvi, JHPIEGO, Baltimore, MD, USA Prof Ola Saugstad, University of Oslo, Oslo, Norway Dr Kerri Schuiling, International Confederation of Midwives, Rochester (MI), USA Ms Gloria Seguranyes, University of Barcelona, Barcelona, Spain Ms Priti Dave Sen, Children’s Investment Foundation, London, United Kingdom Dr Hemantha Senanayake, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka Prof Shi Qi, North Sichuan Medical College, Obstetrics and Gynaecology, Nanchong, China Dr Miannes Silvestre, University of the Philippines College of Medicine, Manila, Philippines 73 Dr Jeffrey Smith, JHPIEGO, Baltimore, MD, USA Dr Howard Sobel, WHO Regional Office for the Western Pacific, Manila, Philippines Prof Williams Stones, FIGO, London, United Kingdom Dr Tang Zengjun, Hebei Provincial People’s Hospital, Shijiazhuang, China Ms Nicole Thiele, European Foundation for the Care of Newborn Infants, Munich, Germany Dr Paul Vinod, All-India Institute for Medical Sciences, New Delhi, India Ms Donna Vivio, United States Agency for International Development, Washington DC, USA Dr Gijs Walraven, Aga Khan Development Network, Paris, France Dr Wang Yeping, Wenzhou City People’s Hospital, Wenzhou, China Dr Martin Weber, WHO Regional Office for Europe, Copenhagen, Denmark Prof Zhang Hongyu, Hainan Medical, Haikou, China Dr Zhang Jim, Shanghai Jiao Tong University School of Medicine, Shanghai, China Dr Zhou Wei, Chongqing medical university, Chongqing, China Dr Nabila Zaka, UNICEF Headquarters, New York, USA Professor Zhang Huixin, Fourth Hospital of Hebei Medical University, Shijiazhuang, China

ISBN 978 92 4 151121 6Department of Maternal, Newborn, Child and Adolescent Health World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4853 E-mail: mach@who.int www.who.int Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth For more information, please contact:

استانداردهایی برای بهبود کیفیت مراقبت از مادران و نوزادان در تسهیلات زایمانی مترجمین: دکتر نیلوفر ستارزاده، شکیبا پوراسد شهرک دانشکده پرستاری و مامایی تبریز استانداردهایی برای بهبود کیفیت مراقبت از مادران و نوزادان در تسهیلات زایمانی دانشگاه علوم پزشکی تبریز دانشکده پرستاری و مامایی، بنام خداوند بخشنده مهربان 2016انتشار توسط سازمان جهانی بهداشت در سال تحت عنوان: nrobwen dna lanretam fo ytilauq gnivorpmi rof sdradnatS seitilicaf htlaeh ni erac 2016سازمان جهانی بهداشت انتشار به زبان فارسی را به دانشگاه انتشارات سازمان جهانی بهداشت حقوق ترجمه و باشد.که تنها مسئول برای انتشار فارسی میاست علوم پزشکی تبریز اعطا نموده استانداردهایی برای بهبود کیفیت مراقبت از مادران و نوزادان در تسهیلات زایمانی *، شکیبا پوراسد شهرک*مترجمین: دکتر نیلوفر ستارزاده لوم پزشکی تبریزناشر: دانشگاه ع 2016سال ترجمه و انتشار: گروه مامایی دانشگاه علوم پزشکی تبریزاعضای * فهرست 7........................................................................................................................................................................ کلمات اختصاری 8............................................................................................................................................................................. تقدیر و تشکر 10.............................................................................................................................................................. خلاصه استخراج شده 10................................................................................................................................................................................... . زمینه0 10........................................................................................................................................................................... معرفی 0.0 70....................................................................... زایمان میر مادران و دوران حول و حوش های کاهش مرگ واولویت 6.0 80............................................................................................................................................................................ منطق 1.0 10............................................................................................................................................................... جمعیت هدف 1.0 16....................................................................................................................................................................کار ..ها و روش .6 16.................................................................................................................دید کلی ....................................................... 0.6 16............................................................................................................................................................................. هدف 6.6 06...................................................................................................................... ارچوب و استانداردهای مراقبتتوسعه چ 1.6 16......................................................................................................................................... هاگیریتوسعه کیفیت اندازه 1.6 16.................................................................................................................................... باکیفیت ارچوب مراقبت. تعریف و چ1 16.............................................................................................................................................. هاهد و خلاصه یافتهاشو 0.1 11................................................................................................................................................ کیفیتبا تعریف مراقبت 6.1 11............................................................................................................................................ چهارچوب کیفیت مراقبت 1.1 11......................................................................................................................................... های استراتژیک کاریحوزه 1.1 11.......................................................................................................................................................... . استانداردهای مراقبت1 11.............................................................................................................................................. هاهد و خلاصه یافتهاشو 0.1 11............................................................................................................................................. تعریف و ساختار استاندارد 6.1 11..................................................................................................... کیفیتهای ه از استانداردها و بیانیهاستفاداهداف و 1.1 71..................................................................................................................... کیفیت هایلیستی از استانداردها و بیانیه 1.1 61....................................................................................................................................... هاگیریکیفیت و اندازه های. بیانیه1 61................................................................................................................................................. ihpleDپیامد فرایند 0.1 11................................................................................................................................ های کیفیتگیریاستفاده از اندازه 6.1 11...................................................................................................................... کیفیت هایهایی برای بیانیهگیریاندازه 1.1 110............................................................................................................................................................................. یات. عمل2 110.......................................................................................................................................................................... انتشار 0.2 110...............................................................................................................................................................رویکرد تهیه 6.2 610................................................................................................................................................................ ارزیابی و بررسی 7 610................................................................................................................................................. روزرسانی استانداردهابه. 8 110...................................................................................................................................................................................... منابع 210................................................. 1016ژوئن 1-1، ژنو، »گروه توسعه دستورالعمل«کنندگان در جلسه : شرکت0ضمیمه 810................................................................................................. ihpleDکنندگان در مطالعه : لیستی از شرکت6ضمیمه یراصتخا تاملک ICD International Classification of Diseases NICE National Institute for Health and Care Excellence UNICEF United Nations Children’s Emergency Fund رکشت و ریدقت نامتراپد یاه نامزاس یناهج نامتراپد هلمج زا تشادهب و یروراب تملاس نامتراپد و ناوجون و کدوک ،دازون ،ردام تملاس هک یدارفا همه زا قیقحت هیهت رد دنس نیایراکمه دنتشاد ، هنامیمصیم یرازگساپس.دنک نینچمهس نیا نامزا زایمامت درک تکرش راک نیا رد هک یناصصختمه ویارب چ هیهت و ناردام زا تبقارم تیفیک بوچرا دازوننانایب و تبقارم یاهدرادناتسا ،هییاه نئوژ هسلج رد تیفیک6101 تکرش درک هدوبدن ،یم هژیو رکشتدنک. Pierre Barker, Institute for Healthcare Improvement, USA; Nynke van den Broek, Liverpool School of Tropical Medicine, United Kingdom; Sheena Currie, Maternal and Child Health Integrated Program, USA; Kim Dickson, UNICEF, USA; Claudia Hanson, Karolinska Institute, Sweden; Kathleen Hill, JHPIEGO, USA; Asia Kassim Hussein, UNICEF, United Republic of Tanzania; Lily Kak, United States Agency for International Development, USA; Joy Lawn, London School of Hygiene and Tropical Medicine, United Kingdom; Tess Lawrie, Evidencebased Medicine Consultancy Ltd, United Kingdom; Norman Lufesi, Ministry of Health, Malawi; Silke Mader, European Foundation on the Care of Newborn Infants, Germany; Ziaul Matin, UNICEF, Bangladesh; Goldy Mazia, Maternal and Child Survival Program, USA; Georgina Msemo, Ministry of Health and Social Welfare, United Republic of Tanzania; Jim Neilson, University of Liverpool, United Kingdom; Lee Pyne-Mercier, Bill & Melinda Gates Foundation; USA; Isabella Sagoe-Moses, Ministry of Health, Ghana; Memuna Tanko, National Health Insurance Authority, Ghana; Donna Vivio, United States Agency for International Development, USA; and Nabila Zaka, UNICEF, USA. یم رکشت ام زا مینک002 زا صصختم12 هعلاطم رد هک روشکDelphi یارب و هدرک تکرشهیهت هلئسم رد قفاوتهینایب- یاه دندرک یراکمه تیفیک( همیمض رد هدش تسیل6). اخ نارواشمر هک یج نیا راک ار فلتخم لحارم رد ؛دنداد رارق تیامح درومریز دارفا لماش :دنتسه Carolyn MacLennan, Rashmi Mathur, Senait Kebede and Tess Lowrie نامزاس ینامزاس لخاد نانکراک یناهجدندوب ریز دارفا لماش لمعلاروتسد هورگ رد تشادهب: Rajiv Bahl, Bernadette Daelmans, Matthews Mathai, Fran McConville, Annie Portela, Severin von Xylander and Wilson Were, Maternal, Newborn, Child and Adolescent Health; Metin Gülmezoglu, Olufemi Oladapo, Ozge Tuncalp, and Joshua Vogel, Reproductive Health and Research; Neelam Dhingra, Shamsuzzoha Syed, Service Delivery and Safety; Margaret Montgomery and Michaela Pfeiffer, Public Health and Environment; Mwansa Nkowane, Health Workforce; and Gerardo Zamora and Lisa Rogers, Nutrition for Health and Development. راک نیا هدش رشتنم یاضعا یراکمه لصاح نانکراک هورگراکی یزکرم ردیم نادازون و ناردام زا تیفیک اب تبقارم دشاب یم ریز دارفا لماش هک :دنشاب Bernadette Daelmans, Olufemi Oladapo, ضzge Tuncalp, Wilson Were and Severin von Xylander مامت زا ام نینچمهی زاس نانکراکتشادهب یناهج نام، مامت زای درک تکرش هسلج رد هک ییاهروشک و قطانمه ار نتم ، دروم ینیبزابهداد رارق ار یبلاطم و(مجرتم .دنس نیا یارب) هیهت دندرک، یم ینادردق و رکشت.مینک زا امBill & Melinda Gates Foundation یم ینادردق و رکشت ،دندرک یلام تیامح ار راک نیا هکنک.می خلاصه استخراج شده تسهیلات زایمانی ایجاد شده است؛ با این وجود، مراکز زیادی در زمینه زایمان در هایدر طول دو دهه گذشته، پیشرفت تسهیلات مراکز ها در است. با افزایش تعداد زایمان کرده تری پیشرفتکاهش مرگ و میر مادران و نوزادان با سرعت آهسته -به سوی کیفیت مراقبتها متمرکز شده است زیرا کیفیت ضعیف مراقبتها منجر به مرگ و میر و بیماری میزایمانی توجهات مادران و نوزادان و پیشگیری از مرگ بیشتری از ترین دوره برای نجات زندگی تعداد شود. دوره حول و حوش زایمان حیاتی هر «کند: ترسیم می )برای این موضوع. مترجم(این صورت ای بهجهانی بهداشت آینده باشد. سازماندر حین زایمان می برای ». کندبا کیفیت بالا دریافت می هایو نوزادش، در طول حاملگی، زایمان و دوره پس از زایمان مراقبت مادر حامله ه کیفیت مراقبتها ارچوبی در زمینرا تعریف کرده و چ» قبت با کیفیتمرا«درک این دیدگاه، سازمان جهانی بهداشت، مسئله برای مادران و نوزادان در زمان زایمان فراهم کرده است. ، بهبود یافته و در سیستم بهداشتی چک باشد که باید ارزیابی شدهدر مراقبت با کیفیت می بعدهشت دارایارچوب این چ و تجربه (تهیه مراقبت مهمداخلی در دو بعد با کیفیت بالا برای دستیابی به مراقبترا سیستم بهداشتی ساختاری شود. درک این دیدگاه در برایارچوب و در حیطه اختیارات سازمان، سازمان جهانی بهداشت کند. در این چمی ایجاد )مراقبت راهنما تهیه جهتجامع و بر پایه شواهد یرویکردایجاد ای برای پایه این کار شش حوزه استراتژیک کار خواهد کرد که های بالینی، استانداردهای کیفیت مراقبتهای مادران و نوزادان خواهد بود. این شش حوزه شامل دستورالعمل برای بهبود باشند. می سازیها، تحقیقات مربوطه و ظرفیتکیفیت مراقبت سنجشمراقبت، مداخلات موثر، کلیدی برای اطمینان از عامل چه آنها گرابودند زیرا در اولویت قرار داده شدهکیفیت هایسنجشاستانداردهای مراقبت و بصورت چیزی که به صراحت . استانداردها، ای در این زمینه وجود نداشتشدهاما اخیرا راهنمای ساخته کیفیت مراقبتها بودند جهت تعریف و تعیین شود. در فاز اولدر زمان زایمان نیاز است، تعریف میدستیابی به مراقبت با کیفیت بالا برای سازمانهای ازنقشه استانداردهای مراقبت یک متون تحقیقی گسترده و ارتباط با تارشان برای تشخیص منابع موجود در ساخ پیشنهاد شده بود که استانداردهای وسیعی تحت اظهارات کیفیتی ویژه . بودقرار گرفته استفاده رویکرد دقیقی مورد گوناگون هشت استاندارد، هر کدام برای یکی از هشت حوزه تنظیم شود. پیامد هایشسنجیا خروجی، ورودیموارد و تعدادی از با یهبیان 10تا 6ارچوب مراقبت استاندارد تعیین شده بودند. برای اطمینان از اینکه استانداردها ویژه و متمرکز هستند، چ ها در حول و حوش یت مراقبتهای قابل سنجش در زمینه کیفجهت دستیابی به پیشرفتکیفیت برای هر استانداردی زایمان تنظیم شده بودند. شواهد تهیهسازمان جهانی بهداشت برای بازبینی و در داخل سازمانی و یک گروه مرکزی کار هدایت کنندهیک گروه یم و برای تنظ» کیفیت مراقبت«برای تعریف 2016تا فوریه 1016در فاصله ژانویه گروه کاری، . ه بودندتاسیس شد ارچوب در این چ .قرار دادبازبینی مطالعات منتشر شده را مورد اطمینان از کیفیت مراقبت از مادران و نوزادان چارچوب جهت کیفیت «که گروه تعریف جایی ( تهیه دستورالعملتشکیل شده در ژنو به گروه در جلسه 1016ژوئن سه و چهارتاریخ مورد ها را مراقبت سنجشهای توصیف کیفیت و شاخص هاینیهی مراقبت، بیاارچوب پیشنهاد شده، استانداردها، چ»مراقبت کیفیت با هاینیهارچوب، استانداردهای مراقبت و بیاچ ابعادتوافق بر روی تعریف، ارائه شد. )بودند قرار دادهبازبینی و بحث قرار دادبحث مورد ها گیرییف اندازهبرای تعررا دستورالعمل شاخصهایی تهیه بدست آمدند. همچنین گروه با بحث جمعی . شداستفاده میها کیفیت مراقبتارزیابی گیری و ، اندازهبررسیکه برای ها را برای هر کدام سنجشو نتایج های داخل سازمان، موارد ورودی، خروجیدستورالعمل هدایت کنندهدر مرحله دوم، گروه مورد استفاده سازمان جهانی بهداشت و نشانگرهایها از سنجشو تنظیم کرد. این بازبینی آوری، جمعکیفیت هاییهاز بیان ها بوسیله سنجشعموم استخراج شده بودند. سپس المللی تشخیص داده شده بودند، در بعد ی که بینهایسایر سازمان شدند. برای اطمینان از ایجادها دستورالعمل هدایت کنندهگروه در جلسهدوباره سازمان تکنیکال مربوطه استخراج شدند و بازبینی ihpleDلیست نتایج در دو دوره از فرایند ،)متخصص 200(و کارکنان )کشور 21( توافق در جغرافیای گسترده و تجربه تدارکات ها برای تشخیص خلاهای کیفیت مراقبت و بهبود سنجشاز توانندهای تسهیلات سلامتی میشدند. تیم استفاده کنند. نتایج توسط رهبران تسهیلات سلامتی، طراحان، مدیران و هابیانیهجه به استانداردها و کیفیت ها با تومراقبت پیشرفت و اثر مداخلاتی را که منجر به بهبود کیفیت برای مناطقمنابع موجود، عملکرد، جهت ارزیابی و بررسی کارکنان قابل استفاده هستند.شود، می اند:کیفیت در زیر لیست شده یهبیان 01قبت و اندارد مراهشت است کیفیت هاییهاستانداردهای مراقبت و بیان های سازمان جهانی بهداشت، هر زن و نوزادانی مراقبت روتین، بر پایه شواهد و اداره : بر اساس دستورالعمل0استاندارد کند.را دریافت می زایمانمشکلات در طول لیبر، زایمان و دوره پس از های کیفیتبیانیه شوند و در طول زمان بطور روتین، زنان در ورود به سیستم بهداشتی و در طول لیبر و زایمان ارزیابی می الف0.0 .آیدبعمل میاز آنها مراقبت مناسب کنند.نوزادان بلافاصله پس از زایمان مراقبت روتین دریافت می ب0.0 کنند.پس از زایمان دریافت می مادران و نوزادان مراقبت روتین ج0.0 اکلامپسی و اکلامپسی سریعا جهانی بهداشت، زنان مبتلا به پرههای سازمان بر اساس دستورالعمل 6.0 کنند.مداخلات مناسب دریافت می های سازمان جهانی بهداشت، زنان با خونریزی پس از زایمان سریعا مداخلات بر اساس دستورالعمل 1.0 کنند.ت میمناسب دریاف یا زنان با زایمان متوقف طول کشیده های سازمان جهانی بهداشت، زنان با زایمانبر اساس دستورالعمل 1.0 کنند.مداخلات مناسب دریافت می ،شده کنند های سازمان جهانی بهداشت، نوزادانی که بطور خودبخود تنفس را شروع نمیبر اساس دستورالعمل 1.0 کنند.یا با بگ و ماسک را در طول یک دقیقه پس از تولد دریافت میتحریک مناسب و اح و زودرس مداخلات مناسب برای خود های سازمان جهانی بهداشت، زنان با زایمانبر اساس دستورالعمل الف2.0 کنند.نوزادشان دریافت می مداخلات مناسب دریافت های سازمان جهانی بهداشت، نوزادان کوچک و زودرس بر اساس دستورالعمل ب2.0 کنند.می های سازمان جهانی بهداشت، زنان با عفونت یا در معرض خطر عفونت در طول بر اساس دستورالعمل الف7.0 کنند. لیبر، زایمان یا دوره بلافاصله پس از زایمان سریعا مداخلات مناسب دریافت می یا در معرض خطر عفونت وزادان مشکوک به عفونت های سازمان جهانی بهداشت، نبر اساس دستورالعمل ب7.0 کنند.بیوتیک دریافت میسزیعا آنتی مراقبت ،های بیمارستانیتمامی زنان و نوزادانشان بر اساس احتیاطات استاندارد برای پیشگیری از عفونت 8.0 کنند.دریافت می از زایمان دریافت پس اولیهدوره زایمان یا زا در طول لیبر، هیچ زن و نوزادی مداخله غیر ضروری یا آسیب 1.0 کند.نمی سیستم اطلاعات بهداشتی استفاده از اطلاعات برای اطمینان از عمل سریع و مناسب جهت پیشبرد مراقبت : 6استاندارد سازد.نوزاد را قادر می از زن و بیانات کیفیت در طول لیبر، زایمان و مرحله اولیه پس از ملت پزشکی استاندارد، مناسب و کاهر زن و نوزادی یک ثب 0.6 زایمان دارد. بعنوان قسمتی از ،هر تسهیلات زایمانی مکانیسمی برای جمع آوری اطلاعات، آنالیز و بازخورد 6.6 برای ارزیابی و پیشبرد عملکرد حول و حوش زایمان دارد. ،فعالیتهایش مناسب ارجاع داده بطور رسیدگی شودموثر تواند با منابع موجود بطور شرایطی که نمی درزن و نوزادی هر : 1استاندارد شود. می کیفیت هایبیانیه هر زن و نوزادی بطور مناسب در ورود به سیستم برای تعیین اینکه آیا باید ارجاع داده شود یا نه، در طول 0.1 ارجاع باید بدون تاخیر انجام شود. شود و تصمیم برای لیبر و در مرحله اول پس از زایمان ارزیابی می تواند شود که میهر زن و نوزادی که نیاز به ارجاع دارد، ارجاع توسط یک طرح از قبل آماده دنبال می 6.1 بدون تاخیر در هر زمانی انجام شود. ارجاع یگریا از تسهیلات زایمانی به تسهیلات زایمانی د تسهیلات زایمانیبرای هر زن و نوزادی که به 1.1 و بازخورد مناسبی برای کارکنان مراقبت بهداشتی مربوطه وجود دارد. تبادلیشده است، اطلاعات باشد.آنها می اولویتهایهایشان موثر است و پاسخی به نیازها و : ارتباط با زنان و خوانواده1استاندارد کیفیتهای بیانیه کنند و واکنش متقابل موثری با ر مورد مراقبت دریافت میهایشان اطلاعاتی دهمه زنان و خانواده 0.1 کارکنان بهداشتی دارند. مناسب و شفاف میان متخصصان تبادلیای با اطلاعات هایشان مراقبت همکاری شدههمه زنان و خانواده 6.1 کنند.سلامتی مربوطه و متخصصان مراقبت اجتماعی دریافت می کنند. با احترام دریافت می توامدانشان مراقبت : همه زنان و فرزن1استاندارد کیفیت هایبیانیه تمامی زنان و فرزندانشان در زمان لیبر و زایمان حریم خصوصی دارند و باید مورد احترام قرار گیرند. 0.1 ض، هیچ زن و نوزادی نباید مورد مداخله درمانی غلط مانند آزار و اذیت جسمی، جنسی و کلامی، تبعی 6.1 اهمال، معطل کردن، تهدید یا خودداری از ارائه خدمات قرار گیرد. شود و دلیل تمام مداخلات و پیامدها کنند، آگاهی داده میبه همه زنان در موررد خدماتی که دریافت می 1.1 شود.به روشنی به آنها توضیح داده می که این حمایت به نیازهای زن حساس است و توانایی گیردیرد حمایت عاطفی قرار مواش م: هر زن و خانواده2استاندارد . کندزن را تقویت می کیفیت هایبیانیه شود.تجربه لیبر و تولد نوزاد با توجه به انتخاب زن به او پیشنهاد داده می گزینه 0.2 کند.حمایت دریافت می اش،تقویت تواناییهر زن در طول لیبر برای 6.2 ادارههای روتین و : همیشه کارکنان بهداشتی شایسته و مشتاق برای هر زن و نوزادی وجود دارند تا مراقبت7 استاندارد مشکلات را انجام دهند. کیفیت هایبیانیه هر زن و نوزادی حداقل یکبار حمایت افراد آموزش دیده زایمانی و کارکنان بهداشتی را برای مراقبت 0.7 کند.دریافت میروتین و اداره مشکلات های چندگانه برای های مناسب و مهارتصلاحیتافراد آموزش دیده زایمانی و کارکنان حمایت کننده، 6.7 برآوردن نیازهای لیبر، زایمان و مراحل اولیه پس از زایمان را دارند. ایجاد سیاست مناسب و توسعهکنندگان بالینی دارد که مجموعا مسئول هر تسهیلات زایمانی مدیر و اداره 1.7 کیفیت مداوم حمایت بهبوددهند که از کارکنان تسهیلات زایمانی در امر هستند و محیطی را رواج می کند. می : تسهیلات زایمانی محیط فیزیکی مناسب، به همراه آب کافی، بهداشت و ذخایر انرژی، پزشکان، منابع و ابزار 8استاندارد دارد.را و نوزاد و اداره مشکلات برای مراقبت روتین از مادر کیفیت هایبیانیه نیازهای نزائد برای برآوردبرای از بین بردن مواد آب، انرژی، بهداشت، بهداشت دست و امکانات 0.8 هایشان عملکردی، قابل اعتماد، ایمن و کافی هستند.کارکنان، زنان وخانواده مان برای تسهیل مراقبت مداوم طراحی شده، سازمان یافته و محیط لیبر، زایمان و مراقبت پس از زای 6.8 در محیط خلوت مراقبت شود. نیازهایش تواند بر اساس بنابراین هر زن و نوزادی می ،اندحفظ شده ذخیره کافی داروها، منابع و ابزار، برای مراقبت روتین و اداره مشکلات موجود است. 1.8 . زمینه1 معرفی 1.1 های چشمگیری برای اطمینان از دو دهه گذشته، با هدف کاهش مرگ و میر و بیماری مادران و نوزادان، تلاشدر طول اند؛ سهم ها تعداد تولدها را در تسهیلات زایمانی افزایش دادهوجود مراقبان زایمانی ماهر انجام شده است. اساسا این تلاش در ٪82به 1110در سال ٪21اهر در کشورهای در حال توسعه از های ارجاع داده شده توسط کارکنان بهداشتی مزایمان نوزاد هر روزه به سبب 1177زن و 118افزایش یافته است. بر خلاف این پوشش افزایش یافته، هنوز هم 6016سال را زایمان زمان زن مرگ نوزاد در 1117میرند. روی هم رفته، مشکلات دوران بارداری، زایمان و دوره پس از زایمان می ها در تسهیلات زایمانی، تعداد بیشتری از مرگ و میر و بیماری قابل پیشگیری اند. با افزایش تعداد زایمانتجربه کرده ،افتند. در تسهیلات زایمانی، پیامدهای مراقبت از مادران و نوزادان در طول زایمانمادری و نوزادی در این مراکز اتفاق می رفته کیفیت خدمات افزایش یافته است. کیفیت خدمات بستگی همباشد و رویای بر پایه شواهد میکننده عملکردهمنعکس به زیرساخت فیزیکی، منابع انسانی، دانش، مهارت و توانایی رفتار در مقابل حاملگی طبیعی و مشکلاتی که نیاز به مداخله ها در تسهیلات زایمانی بعنوان کانون ش کیفیت مراقبتسریع و نجات دهنده زندگی هستند، دارد. بطور روز افزون، افزای شود.میتوجه مهم در موضوع مرگ و میر و بیماری قابل پیشگیری میان مادران و نوزادان تشخیص داده مداخلات ضروری برای جلوگیری از مرگ و میر و بیماری شدید مادری ناکافی زیاد کردن پوشش اند که نشان دادهتحقیقات ای میان تجربه مراقبت و پیامدهای بارداری وجود دارد. برای پایان دادن به مرگ و میر و پیچیده تعاملبعلاوه هستند. بیماری مادری و نوزادی قابل پیشگیری، هر زن باردار و نوزادش باید در طول زایمان مراقبت ماهرانه بر اساس عملکرد بر یافت کند. یک مراقبت با کیفیت خوب به استفاده مناسب از مداخلات در محیط انسانی، محترم و حمایتی پایه شواهد در یک های سلامتی قوی، مهارت بالا و نگرش مثبت به خدمت دهنده نیاز دارند. این موارد پزشکی و غیر پزشکی موثر، زیرساخت دهد. مراقبت با ثبتی میهایشان و مراقبان سلامتی تجربه مبه زنان، خانواده ای سلامتی را افزایش خواهد داد وپیامده .باشدمیشان زنان و کودکان برابری و حفظ ای برایو ریشهمهم بوده کیفیت بالا برای حق سلامتی است زیرا که کمک با کیفیت )مهم. مترجم( موثر اطمینان از دستیابی به فرد آموزش دیده زایمانی و مراقب مامایی ماهر استانداردهای سازمان جهانی بهداشت، در طول دوره .)0(دهد وزادی را کاهش میبالا مرگ و میر و بیماری مادری و ن باشند. سازمان ها و مداخلات بر پایه شواهد میحیاتی مراقبت، برای مراقبت با کیفیت از مادران و نوزادان بر اساس اولویت پس از دوره اولیه در طول بارداری، زایمان و کند که در آن هر زن باردار و نوزادشبینی مییی را پیش، دنیاجهانی بهداشت خط و «: مکمل برنامه جهانی هماهنگ شده است با دو برنامه بیانیه. این )6(کند زایمان مراقبت با کیفیت در یافت می ه دادن ب برای پایان عملیهر نوزاد: یک طرح «و )1( »هایی برای خاتمه دادن به مرگ و میر قابل پیشگیری مادریمشی . )1( »های قابل پیشگیریمرگ مانیهایی برای کاهش مرگ و میر مادری و دوره حول و حوش زااولویت 1.1 مرگ مادران بدلیل مشکلات بارداری و زایمان مانند خونریزی، اختلالات فشار خون، سپسیس ٪17در دنیا، روی هم رفته، از ٪18هنگام زایمان و عفونتهای نوزادی علت بیش از . مشکلات زایمان زودرس، آسفیکسی، مرگ )1(باشد و سقط می ره و ادا پیشگیریبا کیفیت بالا برای موثر و دهند که مراقبت. مطالعات نشان می)2(باشند مرگهای دوره نوزادی می های نوزادان هنگام تولد و های مادری، مرگکاهش تعداد مرگ سبببطور چشمگیری مشکلات در طول این دوره حیاتی بعد از تولد برای زندگی مادر، جنین بلافاصله . از آنجایی که زمان زایمان و)7(د وشمی های زودرس نوزادی چشمگیرمرگ ها گذاری جهت بهبود مراقبتیک فرصت برای افزایش بازگشت به سرمایه دهندهحیاتی هستند، نشان و نوزاد بطور ویژه باشد.می ر اواخر بارداری، زمان زایمان و بلافاصله پس از تولد برای کاهش تعداد موارد مرگ مادر، ها دپیشگیری موثر و اداره موقعیت ن بهبود کیفیت مرگ مادر قبل از زایمان، مرگ مادر هنگام زایمان و مرگ نوزاد پس از تولد چشمگیر هستند. بنابرای ین اثر را روی حیات مادر، جنین و نوزاد تواند بیشترحساس میکننده و درمانی در طول این دوره های پیشگیریمراقبت های اولویتبا روتین و اورژانسی، داشته باشد. بر اساس شواهد اخیر در مورد بار و اثر، نواحی شماتیک ذکر شده، در مراقبت .)6( شوندمی برای عملکردهای بر پایه شواهد در نظر گرفته بالا -یبر و مراقبت از نوزاد در زمان زایمان و هفته اول پس از تولد میمراقبت روتین در هنگام زایمان شامل بررسی ل  باشد. اکلامپسی، اکلامپسی و مشکلات آنها،اداره پره  های پزشکی مناسب و ایمن،اداره مشکلات لیبر با تکنیک  اداره خونریزی پس از زایمان  احیا نوزاد  رسادراه لیبر و زایمان زودرس و مراقبت از کودکان کوچک و زود  های مادری و نوزادیاداره عفونت  منطق 1.1 ان، بعنوان بویژه در زمینه مراقبت پیرامون لیبر، زایمان و دوره بلافاصله پس از زایم ،بطور روز افزون در دنیا، کیفیت مراقبت پوشش بالا . دیده شده است که)8( شودمینوزاد تشخیص داده ناپذیر در مسئله سلامتی مادر و یک موضوع حیاتی پایان به تنهایی برای کاهش مرگ و میر کافی نیست. بطور اساسی، برای کاهش مرگ و میر مادر و نوزاد )پوشش بالای مراقبت( کیفیت دربهبود به همراه باید های افزایش یافته های قابل پیشگیری مرگ مادر و نوزاد، پوششو حرکت بسوی حذف علت . )1،10(باشد طول ادامه مراقبت 111زن از 111111که بر روی بیش از )00(کشوری سازمان جهانی بهداشت در مورد سلامتی مادر و نوزاد العه چندمط مانند (» مداخلات ضروری«کشور انجام گرفته، نشان داده که ارتباط ضعیفی میان پوشش 16مرکز تسهیلات زایمانی در )کننده سولفات منیزیومهمچون زنان مبتلا به اکلامپسی دریافتد کننمیدار دریافت نسبت جمعیتی که مداخله اندیکاسیون ، مورداند که برای اطمینان از اداره موثر و مرگ و میر مادر در تسهیلات زایمانی وجود دارد. همچنین مطالعات نشان داده . )60(د ندار )پزشکی(وازم های با کیفیت بالا نیاز به استفاده مناسب از تجهیزات موجود، کارکنان بهداشتی و لمراقبت مراقبتهای با کیفیت بالا نیاز به استفاده مناسب از تجارب بالینی بر پایه شواهد و مداخلات غیر بالینی، تجهیزات پزشکی قوی، مهارت بالا و نگرش مثبت کارکنان بهداشتی دارد. از زایمان باید مکمل هر نوع استراتژی بهبود فراهم کردن مراقبتهای با کیفیت بالا قبل از زایمان، در حین زایمان و پس یکپارچگی این خدمات را بطور مستقیم ،کیفیت باشد. ضوابط حقوق انسانی، اصول اخلاق پزشکی و استانداردهای تکنیکی -. حق سلامتی، حق اساسی انسان می0کنندیا در طول ارجاع مناسب بعنوان عنصر سازنده مراقبت با کیفیت بالا تشویق می ظ منزلتای برای برابری و حفاشد که سبب بیشتر شدن کاهش مرگ و میر و بیماری مادر، نوزاد و کودک شده و ریشهب .)10(باشد زنان کودکان می جمعیت هدف 1.1 های کیفیت ممکن است بعنوان راهنمایی برای تولید ارچوب مراقبت با کیفیت، استانداردهای مراقبت و سنجشچ های فراهم شده به مادران و نوزادان در ها برای بهبود، ارزیابی و بررسی کیفیت مراقبتارزیابیمراقبت و ملیاستانداردهای های ها و فعالیتای برای استراتژیتواند بعنوان پایهارچوب میاستفاده قرار گیرد. همچنین این چتسهیلات زایمانی مورد ارچوب، استانداردهای مراقبت و موجود مورد استفاده قرار گیرد. چملی های برنامه باکیفیت ترکیببهبود کیفیت و برای فراملی، سطوح نندگان برنامه، طراحان سلامت ملی وکسیاستگذاران، اداره«رای استفاده سنجشهای کیفیت بطور اولیه ب درگیر در مراقبت با هسلامت مادر و نوزاد، متخصصان و همکاران تکنیکی آنها ک ای، متخصصان مراقبو منطقه یتسهیلات توانند بعنوان منبعی در شوند. آنها همچنین می، در نظر گرفته می»های سلامتی هستندکیفیت یا مشاوران وزارتخانه موسسات آموزش پزشکی مورد استفاده قرار بگیرند. که مراقبت از مادر و (هداشتی های میان کشورها، با توجه به ساختار سازمانی تسهیلات سلامتی و کارکنان بدر درک تفاوت ، اسناد بر استانداردهای مراقبت، شایستگی، خدمات و منابع فیزیکی ضروری تمرکز دارند تا اطمینان )دهندنوزاد را انجام می است یا برای فراهم کردن حد بالای حاصل کند از اینکه شرایط سلامتی مادر و نوزاد بطور مناسبی ارزیابی و اداره شده های با کیفیت باید برای است. استانداردهای مراقبت و ارزیابی ت در سیستم سلامتی عملکردی ارجاع داده شدهمراقب ها و بدست آوردن پیامدهای مورد نظر برای مادر و نوزاد، با شرایط محلی تطابق داده شود.اطمینان از ظرفیت dna noitamrofni htlaeh evitcudorper dna lauxes fo ytilauq eht rof smron sthgir namuh gniteeM .A niamreG 1 tnempoleved dna noitalupop no ecnerefnoc lanoitanretni eht ta detneserp repap noissucsid denoissimmoC .secivres .3102 yluJ 01–7 ,kjiwdrooN ,sthgir namuh no ecnerefnoc lanoitanretnI .4102 dnoyeb و فرایند کار ها. روش1 دید کلی 1.1 های کیفیت در سه مرحله تعریف شده بودند. در اولین سنجشارچوب، استانداردهای مراقبت و ت، چمراقبت با کیفیدیدگاه دیدگاه سازمان جهانی بهداشت بدست آمده بود و کیفیت مراقبت از مادر و نوزاد تعریف شده بود. در در موردمرحله، توافق دست آمده بود، یک رویکرد استراتژیک برای ایجاد و ارچوب عقلانی بفق برای مراقبت با کیفیت در یک چمرحله دوم، توا مرحله سوم گروه، خلاهای تشخیص داده شده در مناطق کردن مراقبت با کیفیت. درهای استراتژیک برای فراهمحوزه با ها را برای ارزیابی پیشرفت در مراقبت گیریکاری استراتژیک را مشخص کرده و استانداردها را برای مراقبت و اندازه کیفیت در تسهیلات زایمانی تعریف کرده بود. این مراحل شامل بازنگری متون، تبادل نظر متخصصصان و توافق نامه بود. ihpleDساخته شده در پروسه هدف 1.1 هداشت المللی بود تا با دیدگاه جهانی سازمان جهانی بکردن راهنمای جامع برای کارکنان ملی و بین هدف از این کار فراهم به معنی ( ابعاد سنجشارچوبی برای تعریف آشنا شوند؛ این مسئله نیاز به چ در مورد بهبود کیفیت مراقبت از مادران و نوزادان )برای ارزیابی انتظار داشت های مورد نیازسنجشتوان برای دستیابی به پیامدهای سلامتی مورد نظر و مداخلاتی که می . داشت خانواده، زنان و کودکان شروع شد. یک گروه داخل سازمانی در شاخه مدیر کلت راهنمایی معاون جلسه تح 1016در سال دستورالعمل تنظیم شد که اساسا متشکل از افراد دو سازمان مسئول برای سلامتی مادران و نوزادان بودند: سازمان سلامتی به موضوع را تدا دیدگاه تعریف شد و گروه هدایتمادر، نوزاد، کودک و نوجوان و سازمان سلامت باروری و تحقیق. اب بهداشت و ، سرویس زایمان و ایمنی، نیروی کار های اجتماعی سلامتکنندهتعیینمحیطی و های سلامت عمومی، سازمان های سلامت مادر، نوزاد، کودک وتوضیح داد. گروه مرکزی کار، متشکل از افرادی از سازمانتغذیه برای سلامت و توسعه منجر به بازیابی و تلفیق شواهد شده و هماهنگی را تضمین کردند.نوجوان و سازمان سلامت باروری و تحقیق بودند که جهتها هر دو هفته یکبار برای دستیابی به توافق در مورد دیدگاه سازمان جهانی بهداشت دستورالعملهدایت کننده گروه بندی از بازنگری تعریف کردند. سه طبقهبرگزار می ایتعریف هدف کارشان جلسهمراقبت با کیفیت از مادران و نوزادان و شده بودند: تعاریف کیفیت مراقبت در موضوع سلامتی مادر و نوزاد  های مراقبت با کیفیت از مادران ارچوب کلی از مهمترین حوزهود از کیفیت مراقبت و طراحی یک چهای موجمدل  و نوزادان ها در ز یک استراتژی موثر برای مداخلات سرویس سلامتی و بالینی جهت بهبود کیفیت مراقبتمتون و تعریفی ا  سطح کشور های کاری مراقبت با کیفیت و تشخیص حوزهتشخیص کیفیت مراقبت و چارچوب برای این پایهاها بعنواین حوزه ردهای مراقبت یک خلا مهم تشخیص داده شده استراتژیک، در اولین و دومین مرحله تعیین شده بودند. تعریف استاندا د. دنبو توسعه چارچوب و استانداردهای مراقبت 1.1 هایارچوبهای مراقبت، چمراقبت با کیفیت، مدلگزارش شده شده و نشده را که تعاریف منتشر متونمرکزی گروه کاری و تخصصی برای سلامتی یبطور عمومیفیت بهبود مراقبت با کجهت کهمراقبت با کیفیت و رویکردهای استراتژیک را دستورالعملهای داخل هدایت کننده ها به گروه ، را مورد بازنگری قرار داد. یافتهگرفتمیمادران و نوزادان مورد استفاده قرار استراتژیک ارچوب عقلانی و رویکرد ها در مورد مراقبت با کیفیت، چوافقسازمانی برای بازنگری و بحث ارائه شده بودند و ت .)6(بدست آمده بود ایجاد گیری باشد، نشان د و بنابراین باید قابل اندازهگیری باشاندازهقابل تواند هایی که میاستانداردها، معیارها را در مقابل پیشرفت های ورالعملدهند. استانداردهای تعریف شده از مراقبت بعنوان یک اولویت تشخیص داده شده بودند زیرا به غیر از دستمی بندی و ساختار اندیشیده شده بود و سپس بالینی بر پایه شواهد، راهنماهای اندکی موجود بودند. در اولین قدم، تعریف، طبقه استانداردهای مراقبت بدست آمدند. هاورالعملدست تهیهتوافقی که در تعریف، چهارچوب استخراج شده و استانداردهای مراقبت بدست آمده بود، به جلسه گروه . )0ضمیمه (ارائه شد 1016در ژوئن تلفیقشواهد بدست آمده و 1.1.1 های برای انتشارات مربوطه با واژه ،، انتشارات سازمان جهانی بهداشت و سایر منابع اطلاعاتیENILIDEM ,]senilediug ro lacinilc[ ,]yreviled ecivres[ ,]airetirc[]noitinifed[ dradnats“ بودند. ساختهبا کیفیت را های مراقبت که تعاریف و مدل جستجو شده بودند serudecorp gnitarepo dradnats[ . انتشارات انجام شدند هاواژه به کلید’nrobwen dna lanretam‘هایجستجوهای اضافی با اضافه کردن واژه ای از سایتشان که سایت یا یک قسمت ویژهجعبه جستجوی استفاده ازها با سازمان سایتهایوبمستقر شده بودند در برای عموم و به ویژه برای ی توسعه یافتهاستانداردها محتمل بودند برای داشتن. سازمانهایی که بودمختص به انتشارات حکومتی و تخصصی، های غیرهای حکومتی، سازمانمادران و نوزادان شامل سازمانهای ایمنی و کیفیت بین المللی، آژانس بندی و ساختار بعنوان منابع اصلی برای تعریف، طبقهکه ها و انتشاراتی را سازمان 0یص داده شده بودند. جعبه تشخ کند. همچنین، یک جستجوی اینترنتی عمومی با موتور لیست میمورد استفاده قرار گرفته بودند را استانداردهای مراقبت د در موضوعات تعریف، بود. سپس مدارک دوباره برای تشخیص استاندارها انجام گرفته جستجوی گوگل با همان کلید واژه بندی بازبینی و تجزیه و تحلیل شدند. همچنین گروه تجربه بهبود کیفیت مراقبت در گیری و طبقهبندی، اندازهتوصیف، قالب بازنگری قرار داد. دد را مورتکمیل شده بوسازمان بهداشت جهانی های دپارتمانکه توسط را های گوناگون پروژه : منابع بازنگری شده برای تعریف استانداردها1جعبه noitazidradnatS rof noitazinagrO lanoitanretnI  eraC htlaeH ni ytilauQ rof yteicoS lanoitanretnI  )ASU( noissimmoC tnioJ ehT  detinU ,)ECIN( ecnellecxE eraC dna htlaeH rof etutitsnI lanoitaN  modgniK lanoitaN acirfA nrehtuoS fo noitatiderccA ecivreS htlaeH rof licnuoC  tnemhsilbatsE htlaeH rof sdradnatS eroC lanoitaN :htlaeH fo tnemtrapeD ni )1102( acirfA htuoS  eht fo noitadnuoF sseccAmrahP( sdradnatS eraC htlaeH cisaB erac efaS  eht dna ASU eht fo lanoitanretnI noissimmoC tnioJ eht ,sdnalrehteN )acirfA nrehtuoS fo noitatiderccA ecivreS htlaeH rof licnuoC lanoitaN :eraC htlaeH ni ytilauQ dna ytefaS no noissimmoC nailartsuA  )2102( sdradnats ecivres htlaeh ytilauq dna ytefas lareneG :1 puorG .htlaeh nrobwen dna lanretam rof sdradnats OHW  )7002( htribdlihc dna ycnangerp yhtlaeh rof erac fo sdradnats eraC yrefiwdiM fo sdradnatS :aisA tsaE-htuoS rof eciffO lanoigeR OHW  )9991( بازبینی کارشناسانه و ایجاد توافق 1.1.1 ارچوب مراقبت با کیفیت و استانداردهای تکنیکی، بطور مناسب، چ هایدیدگاهن و تفاوت عقاید متخصصامانعکاس دلیلبه های مربوطه سازمان جهانی تعریف شدند. موضوعات استخراج شده بوسیله دپارتمان یفرایند مشارکتیک مراقبت در ئه دهنده برای ارزیابی و با دفاتر محلی سازمان جهانی بهداشت و کشورهای ارا دقت و صحتبهداشت برای اطمینان از بصورت جلسات الکترونیکی و حضوری بصورت جلسه یک مشاورهکاربردشان در مفاهیم متفاوت مورد بازنگری قرار گرفتند. سازی و استخراج چهارچوب و استانداردهای بازنگری، نهایی جهت اخل سازمانیدستورالعمل د تهیهاعضا گروه توسط روزه دستورالعمل انجام گرفته بود. تهیهتوسط گروه مراقبت برای ارائه و بحث ارچوب سازمان جهانی بهداشت و برای برای بازبینی دیدگاه و چ (0ضمیمه )، یک جلسه تخصصی 1016در ژوئن سال دستیابی به توافق با رویکرد سازمان جهانی بهداشت و استخراج استانداردهای مراقبت برگزار شد. متخصصان اطلاعات ارچوب و از مراقبت با کیفیت، چبازنگری و اینکه آیا تعریف ارائه شده جامعیت تعیین جهت ای و استخراج شده را هزمین آن سازیپیادهدر مناطق با منابع ضعیف و امکان و کاربرد آنها و درک مراقبت با کیفیت فعلیدانش ،استانداردهای مراقبت بدست (بجز در موارد استثنائی) در اکثر موارد با بالا بردن دست . توافقار دادندرا مورد بازبینی قر یا نهکند منعکس میرا پایه پیامدهای جلسه، نهایی شده بودند. آمده بود. موارد استخراج شده بر هاگیریاندازهتوسعه کیفیت 1.1 ها، فرایند مراقبت گیری ورودیندازهها برای اای از استانداردهای مراقبت هستند. آنریشه یکیفیت موضوعهای گیریاندازه دستیابی به مراقبت استاندارد جهتیا تامین خدمات و در صورت مناسب بودن، پیامد مراقبت و بنابراین بررسی پیشرفت از منظر تفاوت در تعاریف، واکنشهای پیچیده میان هاگیریاندازهکیفیت تعریف ویژه مورد نیاز هستند. به هر حال، باشد.قابل بحث می هاآنمسئول برای پیامدها و مفهوم استفاده و کاربرد فاکتورهای ها هر گیری مداخلات در تسهیلات سلامتی را جستجو کرد. آنپارامترهای معقول و یک رویکرد متوازن برای اندازه ،گروه کند، جستجو کردند.منعکس می ایی که اثر مداخلات ترکیب شده راهگیریهای مستقیم مناسب و اندازهگیریدو اندازه های سازمان جهانی که استانداردهای مراقبت را بر اساس دستورالعمل بود برای تشخیص عناصر مداخلاتی ،اولین قدم این موارد بوسیله ؛آوری شدندهای کیفیت جمعگیریکند. سپس لیستی از اندازهبهداشت و سایر منابع مربوطه تعریف می برای ایجاد توافق بازبینی شده بودند. ihpleDهای داخل سازمانی قبل از فرایند عملگروه هدایت دستورال های کیفیت گیریتنظیم و استخراج اندازه 1.1.1 های کیفیت برای هر موضوع را در همکاری با گروه مرکزی کار گیریهای تکنیکال سازمان جهانی بهداشت، اندازهدپارتمان سازمان جهانی چندین ابزارهای سازمان جهانی بهداشت، های موجود را از دستورالعملگیریاندازه. این گروه نداستخراج کرد . آوری و تنظیم کردندالمللی جمعی اطلاعات از همکاران محلی و بینآورسلامتی و جمعبهداشت برای ارزیابی تسهیلات ها در ها و بحثهای جدیدی بر اساس دستورالعملیریگشد اندازهگیری یافت نمیزمانی که در منابع مذکور هیچ اندازه های داخل ها تنظیم شده بودند و دستورالعملگیریشدند. اندازهواحدهای مربوطه سازمان جهانی بهداشت ساخته می ری مورد استخراج کرده بود تا در جلسه بزرگت کیفیت یهبیان 01گیری برای اندازه 801کننده لیستی از سازمانی گروه هدایت بازبینی قرار گیرد. گیری کیفیتتوافق ایجاد شده در اندازه 1.1.1 واحدهای تکنیکال سازمان جهانی بهداشت بطور اولیه در ،ihpleDفرایند یک گیری کیفیت، در برای ایجاد توافق در اندازه در جلسه مذکورکنندگان . شرکتدالمللی، جلسه بزرگتری تشکیل شده بوحلی و کشورها و سپس در دفاتر بینو دفاتر م ند. این افراد شامل تجربه مراقبت دار جهتتری از نظر تامین مراقبت جهانی تشخیص داده بودند که دید وسیع تخصصی ، محققان، (، متخصصان جامعه و وکلامامایی، نوزادان، کودکان، ماماها، پرستاران) کیفیت، متخصصانمتخصصان مراقبت با -های مصرفندهندگان خدمت به سازمامراقبت در سطوح مختلف و ارائه نندگانکنندگان و ایجادکستفادهادانشگاهیان، کشور 12از مذکورشرکت کننده 106ها به امهین المللی و دو سویه بودند. دعوتنهای بکننده، متخصصان جامعه و آژانس بری از گرفته شد. هدف، وارد کردن افراد تقریبا برانامه کنندگان رضایتشان فرستاده شد و از شرکتبرای تعیین علاقه های مختلف سلامت و مراقبت جامعه در عرصه جهانی بود.کنندگان در بخششرکت های گیریکشور با درآمد کم، متوسط و بالا دعوت را قبول کردند. اندازه 81از (٪12) نفر 110فرد دعوت شده، 106از هفته طول کشید. نرم فزار 10که این کار بیش از ،ت در جلسه را قبول کرده بودند، فرستاده شدکه شرک افرادیکیفیت به در دو را ها گیریدهی به اندازهداد تا اظهاراتشان و نمرهکنندگان اجازه میبه شرکت )®yeknoMyevruS(آن لاین گیری کیفیت بود، جهت تائید و اندازه 801که شامل شد تا لیستی کنندگان خواسته . در دور اول، از شرکتدوره وارد کنند ر دوم، از شرکت کنندگان خواسته گیری مطالعه کنند. در دوکردن هر نوع اندازهن، واردکردن اظهاراتشان و اضافهتکمیل کرد بندی کنند. ان گروه توسعه دستورالعمل اولویتهای موافقت شده در جلسه متخصصها را بر اساس شاخصگیریشد تا اندازه ihpleD دور اول از تحقیق های کیفیت که به سه بخش تقسیم شده بود، فرستاده شد، اولین گیریکننده لیستی از اندازهشرکت 110اول، به در دور و سومین بخش شامل ( 2-1استاندارد )، دومین بخش شامل تجربه مراقبت ( 1-0استاندارد )بخش شامل تهیه مراقبت یا تجربه مراقبت توانستند تهیه کنندگان بسته به تخصصشان میبود. شرکت ( 8و 7استانداردهای ) وردهخ نواحی برش ها را انتخاب کنند. از آنها اظهارات عمومی در مورد اثبات و تکمیل یا همه بخش خورده مراقبت به اضافه نواحی برش شد. این تحقیق برای دو هفته گیری اضافی خواسته میاد اندازهکیفیت و در صورت لزوم پیشنه یهها برای هر بیانگیریاندازه کنندگان به تکمیل تحقیق در مکان خودشان و ه ایمیل یادآور فرستاده شد. شرکتادامه داشت و در طول این دوره زمانی س شدند. ها تشویق میبرای بازبینی جوابهایشان قبل از وارد کردن آن قرار دادتجزیه و تحلیل را مورد های کیفیت مورد نظر توسط پاسخ دهندگان گیریمتن و اندازه هایبیانیه ،گروه مرکزی کار دهی شده بودند و سازمانیافته هایی تجزیه و تحلیل متن به مقوله نظراتبندی کرد. کیفیت گروه بیانیهها را برای هر و آن ها شامل بندیبندی شده بودند. طبقهبهبود یافته و طبقه ،های مراقبت انجام شده در زمینه اظهارات کیفیتتوسط جنبهکه هایی که پوشش داده نشده بودند اما مهم در نظر گرفته شده بودند، ایجاد کرده بودند، بودند که درکی در حوزه هاییبیانیه ، ا در چند زمینه بسط داده بودندر یههایی که یک بیانگیری را پیشنهاد کرده بودند وآندوباره یک اندازه تهیهکه هاییبیانیه -بیانیهبندی شده بودند. سپس واحدهای تکنیکال مربوطه اضافی مورد نظر به موضوعاتی گروهکیفیت هایبیانیههمچنین، تدوین کردند. ihpleDدور دوم فرایند و لیستی برای کردههای اضافی را بازبینی گیرشده و اندازهبندیهای گروه ihpleDقیق دور دوم از تح را در دور اول بیان ترجیحات خودای که دهندهپاسخ 200طول کشید، سپس لیست به دور دوم شش هفته بعد از دور اول 7، 1-0استاندارد ) خورده کرده بودند، فرستاده شد. سه تحقیق طراحی شد: یکی در مورد تهیه مراقبت به علاوه نواحی برش -بیانیه یو سومی در مورد تمام (8و 7، 2-1استاندارد ) خورده بت به اضافه نواحی برش، دومی در مورد تجربه مراق( 8و کیفیت. تحقیق آن لاین برای چهار هفته برگزار بود و در طول این دوره چهار ایمیل یادآور فرستاده شد. های -ر اساس پنج شاخص زیر به اندازه گیریشد تا در توافق با گروه توسعه دستورالعمل بگان خواسته دهنددر این دوره، از پاسخ های کیفیت نمره دهند: -ران، مراکز بهداشت عمومی و سیاستمانند بیماران، پزشکان، خریدا)گیری برای کارکنان اهمیت: عنوان اندازه  مهم است آنگیری چشمگیر و بطور استراتژیکی مهم است. اهمیت سلامت: زمینه سلامتی که اندازهگذاران مانند اثر روی مرگ و میر و )طوری که بوسیله شیوع و بروز بالا و/ یا یک اثر چشمگیر در زمینه بار بیماری همان شود.نشان داده می بیماری در یک جمعیت عات مورد گیری، قابل درک و قابل قبول است. منبع اطلاآوری اطلاعات برای اندازهقابلیت اندازه گیری: ابزار جمع  باشد.گیری موجود و قابل دسترس میارچوب زمانی جهت اندازهدر طول چگیری یه اندازهنیاز برای ته تهیهگیری را ه بدون توجه به افرادی که اندازهای از شرایط اصلاح شدگیری برای دورهقابلیت اعتماد: نتایج اندازه  باشد. گیری ایجاد شده است، قابل تکثیر میاند یا زمانی که اندازهکرده گیرد.هایی را اندازه میگیریواقعا اندازه این معیاراعتبار:  .کندفراهم می گیرندگان قابل تغییر در طول زمان برای تصمیمدار یک اندازه گیری معنی این معیار: مفید بودن  تخاب کنند:شده، داشتند تا یکی از آنها را اندهینمرهکنندگان شش گزینه های بالا، شرکتبرای هریک از شاخص بخشد.گیری کیفیت، این شاخص را تحقق نمینه: این اندازه  بخشد.گیری کیفیت، احتمالا این شاخص را تحقق نمینه: این اندازهاحتمالا  ببخشد.گیری کیفیت، این شاخص را تحقق ن مطمئن نیستم که آیا این اندازهعدم اطمینان: م  بخشد.تمالا این شاخص را تحقق میگیری کیفیت، احاحتمالا بله: این اندازه  بخشد.گیری کیفیت، این شاخص را تحقق میبله: این اندازه  ای ندارم.عدم وجود تجربه: من در این زمینه تجربه  های کیفیتگیریبندی کردن اندازهدرجه گیری کیفیت رای هر اندازهمین میانگین نمره بتحقیق، برای تخ دهندگانتوسط پاسخ دومهای انجام شده در دور بندیدرجه مورد استفاده قرار گرفت، همانطوری که در زیر آمده است: بخشد= نمره صفرگیری کیفیت، این شاخص را تحقق نمینه: این اندازه  1/16بخشد= نمره گیری کیفیت، احتمالا این شاخص را تحقق نمیاحتمالا نه: این اندازه  1/1ببخشد= نمره گیری کیفیت، این شاخص را تحقق این اندازهن مطمئن نیستم که آیا عدم اطمینان: م  1/17بخشد= نمره گیری کیفیت، احتمالا این شاخص را تحقق مین اندازهاحتمالا بله: ای  بخشد= نمره یکگیری کیفیت، این شاخص را تحقق میبله: این اندازه  ای ندارم= خالیعدم وجود تجربه: من در این زمینه تجربه  در محاسبه میانگین نمره وارد نشده بودند.» های خالیخپاس« محاسبه میانگین نمرات گذاری شده بود، محاسبه نام» حد واسطنمره «بنام بود و در هر شاخص، میانگین نمره برای هر اندازه کیفیت محاسبه شده انجام شده بود. )های خالیاسخبجز پ) دهندگان پاسخ ک شاخص ویژه تقسیم بر تعدادبصورت جمع همه نمرات برای ی توسط تعدادی از گیری کیفیت اندازهبرای آن )C(گیری کیفیت برای هر شاخص = میانگین نمره متوسط نمره جهت اندازه -می (های خالی بجز پاسخ)ها دهندهآن شاخص تقسیم بر کل تعداد پاسخ ها برایمساوی جمع نمره» C«کنندگان. شرکت باشد. حد میانگین پنج نمره ،گیری کیفیتآوردن نمره نهایی برای هر اندازهیی که پنج شاخص موجود بود، برای بدست از آنجا گیری در جمع متوسط نمرات برای آن اندازه گیری کیفیت بوسیلهدار برای هر اندازهمحاسبه شد. نمره نهایی اولویت واسط پنج شاخص تقسیم بر پنج محاسبه شده بود. .)5C+4C+3C+2C+1C(5/گیری کیفیت = میانگین نمرات متوسط برای پنج شاخص = ایی اندازهنمره نه بندی دار درجهاساس نمره نهایی اولویت کیفیت بر یههای کیفیت برای هر بیانگیریورودی، خروجی و پیامد اندازهسپس شده بود. باکیفیت ارچوب مراقبت. تعریف و چ1 هاصه یافتهشواهد و خلا 1.1 . کیفیت مراقبت چند )80-10(برای کیفیت مراقبت یافت نشد قبول همگانهیچ تعریف جهانی مورد در جستجوی متون، کنندگان مراقبت سلامتی، مدیران یا بیماران و سیستم یا و ابعاد مختلفی که شامل فراهموجهی تشخیص داده شده و از زوا بخشی، عدالت و بیمار های کیفیت مانند ایمنی، موثر بودن، محدوده زمانی، اثرژگیبر اساس وی ،باشدمراقبت سلامتی می . )6جعبه (و تجربه مراقبت تعریف شده است ارائهمحور بودن بعنوان و tievtervO، )10( llewxaM، )80( 8810در سال enidebanoDهای کیفیت مراقبت، از زمان تعدادی از مدل سه مدلی اند. آماده شده )70(و سازمان جهانی بهداشت )20(، موسسه پزشکی )06(و همکاران notluH، )16(همکاران بودند که برای عمل کردن هاها و سیستمنگر، ویژگیهای آیندهاند مدلو بطور واضحی تعریف شده که بیشتر استفاده شده ترین مدل، مدل سازمان جهانی گرفتند. ضروری های کیفیت مراقبت بر اساس عناصر مختلف مورد استفاده قرارویژگی ه بوده و در آن برای تشخیص شش بلوک ساخته شده شامل های سلامتی پیشرفتبود که دارای سیستم )70( بهداشت و حکومت و یها و تکنولوژی، هزینه، رهبر، نیروی کار سلامتی، اطلاعات، تولیدات پزشکی، واکسنسرویس زایمان کردن آنالیز سیستم سلامتی و نکات مداخله فکر شده بود. سیستم سلامتی ساختاری با قدرت ساختاری برای محکم ها برای طراحی یک چهارچوب فکری جهت تعریف، ارزیابی و کند. این مدلدستیابی به مراقبت با کیفیت بالا را ایجاد می . مورد استفاده قرار گرفته بودندبررسی کیفیت مراقبت از مادر و نوزاد تعریف و چهارچوب مراقبت با کیفیت از مادر و نوزاد که در زیر تعریف شده، بر اساس تجزیه و تحلیل بالا و توافق بدست بوده است. گروه توسعه دستورالعمل آمده در جلسه متخصصان تعریف مراقبت با کیفیت 1.1 های مراقبت گسترش سرویس«ا کیفیت بر اساس چندین تعریف در متون، تعریف سازمان جهانی بهداشت از مراقبت ب اقبت سلامتی بخشد. برای دستیابی به این مسئله، مرسلامتی به افراد و بیماران، پیامدهای سلامتی مورد نظر را بهبود می . )6(» روز، کافی، منصف و مردم محور باشد باید ایمن، موثر، به های مراقبت با کیفیتهای عملی از ویژگی. تعریف1جعبه شامل کنندگان از خدمات، ها به استفادهارائه مراقبت سلامتی برای به حداقل رساندن خطرات و آسیب – ایمنی  باشدهای قابل پیشگیری و کاهش خطاهای پزشکی میجلوگیری از آسیب های بر پایه شواهداساس دانش علمی و دستورالعمل ارائه خدمات بر – موثر بودن  ارائه و دریافت مراقبت سلامتی کاهش تاخیر در – به موقع  استفاده از منبع و جلوگیری از اتلاف منابع رساندن حداکثر به مراقبت سلامتی برای ارائه – کافی بودن  های افراد مانند مراقبت سلامتی بطوری که در ارائه کیفیت خدمات بر اساس ویژگی ارائه – عادلانه بودن  مالی تفاوت قائل نشود -یا وضعیت اجتماعیجنس، نژاد، قومیت، منطقه جغرافیایی های افراد استفاده کننده از خدمات و فرهنگ جامعهارائه مراقبت بر اساس ترجیحات و خواسته – مردم محور  هاآن -افراد و جمعیت(مادران و نوزادان برای ای است که خدمات سلامتی از این رو، مراقبت باکیفیت برای زنان و نوزادان، درجه دهند که هم مطابق با دانش احتمال مراقبت به موقع و مناسب را با هدف دستیابی به پیامدهای مورد انتظار افزایش می )ها -کنند. این تعریف ویژگیهایشان را برآورده میتک تک زنان و خانواده هایخواستهتخصصی رایج هستند و هم ترجیحات و و کیفیت مراقبت تجربه شده توسط مراقبت ارائهگیرد: کیفیت راقبت را در نظر میهای مراقبت با کیفیت و دو مورد مهم از م هایشان.خانوادهزنان، نوزادان و باکیفیت چهارچوب مراقبت 1.1 های گوناگونی برای تهیه چهارچوب عقلانی جهت راهنمایی ارائه که کیفیت مراقبت چند بعدی است مدلاز آنجائی گزاران در جهت بهبود کیفیت خدمات سلامتی برای مادران و نوزادان مورد مدیران و سیاستن مراقبت سلامتی، دهندگا های سلامتی سازمان جهانی بهداشت، چهارچوب کیفیت ها و رویکرد سیستماستفاده قرار گرفته بود. بر اساس این مدل مراقبت در تسهیلات سلامتی در مفهوم که باید برای ارزیابی، بهبود و بررسی ابعادیتشخیص بوسیله )0شکل (مراقبت . )6(گرفتند، طراحی شده بود سیستم سلامتی مورد هدف قرار می ارچوب به مراقبت ارائه شده در گرچه چ .مراقبت داردکیفیت ارچوب، هشت حوزه سیستم سلامتی، چدر روی هم رفته نیازها و ترجیحاتشان و اداره دمات در تشخیصکنندگان از خبه نقش حیاتی جوامع و استفادهکند، تسهیلات توجه می ، های مراقبت مادریهایشان و جوامع آنها در مورد کیفیت سرویسکند. دیدگاه زنان، خانوادهسلامتی خودشان نیز توجه می برای اجزا ضروری در به وجود آوردن یک خواسته )این موارد(دهد و یم آنها را در جستجوی مراقبت تحت تاثیر قرار میتصم . بنابراین، علاوه بر تسهیلات سلامتی، جامعه )60( های مادری و نوزادی با کیفیت بالا هستندو دستیابی به سرویس )آنها( مراقبت با کیفیت برای فراهم کردنباشد و باید یک جز سازنده از گرفته شدن می نظر مهمی برای در بعد )نظرمورد (درگیر زنان و نوزادان باشد. و نوزادان مادران با کیفیت از سلامتارچوب سازمان جهانی بهداشت برای مراقبت : چ1شکل ساختار . ارتباط موثر1 . عملکرد بر پایه شواهد برای مراقبت روتین و اداره مشکلات 0 فرایند . احترام و حفظ کرامت1های اطلاعاتی قابل عمل . سیستم6 عاطفی. حمایت 2قابل ارجاع عملکردی های . سیستم1 . توانایی، منابع انسانی مشتاق7 . منابع فیزیکی ضروری موجود8 پیامد پوشش عملکردهای کلیدی پیامدهای مردم محور پیامدهای سلامتی فردی مورد نظر احتمال پیامدهای ،برای زنان باردار و نوزادانشان زایمانی تمراقبت با کیفیت در تسهیلا بعدارچوب هشت چ مراقبت ارائهبرای افزایش کیفیت در دو بعد را دهد. رویکرد سیستم سلامتی ساختاری را افزایش می و رفاهی قابل دستیابی ، ین و اورژانسیشواهد برای مراقبت روت شامل استفاده از عملکرد بر پایه ،مراقبت ارائه. کندفراهم میو تجربه مراقبت عملکردی برای ارجاع بین سیستمهای و رسیحساببازبینی و باشد که در زمینه ضبط اسناد بهمیهای اطلاعاتی سیستم سیستم سلامتی مراقبت با کیفیت تهیه مراقبت تجربه مراقبت فرد و پیامدهای سطح تسهیلات ، هیافتهایشان درباره مراقبت انجام دهند. تجربه مراقبت شامل ارتباط موثر با زنان و خانوادهسطوح متفاوت مراقبت اجازه می -انتخاب آنها می به حمایت عاطفی و اجتماعی در با احترام و حفظ کرامت و دستیابی انتظارات و حقوق آنها، مراقبت همراه ارچوب شامل داشتن کفایت، منابع انسانی مشتاق و منابع فیزیکی که شروط لازم برای خورده در چ باشد. نواحی برش باشند، هستند.مراقبت با کیفیت خوب در تسهیلات سلامتی می سیستم سلامتی، از دیدگاه های مختلفی از را در بخشها یا ابعاد کیفیت مراقبت تواند ارزیابی ویژگیارچوب میاین چ ارچوب و در مسیر اختیار استفاده قرار دهد. بر اساس این چکنندگان خدمت و مدیران مورد کنندگان از خدمت، فراهماستفاده تژیک کاری برای بهبود کیفیت مراقبت مادری و نوزادی تشخیص داده شده بود. این شش ناحیه سازمانی، شش ناحیه استرا ، مداخلات موثر، های مراقبت، استانداردهادستورالعمل تهیهرویکرد سیستماتیک و بر پایه شواهد برای ای برایبعنوان پایه راقبت با کیفیت از مادران و نوزادان مورد استفاده قرار ظرفیت برای بهبود مافزایش مراقبت با کیفیت و تحقیق و نشانگرهای گرفته بود. های کاری استراتژیک حوزه 1.1 و پایان دادن به مرگ و میر و بیماری قابل پیشگیری میان مادران و مراقبت استراتژیک برای بهبود کیفیت شش حوزه ی، برای بررسی جهان نشانگرهاییهای مداخله موثر، تراتژیها، استانداردهای مراقبت، اسنوزادان شامل تحقیق، دستورالعمل .)6(هستند نویسیبرنامهگیری و ندازهاتوانایی برای بهبود کیفیت، افزایشو امکانات، سطوح ملی های استراتژیک، بهبود کیفیت مراقبت مادران و نوزادان را با هدف قوت بخشیدن ، کار در این حوزهدر چارچوب هدایت شده های عملکرد بالینی بر پایه که دستورالعملدر حالیخواهد کرد. یک بازبینی نشان داده، حمایت فنیتوانایی ملی و حمایت به گیری کیفیت مناسب شواهد بطور عموم موجود هستند، هیچ راهنمایی برای استانداردهای مورد انتظار از مراقبت و اندازه های کیفیت بعنوان اولین محصولات تجویزی در اولویت قرار داده گیریاقبت و اندازهوجود ندارد. بنابراین استانداردهای مر شده بودند. . استانداردهای مراقبت1 هاشواهد و خلاصه یافته 1.1 -ای نمیبندی و ساختار استانداردهای مراقبت در هیچ تعریف ثابت یا ساختار استاندارد شده ویژهبرای تعاریف، طبقهجستجو کردند تعریف می ایبیانیهبعنوان را های غیر مرتبط با سلامتی بودند که استاندارد ، از حوزهشناسایی شدهگنجد. اکثر منابع . استانداردهای مرتبط با سلامتی، عمدتا، )66(کند در فرایندها و تولیدات فراهم می هماهنگیکه راهنمایی برای اطمینان از هایی از استانداردهای مادر و ، مثال)ECIN(. مرکز ملی برای سلامتی و مراقبت عالی )16، 16(دند از مراکز با درآمد بالا بو ها برای عفونت نوزادان، فشار خون بالا در حاملگی، تقویت بیوتیکهایی برای استفاده از آنتیزند که شامل مثالنوزاد می ، هیئت )26(در نتردام sseccAmrahP. بنیاد )16(باشد می های پس از زایمان و در حین زایمانلیبر، سزارین، مراقبت استانداردها )16(و انجمن مسئول برای سرویس سلامتی در جنوب آفریقا )16(بین المللی در ایالات متحده آمریکا مشترک حدودی از ، سازمان جهانی بهداشت تعداد م7116بندی کردند. در سال شورهای با درآمد کم و متوسط طبقهرا برای ک زمان تولد نبودند.برای که هیچ کدام ویژه )76(استانداردها را برای مراقبت از مادران و نوزادان منتشر کرد تعریف کردند، گرچه تعداد کمی از آنها برای » اعتباربخشی«این منابع وابسته به سلامتی بطور اولیه استانداردهایی برای با تشخیص خلاها در ایمنی و کیفیت » دارنواحی اولویت«ای ایجاد استانداردها در هایی بربهبود کیفیت بودند اما شاخص -، تعداد کمی چنین اندازهکردندپیشنهادات می »گیریهای اندازهشاخص«کردند. در حالی که اکثرا نیازهایی برای فراهم می کردند.هایی را ایجاد میگیری تعریف و ساختار استانداردها 1.1 چیزی که مورد انتظار است تا دستیابی به مراقبت «مادران و نوزادان استاندارد بصورت از برای مراقبت ، هاین یافتهبر اساس ا -کیفیت و اندازه یهتعریف شده است. استاندارد مراقبت دو عنصر مهم دارد: بیان» با کیفیت بالا در زمان تولد را فراهم کند های کیفیت گیریکند و اندازهبا استاندارد تنظیم می انطباقدستیابی به ازها را برای نیکیفیت، بیانیه. )6شکل (گیری کیفیت کند.، فراهم مییا نه شواهد عینی برای تعیین اینکه آیا ابزارها مورد نیاز هستند ن هستندگیری در زمان زایماکیفیت قابل اندازهها برای مراقبت بامختصری از اولویت هایبیانیه کیفیت هایبیانیه های کیفیت استخراج شده از شواهد در نواحی شماتیک و شاخص که ؛)16( )ECHNبرگرفته از استانداردهای کیفیت ( کنند. منابع مورد نیاز را تعریف می کیفیت بیانیهگیری و بررسی کیفیت مراقبت بصورت ویژه در هایی برای ارزیابی، اندازهشاخصهای کیفیت گیریاندازه باشند:سه نوع می کههستند. ،)هاها، دستورالعملمانند منابع فیزیکی، منابع انسانی، سیاست( ایجاد شودداد: چیزی که باید برای مراقبت مورد نظر درون فراهم شده است، ،که مورد انتظار بوده صورتیهمان به داد: آیا فرایند مورد نظر مراقبت برون مردم محور.پیامدهای و یسلامت رویبر و تجربه مراقبت تهیهپیامد: اثر : ساختار استانداردها1شکل ها جهت بهبود ارچوب کیفیت مراقبت سازمان جهانی بهداشت، هشت استاندارد برای تعریف اولویتچ ازدر هشت حوزه اند:شده طراحیکیفیت عملکرد بر پایه شواهد برای مراقبت روتین و اداره مشکلات .0 های اطلاعاتی قابل عملستمسی .6 های ارجاعی عملیسیستم .1 ارتباط موثر .1 کرامت احترام و حفظ .1 حمایت عاطفی .2 پرسنل با کفایت و مشتاق .7 وجود منابع فیزیکی ضروری .8 هشت استاندارد، برای هر کدام از قلمروهای اشتکیفیت سازمان جهانی بهد با چهارچوب مراقبت کیفیت برای هر استاندارد بیانیهسه یادو )، پیامددادبرون ،داددرون(های کیفیت گیریاندازه باشد که بر اساس عملکردهای کیفیت هستند. تنها مورد استثنا، استاندارد یک می بیانیهبا دو یا سه استانداردها در همراهی های کیفیت برای انعکاس اولویت یهبیان 10باشد که برای هر کدام ایه شواهد برای مراقبت روتین و اداره مشکلات میبر پ ها بیانیهباشد کیفیت وجود دارد. برای استاندارد یک، اگر منظور فقط زن میبیانیه 01مداخله وجود دارد. در کل جهتویژه باشد از اند و اگر منظور مادر و نوزاد میتوضیح داده شده» ب«باشد با ور نوزاد میاند، اگر منظتوضیح داده شده» الف«با داد و پیامد دارد.داد، برونگیری در درونشش تا هجده اندازه کیفیت بیاینه 01استفاده شده است. هر کدام از » ج« کیفیت هایاستفاده از استانداردها و بیانیه هدف و 1.1 د که برای زنان و کودکانشان در طول لیبر، زایمان و نگیرمیبت روتین و اداره مشکلاتی را دربرمراق ،مراقبت استاندادهای شود. های کوچک در طول هفته اول زندگی هم میشامل بچهافتد، استاندارد مراقبت دوره بلافاصله پس از زایمان اتفاق می دهند قابل کاربرد ر تمام تسهیلات سلامتی که خدمات مامایی ارائه میاستانداردها متمرکز بر زن، نوزاد و خانواده هستند و د تشخیص داده خاصهای اولویت رسیدن بههای سازمان جهانی بهداشت بوده و برای باشند. آنها مطابق با دستورالعملمی اند.طراحی شده 6.0شده در قسمت گیری عملکرد بر بررسی و اندازهاز کنند، فراهم میاست، نیاز ردمو مورد انتظار و آنچهای برای پایهاستانداردهای مراقبت، و اطلاعاتی در مورد اینکه کندمیها جهت بهبود حمایت های بهترین عملکرد برای تشخیص اولویتگیریخلاف اندازه ده قرار گیرد را فراهم تواند برای حمایت از مراقبت با کیفیت بالا یا خدمات زایمانی مورد استفاچگونه بهترین عملکرد می ریزان، مدیران و فراهم استفاده توسط برنامه جهتها را برای بهبود کیفیت مراقبت از مادر و نوزاد کند. آنها اولویتمی :کنندتعریف می کنندگان مراقبت سلامتی مات سلامتی موثر ایجاد استانداردهای ملی و فراملی بر پایه شواهد جهت اطمینان از مراقبت با کیفیت بالا، خد  برای مادر و نوزاد در حول و حوش زایمان جهت نیازمند بهبود یافتنمعرفی استانداردهای مورد انتظار برای مراقبت و زایمان برای تشخیص اجزا مراقبت  از خدمت با کیفیت بالا یافتن اطمینان و بهبود استفاده و رضایت افراد، استفاده از منابع موجود برای دستیابی به پیامدهای مراقبت سلامتی مطلوب  ها و جوامع از خدمات سلامتی مادر و نوزادخانواده انجام گرفته است و با کیفیت بالا از مادر و نوزادمراقبت یا خدمات دهد کهمیهای خدمات، نشان بررسی پیشرفت  اندشده پررنگنواحی پیشرفت کنندگان عملکردلی، اعتبار وجوایزی برای فراهمم تسهیلات سلامتی هایممیزیبرای ارائه یک معیار  های ملی مراقبت باکیفیت و با استراتژی خدمات برای اطمینان از اینکه خدمات فراهم شده کیفیت بالا دارند یا نه، باید ها برای زایمان مادران و خدمات سلامتی نوزاد تطابق یافته و کارآمد باشند. ارچوبچ کیفیت هاییهدها و بیانلیستی از استاندار 1.1 عملکردهای بر پایه شواهد برای مراقبت روتین و اداره مشکلات بر پایه شواهد و اداره مشکلات در طول لیبر، زایمان و دوره اولیه پس از هر زن و نوزادی مراقبت روتین،: 1استاندارد .کنددریافت می ،های سازمان جهانی بهداشتزایمان، مطابق با دستورالعمل بر پایه شواهد در لیبر، زایمان و دوره بلافاصله پس از و هدف از این استاندارد، اطمینان یافتن از اداره مورد انتظار هدف: تشخیص زودرس مشکلات و اداره باشد؛ که شامل مراقبت روتین، زایمان برای مادران و نوزادان در چند روز اول زندگی می شده است مواردیزیادی نیاز به توجه در طول این دوره دارند؛ بنابراین، استاندارد محدود به موقعیتهایباشد. مناسب آنها می دهد و ها را بطور چشمگیری کاهش میها تعداد مرگکه با مرگ و میر و بیماری بالا ارتباط دارند. اداره مناسب این موقعیت بخشد.پیامدهای زنان و نوزادان را در طول این دوره بهبود می کیفیت هایبیانیه وند و از آنها مراقبت مناسب شالف: زنان بطور روتین در ورود به بخش و در طول لیبر و زایمان ارزیابی می 0.0کیفیت یهبیان .آیدبعمل میموقع و ب کنند.ب: نوزادان بلافاصله پس از تولد مراقبت روتین دریافت می 0.0کیفیت یهبیان کنند.ن و نوزادان بطور روتین مراقبت بعد از زایمان دریافت میج: مادرا 0.0کیفیت یهبیان های سازمان اکلامپسی یا اکلامپسی سریعا مداخلات مناسب، مطابق با دستورالعمل: زنان مبتلا به پره6.0کیفیت یهبیان کنند.جهانی بهداشت دریافت می های سازمان جهانی ت مناسب، مطابق با دستورالعملایمان سریعا مداخلاز: زنان با خونریزی پس از 1.0کیفیت یهبیان کنند.بهداشت دریافت می های سازمان جهانی ت مناسب، مطابق با دستورالعملمداخلا لیبر طول کشیده یا لیبر متوقف شده: زنان با 1.0 کیفیت یهبیان کنند.بهداشت دریافت می کنند، تحریک مناسب و احیا با کیسه و ماسک را در یک دقیقه نمی: نوزادانی که خودبخود تنفس را شروع 1.0کیفیت یهبیان کنند.های سازمان جهانی بهداشت دریافت میاول تولد، مطابق با دستورالعمل های سازمان الف: زنان با زایمان زودرس مداخلات مناسب برای خود و نوزادشان، مطابق با دستورالعمل 2.0کیفیت یهبیان کنند.ت میجهانی بهداشت دریاف های سازمان جهانی بهداشت دریافت ب: نوزادان زودرس و کوچک مراقبت مناسب، مطابق با دستورالعمل 2.0کیفیت یهبیان کنند.می الف: زنان مبتلا به عفونت یا در معرض خطر عفونت در طول لیبر، زایمان یا دوره اولیه پس از زایمان 7.0کیفیت یهبیان کنند.های سازمان جهانی بهداشت دریافت میمطابق با دستورالعمل سریعا مداخلات مناسب، بیوتیکی، مطابق با خطر برای عفونت سریعا درمان آنتیب: نوزادان مشکوک به عفونت یا دارای عامل 7.0کیفیت یهبیان کنند.های سازمان جهانی بهداشت دریافت میدستورالعمل های با منشا بیمارستانی برای پیشگیری از عفونتاستاندارد هاییاطمطابق با احت : همه زنان و نوزادان،8.0کیفیت یهبیان کنند.مراقبت دریافت می قرار زا مورد اقدامات غیرضروری و آسیب: هیچ زن و نوزادی در طول لیبر، زایمان و دوره اولیه پس از تولد 1.0کیفیت یهبیان گیرد.نمی های اطلاعاتی عملکردیسیستم و مناسب جهت سریع کرداز عملسیستم اطلاعاتی سلامتی، ما را به استفاده از اطلاعات برای اطمینان : 1دارد استان سازد.قادر می یو نوزادبهبود مراقبت از هر زن جهت هاز آنبرای استفاده مناسب ااطلاعات بطور دقیق در تسهیلات زایمانی تمامیهدف از این استاندارد ثبت هدف: آوری اطلاعات همه بیماران در های استاندارد برای جمع؛ این عمل نیاز به وجود فرمباشدمی اقبت از زنان و نوزادانبهبود مر آوری و آنالیز اطلاعات و استفاده دیده و ماهر جهت جمعتسهیلات زایمانی و وجود کارکنان آموزشمدت اقامتشان در طول از جمله عملکرد رسی و بهبود عملکرد در همه سطوح سیستم مراقبت سلامتی بر جهتاز نتایج آنها برای ایجاد بازخورد .داردسلامتی کارکنان مراقب کیفیت هایانیهبی : هر زن و نوزادی یک ثبت پزشکی استاندارد، دقیق و کامل در طول لیبر، زایمان و دوره بلافاصله پس از 0.6کیفیت یهبیان زایمان دارد. -آوری اطلاعات، آنالیز و بازخورد بعنوان قسمتی از فعالیتمکانیسمی برای جمع سهیلات زایمانی: هر ت6.6کیفیت یهبیان هایش برای بررسی و بهبود عملکرد در حول و حوش زایمان دارد. های ارجاعی عملکردیسیستم د تحت مداوا قرار گیرد، تواند بطور موثر با منابع موجوشرایطی که نمیدر صورت داشتن نوزادی هر زن و :1استاندارد شود.ارجاع داده می -موقع و مناسب همه بیمارانی است که نیاز به مراقبت دارند و نمیندارد اطمینان یافتن از ارجاع بهدف از این استا هدف: ماری ، در شرایطی که بیارجاع یک بیمار هر چه زودترتوانند در تسهیلات زایمانی مورد مداوا قرار بگیرند. تصمیم برای که است در حالیگرفته شود؛ این باید تواند در تسهیلات زایمانی مورد درمان قرار بگیرد، تشخیص داده شده است و نمی شود باید قبل از ارجاع بیمار برقرار ارتباط با مرکزی که بیمار ارجاع داده میدرمان قبل از ارجاع مورد نیاز داده شده است. تواند ایجاد شود. باید تحویل کامل بیمار به تسهیلات زایمانی دریافت ب برای دریافت بیمار میمناس اقداماتبنابراین شود، برای بهبود مراقبت در هر دو تسهیلات زایمانی ارجاع دهنده و ،ایشرایط بیمار باید بطور دوره ازو بازخورد دهکننده داده ش شود. گرفته ،ارجاع شده کیفیت هایبیانیه برای تعیین اینکه آیا ،: هر زن و نوزادی در ورود به تسهیلات، در طول لیبر و در دوره اولیه پس از زایمان1.0یت کیف یهبیان .گیردبطور مناسبی مورد ارزیابی قرار می نه گیرد یاارجاع مورد نیاز است و آیا تصمیم برای ارجاع بدون تاخیر انجام می ن تاخیر در هر وکه نیاز به ارجاع دارد، ارجاع با یک طرح از قبل مشخص که بد : برای هر زن و نوزادی6.1کیفیت یهبیان شود.می انجام قابل اجرا است،زمانی ، اطلاعات است یا بین تسهیلات زایمانی ارجاع داده شدهتسهیلات زایمانی : برای هر زن و نوزادی که به 1.1کیفیت یهبیان موجود است. سلامتی مربوطه ان مراقب، برای کارکنو بازخورد تبادلمناسبی جهت ارتباط موثر دهد.هایشان موثر است و به نیازها و ترجیحات آنها پاسخ میارتباط با زنان و خانواده :1استاندارد اش که یک عنصر ضروری برای تجربه مراقبتی که توسط بیمار و خانواده(هدف از این استاندارد، ارتباط موثر هدف: بیمار باید تمام اطلاعات درباره مراقبتش را دریافت کند و باید احساس کند که در تمام تصمیماتی باشد. می )ودشدریافت می تواند تنش غیرضروری را کاهش شود، دخالت دارد. ارتباط موثر میان مراقب سلامتی و بیمار میکه برای درمانش گرفته می یل کند.دهد و زایمان را به یک تجربه مثبت برای زن تبد کیفیت هایبیانیه کنند و ارتباط موثری با کارکنان دارند.هایشان درباره مراقبت اطلاعات دریافت می: همه زنان و خانواده0.1کیفیت یهبیان بین صحیحی که واضح و ، با اطلاعات)چند تخصصی(هایشان مراقبت همکاری شده : همه زنان و خانواده6.1کیفیت یهبیان . کنندمی دریافت ، راشودمیاجتماعی مبادله متی مربوطه و متخصصان مراقبتن سلامتخصصا احترام و حفظ کرامت .کنندکند، دریافت میحفظ را د کرامتشان توانمی کههمراه با احترام زنان و نوزادان مراقبت :5استاندارد طول اقامتشان در تسهیلات زایمانی است. به هدف از این استاندارد احترام همه جانبه و حفظ کرامت همه زنان درهدف: درمان نامناسب مانند آزار بدنی، جنسی یا ها احترام گذاشت و از هر نوعخلوت و شرایط محرمانه آنها باید در همه زمان کردن، تهدید یا عدم ارائه خدمت باید خودداری شود.توجهی، معطلکلامی، تبعیض، بی کیفیتهای بیانیه قرار دارند و شرایط محرمانه آنها مورد احترام شرایط خصوصیزنان و نوزادان در زمان لیبر و زایمان : همه0.1ت کیفی یهبیان .گیردمی توجهی، معطل : هیچ زن و نوزادی مورد درمان نامناسب مانند آزار بدنی، جنسی یا کلامی، تبعیض، بی6.1کیفیت یهبیان گیرد.یدن، تهدید یا عدم ارائه خدمت قرار نمش کنند، داشته باشند و دلیل مداخلات های آگاهانه درباره خدماتی که دریافت میتوانند انتخاب: همه زنان می1.1کیفیت یهبیان شود.توضیح داده میبه آنها و پیامدها بطور شفاف حمایت روانی های آنها حساس بوده و ظرفیت و توانایی که به نیاز شوداش حمایت روانی فراهم میبرای هر زن و خانواده :6استاندارد .دهدافزایش میزن را -باشد. داشتن همراه زایمانی به انتخاب مادر به زن کمک مییک جزء ضروری از تجربه مراقبت می انیحمایت رو هدف: ا در طول زایمان اش رکند، تواناییکند تا در حین زایمان اعتماد به نفس بیشتری داشته باشد. حمایتی که زن دریافت می دهد.افزایش می کیفیت هایبیانیه شود.هایی برای تجربه لیبر و زایمان به انتخاب خودش پیشنهاد میگزینه : به هر زن0.2کیفیت یهبیان کند.اش در طول زایمان حمایت دریافت می: هر زن برای افزایش توانایی6.2کیفیت یهبیان منابع انسانی ماهر و مشتاق مراقبت روتین و اداره مشکلات وجود دارند. انجامبرای : برای هر زن و نوزادی، کارکنان ماهر و مشتاق 7دارد استان کفایت و خوب آموزش دیده داشته باشند و باید باتمامی مناطق تسهیلات زایمانی برای لیبر و زایمان باید کارکنان هدف: د. در تسهیلات نکاری مورد انتظار وجود داشته باش داد کافی برای بارساعت روز، به تع 16متخصصان زایمانی ماهر در طول .باشدمیکننده خوب برای حمایت و اطمینان از بهبود مداوم کیفیت ضروری یک مدیر و ادارهزایمانی، وجود کیفیت هایبیانیه ایت کارکنان جهت مراقبت روتین به حداقل یک متخصص زایمانی ماهر، برای حم دائما: هر زن و نوزادی 0.7کیفیت یهبیان و اداره مشکلات، دسترسی دارد. های چندگانه برای برآوردن نیازهای : متخصصان زایمانی ماهر و کارکنان حامی توانایی مناسب و مهارت6.7کیفیت یهبیان دارند.را لیبر، زایمان و مراحل اولیه بعد از زایمان های خوب توسعه و ایجاد سیاست مسئول، در کلکننده بالینی دارد که دیر و ادارههر تسهیلات زایمانی م: 1.7کیفیت یهبیان .باشدمی هیلات در جهت بهبود مداوم مراقبتکردن محیطی برای حمایت از کارکنان تسو فراهم منابع فیزیکی ضروری موجود شکلات، محیط فیزیکی مناسب به همراه آب تسهیلات زایمانی، برای مراقبت روتین از مادر و نوزاد و اداره م :8استاندارد کافی، بهداشت و ذخایر انرژی، داروها، منابع و تجهیزات دارد. ات رفاهی اساسی که شامل آب، نظافت، بهداشت، الکتریسیته، انهدام وسایل نامکا هر تسهیلات زایمانی ساختار و هدف: داشته باشد. واحدهای را باید ای مراقبت از مادران و نوزادان وسایل برای برای داروهای ضروری، منابع و دور ریختنی، جعبه مراقبت از لیبر، زایمان و بعد از زایمان، برای دستیابی به مراقبت مداوم باید تمیز و راحت بوده و بطور منطقی طراحی و د.ندهی شده باشسازمان کیفیت هایبیانیه ت و امکانات انهدام وسایل دور ریختنی برای برآوردن نیازهای : آب، انرژی، بهداشت، بهداشت دس0.8کیفیت یهبیان ها، کاربردی، معتبر، ایمن و کافی هستند.کارکنان، زنان و خانواده اند که هر دهی و ایجاد شده: واحدهای مراقبت از لیبر، زایمان و دوره پس از زایمان طوری طراحی، سازمان6.8کیفیت یهبیان مورد مراقبت قرار گیرد. مراقبت مداوم انجامردن نیازهایش در محیط خلوت جهت ورای برآتواند بزن و نوزادی می های کافی برای داروها، ذخایر و تجهیزات جهت مراقبت روتین و ادراه مشکلات وجود دارند.: جعبه1.8کیفیت یهبیان هاگیریکیفیت و اندازه های. بیانیه5 ihpleDپیامد فرایند 1.5 داد بودند، همانطوری داد و برونهای درونگیریاندازه ihpleDشده برای جلسه اینترنتی گیری استخراج اندازه 801اکثر هایی های پیامدها اساسا آنگیریرد پوشش داده شده نیستند. اندازهکیفیت منف یهها ضرورتا بوسیله یک بیانگیریکه اندازه کیفیت مورد استفاده قرار گیرند و به مقایسه میان باارزیابی منبع موثق مراقبت توانند در سطح موردی برای هستند که می . پردازندمیتسهیلات یا تغییرات در طول زمان کل، آنها موافق بودند پاسخ دادند. در )٪18(نفری که تحقیق را دریافت کرده بودند 110کننده از شرکت 200در دور اول، دادها، فرایند و پیامدهای کیفیت مراقبتی که زنان و نوزادان در زمان تولد دریافت وردنظر، درونهای کیفیت مگیریکه اندازه ودند، نشان نظرهای دریافت شده، بعضی از آنها نواحی مهمی را که پوشش داده نشده ب. از اظهارپوشش داده استکنند را می از تعدادیکیفیت را گسترش دادند. هایبیانیه حواشیا انعکاس یها را پیشنهاد کردند گیریاندازهاز تعدادی اصلاح دادند، کنندگان را در مورد کیفیت مراقبت منعکس کردند. فیت نبودند اما دیدگاه عموم شرکتکی هایبیانیهآنها مستقیما مربوط به فه شده اظهار جدید اضا 01و بودند مورد از آنها حذف شده 10کیفیت بر اساس اظهارات روشن بودند، های بیانیهتعدادی از شدن در دور دوم وجود داشت. گرفته گیری کیفیت برای درنظراندازه 111بود، در نتیجه، در کل یکی از سه )08/200( ٪17کشور با درآمد بالا، متوسط و ضعیف با میزان پاسخ 21کننده از شرکت 08در دور دوم، کلا، شرکت کننده در مورد تجربه 17نفر از 81مراقبت و تهیهدهنده در مورد پاسخ 18نفر از 02تکمیل کردند. تحقیق را مراقبت اظهار نظر کرده بودند. -بندی شده بودند ؛ فقط سه اندازهرتبه ٪12/1تا کمترین مقدار ٪11/8های کیفیت از بالاترین مقدار گیریاکثریت اندازه -اندازه 200، برای 11، بالای گیریاندازه 11برای مراقبت، میانگین نمره بندی شده بودند. برای تهیهرتبه 17گیری زیر ، 11گیری بالای اندازه 1بود. برای تجربه مراقبت، میانگین نمره برای 18زیر ،اندازه گیری 11و برای 11-18بین ،گیری 60نگین نمره برای های بینابینی، میاگیریبود. برای اندازه 18گیری زیر اندازه 20و برای 11-18گیری بین اندازه 71برای 21 بود. بنابراین 18گیری مساوی و کمتر از اندازه 20و برای 11-18گیری اندازه 11، برای 11ساوی و بالای گیری ماندازه های گیریدازهدی شده بصورت اکثرا زیاد، انبنکیفیت رتبه هایبیانیهداشتند. اکثر 11بندی بالای گیری کیفیت رتبهاندازه داد بودند.دورن های کیفیتگیریاستفاده از اندازه 1.5 کیفیت مراقبت و بهبود تدارک و های کیفیت را برای تشخیص خلاها درگیریاندازه توانندهای تسهیلات زایمانی میتیم هبران، طراحان، مدیران و فراهم کیفیت مربوطه مورد استفاده قرار دهند. ر یهمطابق با استاندارد و بیان ،تجربه مراقبت توانند از آنها برای ارزیابی و بررسی وجود منابع، اجرای فرایندها، نواحی نیازمند پیشرفت و اثر کنندگان تسهیلات زایمانی می اما ها باید مطابق با هر مفهوم باشند گیریین سبب بهبود کیفیت شوند. اندازهمداخلات مورد استفاده قرار دهند و بنابرا استانداردها باید بطور مداوم برای اطمینان از بهبود کیفیت ایجاد شوند. داد شامل منابع های درونگیریاندازههای پیامد هستند. گیریداد/فرایند و اندازهداد، برونهای کیفیت شامل درونگیریاندازه داد شامل پوشش عملکردهای های برونگیریاندازه ها هستند.ها و دستورالعملها، پروتکلفیزیکی، منابع انسانی، سیاست کرده در تسهیلات زایمانی که نتیجه نسبت تمام زنان زایمان«مانند ؛شوندها بیان میکلیدی بوده و اکثرا بعنوان اولویت ای پیامد شامل هگیریاندازه» از زایمان ثبت شده بود. آزمایش ادرارشان بطور مناسبی در لیبر، زایمان و مراحل اولیه پس پیامدهای مردم محور و پیامدهای سلامتی هستند. -جود این، بعضی اندازهشوند؛ با وویژه هستند، دنبال می یههایی که برای آن بیانگیریتوسط اندازهکیفیت هایبیانیهاکثر -گذاری اندازه. شماره)8اندارد است(باشند، بویژه با توجه به منابع فیزیکی یهها ممکن است مربوط به بیش از یک بیانگیری قرار دارد و سه گیری داخل پرانتز کنند. درجه هر اندازههای کیفیت، دستورات لیست شده در تحقیق را منعکس میگیری اند.گذاری شدهستاره نشان با علامت یهبندی شده برای هر بیانهای کیفیت اکثرا زیاد درجهگیریمورد از اندازه کیفیت هایها برای بیانیهیگیراندازه 1.5 کند و اداره : هر زن و نوزادی مراقبت روتین و بر پایه شواهد دریافت می1استاندارد مشکلات در لیبر، زایمان و دوره بلافاصله پس از زایمان مطابق دستورالعمل سازمان باشد. جهانی بهداشت می د و شونبر، در طول لیبر و زایمان بررسی میالف: زنان بطور روتین در ورود به لی 1.1کیفیت یهبیان کنند.موقع دریافت میمراقبت مناسب و ب برای زن که ضروریمراقبت در طول لیبر و زایمان برای اطمینان از ، ارزیابی زن و بررسی منظم در ورود به لیبر: طقمن شخیص خطرات یا مشکلاتی که نیازمند که این ارزیابی جهت پیشگیری از شروع مشکلات و ت باشدمیاست، حیاتی مناسب باشد.اورژانسی یا برای ارجاع جهت پیامدهای بهتر حاملگی و لیبر برای هر دو مادر و نوزاد می واکنش لیبر و حاملگی، معاینه واژینال و تائید حالشرحدوره قبل از حاملگی، در در ورود، زنان بطور کامل از نظر مدارک مراقبت گیرند. میزان ضربان قلب جنین، قرار، وضعیت و عضو نمایش جنین، فشار خون، ضربان قلب ررسی قرار میشروع لیبر مورد ب در « VIHشود. نوع گروه خونی و ارهاش، هموگلوبین، پروتئین و گلوکز ادرار و وضعیت و دمای بدن مادر تعیین و ثبت می شود.و ثبت می گیردمیمورد آزمایش قرار » صورت لزوم و میزان ضربان قلب جنین بطور منظم ی بدن مادرشود؛ فشار خون، ضربان قلب، دمالیبر با پارتوگراف ارزیابی می پیشرفت شود. زایمان شود. تسکین درد پیشنهاد شده و انتخاب مادر در نظر گرفته میبررسی می» ساعت خط عمل پارتوگراف 1در « شود. مرحله سوم زایمان بطور فعال ترغیب مادر به زور زدن هدایت می طتوسگیرد و واژینال خودبخود مورد حمایت قرار می شود.شود، اداره میبا اکسی توسین داخل وریدی یا داخل عضلانی که بلافاصله پس از زایمان تجویز می هایبیانیه(د شوشود بطور مناسبی اداره میهر مشکلی که در ورود به لیبر و در طول لیبر و زایمان به سرعت تشخیص داده .)الف و ب را ملاحظه فرمائید 7.0الف و ب، 2.0، 1.0، 1.0، 1.0، 6.0کیفیت های کیفیتگیریاندازه دادهای درونگیریاندازه ترمومتر، فشارسنج، (زایمانی منابع و تجهیزات اساسی پایه برای مراقبت روتین و تعیین مشکلات تتسهیلا .0 دارد که به تعداد کافی همیشه در واحدهای مامایی برای لیبر )رای آزمایش ادراراستتوسکوپ برای جنین، نوار ب )81.11(. *و زایمان موجود هستند روز برای ارزیابی مراقبت در طول زایمان و فعالیت در واحدهای های نوشته شده و بهتسهیلات زایمانی پروتکل .6 )71.18(. *باشندبهداشت میجهانی ی سازمان هامامایی لیبر و زایمان دارد که بر اساس دستورالعمل طور منظم کنند و بواحدهای مامایی لیبر و زایمان آموزش ضمن خدمت دریافت می ررکنان مراقبت سلامتی دکا .1 های مامایی در طول لیبر و زایمان تازه ماه در زمینه تشخیص و اداره اورژانس 60 رحداقل یکبار د را هاآموزش )61.18(کنند. می تمرین تحریک لیبر و بررسی حمایتی یکبارکارکنان مراقبت سلامتی در واحدهای لیبر و زایمان حداقل ماهی .1 )12.87(. دهندرا انجام می در مراقبت روتین و تعیین مشکلات مامایی در طول لیبر و زایمان داد/فرایندهای برونگیریاندازه که فشار خون، ضربان قلب و دمای بدنشان افرادیکنند، زایمان میتمام زنانی که در تسهیلات زایمانی نسبت .0 و در صورت مناسب بودن روی آنها (بطور مناسب در طول لیبر، زایمان و بلافاصله پس از زایمان ثبت شده بود )16.78(. )عمل شود دقیقه پس عرض یک توسین درافرادی که اکسیکنند، تمامی زنانی که در تسهیلات زایمانی زایمان می نسبت .6 )80.28(اند. یافت کردهاز زایمان نوزادشان در در لیبر بطور صحیح با شانکه پیشرفت افرادیکنند، تمامی زنانی که در تسهیلات زایمانی زایمان می نسبت .1 )21.18(استفاده از پارتوگراف و یک خط عمل چهار ساعته بررسی و ثبت شده است. که نتیجه آزمایش ادرارشان در طول لیبر، افرادیکنند، تسهیلات زایمانی زایمان میتمامی زنانی که در نسبت .1 )11.87(زایمان و بلافاصله پس از زایمان بطور مناسبی ثبت شده است. ای برای تسکین درد در طول که هر گزینه افرادیکنند، تمامی زنانی که در تسهیلات زایمانی زایمان می نسبت .1 )11.17(اند. ریافت کردهلیبر و زایمان د های پیامدگیریاندازه یا مرگهای زودرس )مرگ در زمان تولد(در تسهیلات زایمانی [تعداد مرگ جنینی ناتالپریمیزان مرگ .0 های مرگ(هفته بودند 86یا حداقل بوده گرم 1110که وزنشان حداقل نوزادی/ تعداد کل نوزادان متولد شده )11.01(. *]1110 × )زندههنگام تولد+ تولدهای )61.88(. )افتدتولد اتفاق می 1110هر که به ازایهای نوزادی تعداد مرگ(میزان مرگ در دوران حاملگی .6 ساعت 60که در عرض افرادیشوند، تمامی زنانی که در تسهیلات زایمانی در فاز فعال لیبر پذیرش می نسبت .1 )18.67(کنند. زایمان می کنند.ب: نوزادان بلافاصله بعد از تولد مراقبت روتین دریافت می1.1 کیفیت یهبیان کند، نیازهای فوری آنها تطابق نوزادان با محیط جدید را تسهیل می ،مراقبت روتین از نوزادان بلافاصله بعد از تولدمنطق: کند.کند و از مشکلات قابل پیشگیری جلوگیری میرا به بهترین راه ممکن برآورده می حداقل یک ساعت برقرار به مدت شوند و تماس پوست به پوست با مادر بلافاصله بعد از زایمان، نوزادان کاملا خشک می شود و تغدیه با شیر مادر در اولین ساعت بعد از شود. بریدن بند ناف یک تا سه دقیقه بعد از زایمان به تاخیر انداخته میمی شود. مشکلی بطور مناسبی تشخیص داده شده و اداره می گیرد. هرتولد مورد حمایت قرار می های کیفیتگیریاندازه داددرون روز دارد که مطابق با های بالینی نوشته شده و بهتسهیلات زایمانی برای مراقبت ضروری از نوزاد، دستورالعمل .0 )11.01(. *زایمان موجود هستندهای سازمان جهانی بهداشت بوده و در واحدهای مامایی در لیبر و دستورالعمل تمامیدارد که به تعداد کافی در )یا تیغ(و قیچی )یا کلامپ بند ناف( ای از گیره بند ناف تسهیلات زایمانی ذخیره .6 )28.18(. *های مورد انتظار موجود هستندزایمان تمامی ها برایزمان لیبر و زایمان دارد که واحدهای تمیز در ای از حولهتسهیلات زایمانی برای خشک کردن بلافاصله نوزادان، ذخیره .1 )18.18(های مورد انتظار موجود هستند. زایمان تمامیها برای به تعداد کافی در همه زمان -ماه آموزش ضمن خدمت یا دوره 60کارکنان مراقبت سلامتی در واحدهای مامایی لیبر و زایمان، حداقل یکبار در .1 )11.18(. کنندرد مراقبت لازم از نوزاد و حمایت از شیردهی دریافت میهای منظم آموزش در مو درجه 16در دمای اتاق ثبت شده داشتن درجه حرارت ای و مکانیسمی برای نگهناحیهتسهیلات زایمانی، تنظیمات .1 )1.77(. دارددر واحدهای لیبر و زایمان ،گراد یا بالاتر و بدون کوران هواسانتی سازی شده و نظارت ماه آموزش و تمرینات شبیه اقبت سلامتی در لیبر و زایمان حداقل یکبار درکارکنان مر .2 )68.77(. کننددریافت می را حمایتی در مراقبت لازم از نوزادان و حمایت از شیردهی داد/فرایندبرون )28.61(. *نسبت همه نوزادانی که در ساعت اول پس از تولد شیردهی از پستان داشتند .0 با بدن یا سر (اند نسبت همه نوزادانی که با مادرانشان برای یک ساعت پس از تولد تماس پوست به پوست داشته .6 )11.18( .)پوشیده شده نسبت همه نوزادانی که تمام چهار مورد مراقبت ضروری از نوزاد را که شامل: خشک کردن کامل و بلافاصله پس .1 را دریافت و شروع شیردهی در ساعت اول تولد پوست، تاخیر در بریدن بند ناف از تولد، تماس بلافاصله پوست با )11.87(بودند. کرده )21.27(نسبت همه نوزادانی که بریدن بند نافشان یک تا سه دقیقه پس از تولد انجام شده بود. .1 )11.27(خشک شده بودند. کاملا نسبت تمام نوزادانی که بلافاصله پس از تولد .1 مدپیا ) دقیقه پس از تولد 160تا 12( )21/1-71/1˚С(دمای بدن نرمال در اولین معاینه تکمیلی نسبت همه نوزادانی که .0 )71.18(داشتند. کنند.ج: مادران و نوزادان مراقبت روتین پس از تولد دریافت می1.1کیفیت یهبیان برای پیشگیری، تشخیص زودرس و درمان مشکلات در مادر مراقبت روتین پس از تولد، استفاده از بهترین عملکرد منطق: دهد.مورد اینکه چگونه از خود و نوزادانشان مراقبت کنند را نشان می و کودک و مشاوره مادران در نرمال مورد وضعیتاز یباید هر نوع تغییری انجام گرفته برای مادر و کودکش، ، مراقبت فردزایمانمراقبت پس از در ساعت اول پس از 81بطور مداوم در دفع ادرار. فشار خون، دمای بدن، خونریزی و مورد بررسی قرار گیرداز تولد انتظار پس -شوند و تغذیه انحصاری با شیر مادر مورد حمایت قرار میشوند. مشکلات تشخیص داده شده و اداره میتولد بررسی می های پیشگیری از بارداری ها و روشگذاری بین زایمانادشان، فاصلهنوزمورد خود و های خطر درگیرد. مادران در مورد نشانه گیرند.مورد مشاوره قرار می و بند یچشمنظر شوند و از نگه داشته می گیرند، در تماس پوست با پوست با مادرنوزادان تحت بررسی کامل بدنی قرار می ها طبق و واکسن» ک«شود، ویتامین عت به تاخیر انداخته میسا 16گیرند. حمام نوزاد به مدت میمورد مراقبت ناف قرار گیرد و مشکلات تشخیص داده شده و اداره شود، دمای بدنشان مورد بررسی قرار میمی تزریقی به آنها های ملدستورالعمل کیفیت یهبیان( شودهای کوچک مراقبت اضافی داده میشوند. در صورت لزوم به نوزادان با وزن کم زمان تولد و بچهمی .)ب را ملاحظه فرمائید2.0 های کیفیتگیریاندازه داددرون های مامایی یا روز برای مراقبت پس از زایمان در بخشهای بالینی نوشته شده و بهتسهیلات زایمانی دستورالعمل .0 . *انی بهداشت هستندهای سازمان جهبخش مراقبت پس از زایمان در واحد مامایی دارد که مطابق با دستورالعمل )10.11( روز ساعت 16دهد به مادران و نوزادان اجازه می ورا فراهم کرده مادر و نوزاد تسهیلات زایمانی امکان هم اتاقی .6 )71.28(. *را با همدیگر باشند ان شیردهی با پستان دارد که بطور روتین به تمامی مراقبان سلامت و کارکنمکتوب تسهیلات زایمانی سیاست .1 )80.18(. شده است ارائه پشتیبان کارکنان مراقبت سلامتی در واحد مامایی، بطور روتین در مورد مراقبت پس از زایمان و شیردهی با پستان حداقل .1 )11.18(. کنندماه یکبار آموزش ضمن خدمت یا جلسات منظم بازآموزی دریافت می 60هر بعد از مرخص شدن از بیمارستان زمان از اینکه آیا هر مادری طمینانا دارد، برایتسهیلات زایمانی برنامه محلی .1 )81.17(. داند یا نهرا میبعمل خواهد آمد خود و نوزادش و مکان مراقبتی که از های جایگزین شیردهی دارد که این موارد شامل استفاده از فنجان های محلی برای روشتسهیلات زایمانی برنامه .2 )71.87(. باشندممانعت از شیردهی با شیشه شیر می یا فنجان و قاشق و هایشان درباره مزایا و اداره شیردهی با پستان تسهیلات زایمانی برنامه محلی برای آگاه کردن زنان حامله و خانواده .7 )11.17(. دارد اش با توضیح کامل انوادهبه مادر و خفقط در موادر نیاز که تغذیه نوزاد با فورمولا کندتضمین میتسهیلات زایمانی .8 )18.07(. نشان داده شده استاز آن در مورد خطرات استفاده نامناسب داد/فرایندبرون و تمام » ک«تسهیلات زایمانی که ویتامین واحدهاینسبت تمام نوزادان در بخش مراقبت پس از زایمان یا .0 )16.01( .*انددریافت کرده های ملیرا مطابق با دستورالعمل هاواکسن را در تسهیلات زایمانی که تغذیه انحصاری با شیر مادر از زمان تولد تا زمان ترخیص موجودنسبت همه نوزادان .6 )71.18(. اندداشته تسهیلات زایمانی که مشکلات فشار خون، ضربان واحدهاینسبت تمام زنان در بخش مراقبت پس از زایمان یا .1 )61.18(. تغذیه با شیر مادرشان ثبت شده است قلب، خونریزی واژینال، لوشیا یا )10.18(. اندنسبت همه نوزادان در تسهیلات زایمانی که معاینه کامل بالینی قبل از ترخیص داشته .1 در تسهیلات عارضه،ساعت بعد از یک زایمان واژینال بدون 16ت همه مادران و نوزادان سالمی که به مدت بسن .1 )11.68(. اندردهزایمانی مراقبت دریافت ک در مورد دمای بدن شاناطلاعاتدر تسهیلات زایمانی که نسبت همه نوزادان در بخش مراقبت پس از زایمان یا .2 )01.68(. های خطر ثبت شده استنوزاد، تعداد تنفس، رفتار شیر خوردن و وجود یا عدم وجود نشانه را از یک در تسهیلات زایمانی که مشاوره شیردهی نسبت همه مادران سالم در بخش مراقبت پس از زایمان یا .7 )10.68(. اندسلامتی ماهر دریافت کرده تدهنده مراقبارائه روز ساعت 16در تسهیلات زایمانی که به آنها اجازه هم اتاقی با نوزادشان به مدت نسبت همه زنان زایمان کرده .8 )11.87(. داده شده است گذاری بین تولدها و ایمانی که به آنها در مورد فاصلهزایمان در تسهیلات ز نسبت تمام زنان در زمان پس از .1 )18.77(. روشهای پیشگیری از بارداری قبل از ترخیص مشاوره داده شده بود پیامد )11.18(. نسبت تمام نوزادان در تسهیلات زایمانی که در زمان ترخیص از بیمارستان شیردهی انحصاری داشتند .0 -یشگیری از بارداری در مورد فاصلهنان در زمان پس از زایمان در تسهیلات زایمانی که مشاوره پنسبت همه ز .6 )11.18(. انددریافت کرده را ها قبل از ترخیصگذاری بین زایمان کنند.ریعا مداخلات مناسب دریافت میاکلامپسی یا اکلامپسی س: زنان مبتلا به پره1.1کیفیت یهبیان مرگ و میر مادری، مرگ و میر زمان زایمان مهمترین عللاکلامپسی و اکلامپسی پرهخون ناشی از حاملگی، فشار منطق: تواند بطور چشمگیری مرگ و میر و موقع و درمان مناسب میسریع و بو مرگ و میر نوزادی هستند. پیشگیری، تشخیص بیماری مربوطه را کاهش دهد. داخل وریدی یا عضلانی و یک داروی کاهنده فشار خون در منیزیوم فورا سولفات ،دکلامپسی شدیبه زنان مبتلا به پره های کارکرد بد اعضا و داده شود. نشانهمنیزیوم وز اولیه مرجع سولفات در صورت ارجاع زن باید دشود. صورت نیاز داده می )، رفلکس تاندون و میزان ضربان قلب جنینردراامانند فشار خون، تعداد تنفس، تعادل مایع، میزان (های خطر نشانه سایر کنند. اگر زن در حاملگی ترم ها پیشرفت بیماری را تعیین میهای آزمایشگاهی مانند اوره و الکترولیتشوند. تستبررسی می حاملگیهای شود. برای پیشنهاد می قرار دارد یا جنین قابلیت حیات ندارد، لیبر با مداخله ابزاری یا در صورت نیاز سزارین شود.کورتیکواستروئیدها داده میهمراه منیزیوم به زودرس اگر شرایط ثابت باشد، سولفات های کیفیتگیریاندازه داددرون دارد که همیشه به تعداد منیزیوم تسهیلات زایمانی ذخایری از داروهای ضد فشار خون خوراکی، وریدی و سولفات .0 )8.01(. *ن از واحد مامایی موجود هستندکافی در واحدهای لیبر و زایما -روز در مورد اداره پره اکلامپسی دارد که مطابق دستورالعملهای نوشته شده و بهتسهیلات زایمانی دستورالعمل .6 های سازمان جهانی بهداشت بوده و در واحدهای لیبر، زایمان و بعد از زایمان از واحد مامایی موجود هستند. )11.11( آموزش ضمن خدمت و جلسات منظم ماه یکبار، 60حداقل هر مراقبت سلامتی در واحد مامایی، کارکنان .1 -و سولفات منیزیوم برای درمان پرهبازآموزی در مورد استفاده از داروهای ضد فشارخون، تزریقات داخل وریدی )11.18(کنند. اکلامپسی و اکلامپسی دریافت می داد/فرایندنبرو منیزیوم را اکلامپسی شدید یا اکلامپسی که در تسهیلات زایمانی دوز کامل سولفات ه پرهن مبتلا بنسبت تمام زنا .0 )71.01(. *انددریافت کرده نسبت همه زنان مبتلا به فشار خون افزوده شده شدید در حاملگی که در تسهیلات زایمانی داروی ضد فشار خون .6 )61.88(اند. تجویز شده را دریافت کرده اکلامپسی که در تسهیلات زایمانی وضعیتشان به طرف اکلامپسی پیشرفت کرده مبتلا به پرهبت همه زنان نس .1 )1.08(است. پیامد اکلامپسی یا سهیلات زایمانی در اثر عوارض پرهاکلامپسی یا اکلامپسی که در تنسبت همه زنان مبتلا به پره .0 )66.01(. *اندفوت کردهاکلامپسی اند و اکلامپسی یا اکلامپسی که با یک جنین زنده به تسهیلات زایمانی رسیدهان مبتلا به پرهنسبت همه زن .6 )11.28(مرده است. )زودرس نوزادییا مرگ های هنگام تولدمرگ(کودکشان در دوره حول و حوش زایمان اکلامپسی یا اکلامپسی پرهدر تسهیلات زایمانی که بخاطر اکلامپسی یا اکلامپسی نسبت همه زنان مبتلا به پره .1 )88.27(اند. شرایط نزدیک به مرگ را تجربه کرده کنند.: زنان مبتلا به خونریزی پس از زایمان سریعا مداخلات مناسب دریافت می1.1کیفیت یهبیان ساعت اول 81تا 16های اتفاق افتاده در خونریزی پس از زایمان علت قابل پیشگیری مرگ مادری و اکثر مرگ منطق: ای برای کاهش موثر مرگ هستند.پایه ،موقع و اداره مناسبباشد. تشخیص زودرس و بپس از زایمان می شود. اگر خونریزی اتفاق بیفتد، باید سریعا با اکسی توسین داخل وریدی، خونریزی پس از زایمان بطور روتین بررسی می های موقتی یا در صورت لزوم با مداخلات جراحی اداره شود. ماساژ رحمی، خارج سازس دستی جفت محبوس شده، بررسی شوند و شوک با احیا فوری توسط مایعات داخل وریدی و در خونریزی مداوم، ضربان قلب و فشار خون مرتبا بررسی می شود. صورت لزوم با تزریق خون اداره می های کیفیتگیریاندازه داددرون روز برای اداره خونریزی پس از زایمان دارد که مطابق با شده و بهتههای نوشتسهیلات زایمانی دستورالعمل .1 . *های سازمان جهانی بهداشت بوده و در واحدهای زایمان و مراقبت پس از زایمان موجود هستنددستورالعمل )27.11( ها، سر شامل سرنگ(تسهیلات زایمانی داروهای یوتروتونیک و ذخایری برای تزریق مایعات داخل وریدی و خون .1 دارد که همیشه به تعداد کافی در واحدهای زایمان و مراقبت )های داخل وریدی و خونها، برانول، محلولسوزن )11.18(پس از زایمان موجود هستند. )68.28(. موجود است ی، همیشه یک سرویس تزریق خون عملکردیدر تسهیلات زایمان .2 ماه 60ای لیبر، زایمان و مراقبت پس از زایمان از واحد مامایی، حداقل هر کارکنان مراقبت سلامتی در واحده .7 . کنندبازآموزی در مورد اداره خونریزی پس از زایمان دریافت میمنظم یکبار آموزش ضمن خدمت و جلسات )16.18( داد/فرایندبرون -ای درمانی یوتروتونیک دریافت کردهنسبت تمام زنان با خونریزی پس از زایمان که در تسهیلات زایمانی داروه .0 )17.18(. *اند نسبت تمام زنان در تسهیلات زایمانی، با خونریزی پس از زایمان بعلت جفت محبوس مانده که برای آنها خارج .6 )81.18(. سازی دستی جفت توسط دستیار ماهر زایمانی انجام گرفته بود پیامد . *انددر تسهیلات زایمانی که بعلت خونریزی پس از زایمان مرده نسبت تمام زنان با خونریزی پس از زایمان .0 )81.61( )18.18(. اندسزارین که خون دریافت کرده به روشنسبت تمام زنان زایمان کرده در تسهیلات زایمانی .6 )81.18(. انداند و خون دریافت کردهنجام دادهانسبت تمام زنانی که در تسهیلات زایمانی زایمان واژینال .1 خونریزی ( انددر تسهیلات زایمانی که خونریزی شدید پس از زایمان داشته نسبت تمام زنان زایمان کرده .1 )71.01(. )سی یا هر نوع خونریزی به همراه کاهش فشار خون یا نیازمند تزریق خونسی 1110غیرطبیعی بیش از نی که بعلت خونریزی پس از زایمان شرایط نزدیک نسبت تمام زنان با خونریزی پس از زایمان در تسهیلات زایما .1 )71.77(. اندبه مرگ را تجربه کرده های ، مطابق با دستورالعملاندشده داشتهیا متوقف طول کشیده لیبر: زنانی که 1.1کیفیت یهبیان کنند.سازمان جهانی بهداشت مداخلات مناسب دریافت می باشد. لیبر متوقف شده تشخیص مادر و هم در نوزاد می درو مرگ و میر هم لیبر متوقف شده علت اصلی بیماری منطق: مادر شده و منجر به خطرات واژینال در-واژنی یا فیستول رکتال-ایتواند منجر به پارگی رحم، فیستول مثانهداده نشده می بررسی مناسب لیبر برای پیشگیری ی برای زایمان، آسفیکسی نوزادی، سندرم آسپیراسیون مکونیوم و سایر شرایط شود.زیاد تواند بروز این مشکلات را موقع لیبر متوقف شده میلات آن و تشخیص زودرس و اداره باز طول کشیدن لیبر و مشک کاهش دهد. با لیبر طول کشیدهو تشخیص سریع بوده فواصل چهار ساعته بامداخلات برای لیبر طول کشیده شامل معاینه واژینال هیدراسیون زن وضعیت لگنی و ارزیابی و اداره -پارتوگراف دارای خط عمل چهار ساعته، بررسی عدم تناسب سری استفاده از و در (توسین داخل وریدی ، تقویت لیبر با اکسیلگنی-عدم تناسب سری یاتاخیر در اولین مرحله باشند. در صورت می وکیوم یا (ومین مرحله لیبر با استفاده مناسب از زایمان ابزاری . تاخیر در د)ها سالم نباشند با آمنیوتومیصورتی که پرده -های لیبر متوقف شده مورد درمان قرار مییا بوسیله سزارین در صورت وجود شواهدی از آسیب جنینی یا نشانه )فورسپس گیرد. داشتن امکانات موجود، با لگنی و-تقویت لیبر فقط در موارد اثبات شده تاخیر در لیبر بعد از رد عدم تناسب سرینکته: باید مورد استفاده قرار هر اثر سوئی، و با توانایی ادارهبررسی منظم و مناسب ضربان قلب جنین و الگوی انقباض رحمی گیرد. های کیفیتگیریاندازه داددرون ارد که مطابق با روز برای پیشگیری و اداره لیبر طول کشیده دهای مکتوب و بهتسهیلات زایمانی دستورالعمل .0 )88.11(. *باشندهای سازمان جهانی بهداشت بوده و در واحدهای لیبر و زایمان موجود میدستورالعمل با وکیوم یا فورسپس، همچنین تجهیزات انجام شده های تسهیلات زایمانی وسایل ضروری و کافی برای زایمان .6 )11.11(. *ن از بخش مامایی موجود هستنداکه همیشه به تعداد کافی در واحد زایم احیا نوزاد دارد )10.11(. *واحد زایمان از بخش مامایی دارد تسهیلات زایمانی یک اتاق عمل مناسب مجهز نزدیک به .1 )11.78(. داردروز را ساعت 16تسهیلات زایمانی تعداد کافی از کارکنان ماهر برای انجام سزارین در تمام .1 حدهای لیبر و زایمان از بخش مامایی، آموزش ضمن خدمت و جلسات منظم کارکنان مراقبت سلامتی در وا .1 )10.68(کنند. در مورد اداره لیبر طول کشیده و متوقف شده دریافت می )هر شش ماه یکبار( بازآموزی داد/فرایندبرون هفته که با لیبر 71مساوی یا قلو سفالیک بزرگتر کجنین ت دارایزا در تسهیلات زایمانی نسبت همه زنان اول .0 )76.78(. )0 nosboRگروه ( خودبخود تحت سزارین قرار گرفتند . اندنسبت تمام زنان در تسهیلات زایمانی با لیبر طول کشیده یا متوقف شده که به روش سزارین زایمان کرده .6 )11.28( لیبر تحت زایمان واژینال ابزاری نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که بخاطر تاخیر در مرحله دوم .1 )06.18(. قرار گرفتند دقیقه از تصمیم برای انجام سزارین تحت سزارین 11نسبت زنان با لیبر طول کشیده یا متوقف شده که در عرض .1 )1.17(. اورژانسی قرار گرقتند -که برای تقویت لیبر اکسییبر در پیشرفت مرحله اول لاثبات شده نسبت تمام زنان در تسهیلات زایمانی با تاخیر .1 )21.17(. اندیافت کردهتوسین در ساعت طول 60نسبت همه زنان زایمان کرده در تسهیلات زایمانی که فاز فعال اولین مرحله لیبر آنها بیش از .2 )17.27(. کشیده است )68.17(. ده استنسبت همه زنان زایمان کرده در تسهیلات زایمانی که لیبر آنها در مرحله دوم طول کشی .7 پیامد )11.18(. انددچار پارگی رحم شدهنسبت همه زنان زایمان کرده در تسهیلات زایمانی که در طول لیبر .0 بعد از لیبر طول کشیده یا متوقف شده، اتفاق که های حول و حوش زایمان در تسهیلات زایمانی نسبت همه مرگ .6 )16.18(. افتاده است -ها، سفالفلج بازویی، شکستگی( های زایمانیه آسیبک لد شده در تسهیلات زایمانینسبت همه نوزادان متو .1 )17.18(. داشتند )هماتوم بعلت لیبر طول کشیده یا متوقف نسبت همه زنان با لیبر طول کشیده یا متوقف شده در تسهیلات زایمانی که .1 )1.17(. اندشرایط نزدیک به مرگ مادری را تجربه کردهشده، های سازمان جهانی : نوزادانی که تنفس خودبخود ندارند، مطابق با دستورالعمل5.1کیفیت یهانبی کنند.از تولد دریافت میپس بهداشت، تحریک مناسب و احیا با بگ و ماسک در عرض یک دقیقه و همچنین ده های نوزادی در طول هفته اول زندگی بوآسفیکسی حین تولد یکی از علل منجر شونده به مرگمنطق: تواند با احیا موثر و مناسب نوزادانی که در زمان تولد تنفس ندارند، باشد؛ که میمدت و مرگ میمسئول اختلال عصبی دراز قابل پیشگیری باشد. شود. کنند، پشتشان دو یا سه بار برای تحریک اضافی مالیده میکردن خودبخود تنفس نمینوزادانی که بعد از خشک شود که نوزاد آسپیراسیون مکونیوم داشته یا ترشحات دهان یا بینی دارد. تهویه با فشار در صورتی استفاده میساکشن فقط هفته و با اکسیژن 61دقیقه اول تولد برای نوزادان بالای ماسک خودبخود باد شونده با هوا در مثبت با استفاده از بگ و قلب، حرکت قفسه سینه و گیری ضربان ود. کفایت تهویه بوسیله اندازهشهفته شروع می 61برای نوزادان زودرس زیر ٪11 شود که ضربان قلب پس غلظت بالاتر اکسیژن فقط در صورتی داده میشود. ارزیابی می )در صورت وجود( متریاکسیپالس بار در دقیقه باشد. 12ثانیه احیا زیر 12از های کیفیتگیریزهاندا داددرون شونده در خود باددی حداقل در دو سایز و یک بگ خودبهمانی دستگاه ساکشن همراه با ماسک نوزاتسهیلات زای .0 )18.11(. *دارواحدهای زایمان و نوزادی از بخش مامایی د های سازمان جهانی بهداشت، برای اداره روز، مطابق با دستورالعملمکتوب و بههای تسهیلات زایمانی دستورالعمل .6 )28.01(. *دارکشند، در واحدهای زایمان از بخش مامایی دخودبخود نفس نمینوزادانی که همه کارکنان مراقبت سلامتی که در تسهیلات زایمانی از زنان حامله، زنان در مرحله پس از زایمان و نوزادان .1 بگ و استفاده از سازی تهویه با فشار مثبت باطوری که بوسیله شبیههمان( کنند در احیا پایه نوزادمراقبت می )12.18(. مهارت دارند )نشان داده شده است ماسک بر روی مدل ماه یکبار آموزش ضمن 60کارکنان مراقبت سلامتی در واحدهای زایمان و نوزادی از بخش مامایی حداقل هر .1 )21.78(. کنندخدمت و جلسات منظم بازآموزی در مورد احیا پایه نوزاد دریافت می سازی ی هر ماه تمرینات آموزشی یا شبیهقبت سلامتی در واحدهای زایمان و نوزادی از بخش مامایکارکنان مرا .1 )01.18(. کنندحمایتی در مورد احیا پایه نوزاد دریافت می نظارتشده و داد/فرایندبرون از تحریک اضافی نسبت همه نوزادنی که در تسهیلات زایمانی تحت احیا با بگ و ماسک قرار گرفته بودند و بعد .0 )10.08(. تنفس خودبخودی نداشتند نسبت همه نوزادنی که در تسهیلات زایمانی تحت احیا با بگ و ماسک در عرض یک دقیقه پس از تولد قرار .6 )21.17(. گرفته بودند و بعد از تحریک اضافی تنفس خودبخودی نداشتند پیامد در تسهیلات زایمانی با عدم )هفته 71املگی مساوی یا بیشتر از سن ح(نسبت همه نوزادان زنده متولد شده در ترم .0 )10.01(. *)مرگ زودرس نوزادی(ناهنجاری مادرزادی بزرگ که در عرض هفت روز بعد از تولد مردند در تسهیلات زایمانی که )هفته 71سن حاملگی مساوی یا بیشتر از (نسبت همه نوزادان زنده متولد شده در ترم .6 )21.17(خود نداشتند اما پنج دقیقه بعد از احیا تنفس خودبخود داشتند. تنفس خودب و نوزادشان مطابق با مناسب برای خودزودرس مداخلات الف: زنان با لیبر6.1کیفیت یهبیان کنند. یافت میهای سازمان جهانی بهداشت دردستورالعمل کودک شود که سبب خطرات زیادی برای سلامتیواند منجر به تمی )هفته کامل حاملگی 71قیل از ( لیبر زودرسمنطق: شود. پیشگیری از لیبر زودرس و اداره مناسب لیبر زودرس قریب الوقوع، جهت کاهش میکودک تولد زودتر از موقعافزایش ستند.خطرات مرتبط برای کودک، پیشگیری از مشکلات قابل پیشگیری و بهبود پیامد و حیات کودکان زودرس ضروری ه اره نوزادان زودرس و مشکلات آنها، انجام یک شوند که توانایی ادتسهیلاتی پذیرش میمراکز در ،زنان با لیبر زودرس ها و علائم از نظر نشانهارزیابی ارزیابی کامل و بررسی برای اثبات سن حاملگی بوسیله سونوگرافی یا زمان آخرین قاعدگی، .را داشته باشند تواند با تاخیر انجام شودقریب الوقوع است یا می آیا زایمان اینکهعفونت و بررسی حاملگی 11-16های زایمان در هفته بودن بعد از رد کوریوآمنیونیت، کورتیکواستروئید قبل از زایمان در موارد قریب الوقوع 61در موارد زایمان زودرس زیر قبل از زایمانمنیزیوم سولفات شود.داده می )در صورت مناسب بودن( به همراه توکولیز بیوتیک داده ها آنتیشود. به زنان با پارگی پیش از موعد و زودرس پردههفته برای حفظ جنین از مشکلات عصبی داده می شود.می های کیفیتگیریاندازه داددرون های زایمان از بخش مامایی روز برای اداره لیبر زودرس در واحدهای مکتوب و بهتسهیلات زایمانی دستورالعمل .0 )21.01(. *دنباشهای سازمان جهانی بهداشت میدارد که مطابق با دستورالعمل ها و بیوتیک، آنتی)دگزامتازون یا بتامتازون( ایمانزتسهیلات زایمانی ذخایری از کورتیکواستروئیدهای قبل از .6 های سازمان یمان زودرس، مطابق با دستورالعملدارد که همیشه به تعداد کافی برای اداره زامنیزیوم سولفات )21.11(. *جهانی بهداشت موجود هستند ماه یکبار آموزش ضمن خدمت و جلسات منظم 60کارکنان مراقبت سلامتی در واحد مامایی، حداقل هر .1 )61.18(. کنندبازآموزی در مورد اداره لیبر زودرس دریافت می حمایتی در نظارتسازی شده و ها یا تمرینات شبیهماهانه آموزش ماماییکارکنان مراقبت سلامتی در واحد .1 )80.17(. کننددریافت میرا مورد اداره لیبر زودرس داد/فرایندبرون حاملگی در تسهیلات زایمانی که مادرانشان در صورت 11و 16های نسبت همه نوزادان به دنیا آمده بین هفته .0 )00.28(اند. کردهدوز کورتیکواستروئید قبل از ازیمان دریافت وجود اندیکاسیون حداقل یک حاملگی در تسهیلات زایمانی که مادرانشان برای حفظ 61نسبت همه نوزادان به دنیا آمده قبل از هفته .6 )61.87(. انددریافت کردهمنیزیوم نوزادشان از مشکلات عصبی جنینی سولفات بیوتیک یلات زایمانی زایمان کرده و آنتیها که در تسهوعد و زودرس پردهنسبت همه زنان با پارگی پیش از م .1 )12.78(. اندپیشگیرانه دریافت کرده پیامد بیوتیک یلات زایمانی زایمان کرده و آنتیها که در تسهنسبت همه زنان با پارگی پیش از موعد و زودرس پرده .0 )12.78(. *اندپیشگیرانه دریافت کرده حاملگی در تسهیلات زایمانی که با 11تا 16های هفته درکودکان در معرض خطر تولد نسبت تمام .6 )02.17(. اندکورتیکواستروئید قبل از زایمان مواجه شده حاملگی یا بالاتر در تسهیلات زایمانی که با 11 نسبت تمام کودکان در معرض خطر تولد در هفته .1 )11.67(. اندشدهکورتیکواستروئید قبل از زایمان مواجه های سازمان جهانی بهداشت، ب: کودکان زودرس و کوچک، مطابق با دستورالعمل6.1کیفیت یهبیان کنند.مراقبت مناسب دریافت می و دیررس برای مرگ دوره نوزادی و مشکلات سلامتی زیادیکودکان زودرس و کوچک در معرض خطر بسیار منطق: دیده که در تمام مدت توسط کارکنان خوب آموزشند. آنها باید در واحدهای نوزادی مجهز ناتوانی در تمام عمر قرار دار حضور دارند، مراقبت شوند. شوند و دقیقا برای مشکلات در تمام مدت گرم نگه داشته می )گرم 1116کمتر از (کودکان زودرس و با وزن کم زمان تولد )دوشیدن شیر پستان، شیر اهدایی یا شیر خشک(صاری یا تغذیه جایگزین شوند، مادرانشان در مورد شیردهی انحبررسی می گرم مورد مراقبت کانگروئی 1116با علائم حیاتی ثابت با وزن مساوی یا زیر گیرند. نوزادان زودرسمورد حمایت قرار می گیرند و دمای مورد مراقبت قرار می گیرند. نوزادانی که علائم ثابتی ندارند در انکوباتور تمیز یا زیر بخاری تابشیقرار می کاهش دمای بدن، مشکلات تغذیه، قطع تنفس، سندرم زجر (شود. خطر مشکلات معمول بدنشان زود به زود بررسی می -بیوتیک، آنتیشوند. در صورت لزومسریعا ارزیابی، بررسی و تشخیص داده شده و بطور مناسبی اداره می )هاتفسی و عفونت شود.مانی ایمن، فشار مثبت مداوم راه هوایی و سورفکتانت جایگزین داده میها، اکسیژن در های کیفیتگیریاندازه داددرون روز برای مراقبت از نوزادان کوچک و زودرس در واحدهای مکتوب و بههای تسهیلات زایمانی دستورالعمل .0 )01.01(. *باشدان جهانی بهداشت میهای سازماز بخش مامایی دارد که مطابق با دستورالعمل یزایمان کردن مراقبت حرارتی خوب برای نوزادان زودرس ثابت و زایمانی ذخایر و موادی جهت فراهمتسهیلات .6 ، )هاهای کودک، جوراببندهای حمایتی، کلاه(دارد که شامل مراقبت کانگروئی حیاتی غیرثابت از نظر علائم )10.18(. *ی هستندهای تابشانکوباتورهای تمیز و بخاری کردن تغذیه مناسب برای نوزادان زودرس دارد و از شیردهی با زایمانی ذخایر و موادی جهت فراهمتسهیلات .1 شامل شیردهی با فنجان یا قاشق، شیرخشک نوزادی، شیردوش، امکانات ذخیره شیر، (پستان یا تغذیه جایگزین ای، سرنگ، مایعات داخل وریدی و لوله معده-های بینیپاستوریزه کردن، در صورت امکان بانک شیر، لوله )21.28( کند.حمایت می )گذاری کنند، حداقل هر کارکنان مراقبت سلامتی که با زنان حامله، زنان در مرحله پس از زایمان و و نوزادان کار می .1 های زودرس و با بچهماه یکبار، آموزش ضمن خدمت و جلسات منظم بازآموزی در مورد مراقبت مناسب از 60 )68.18(. کنندوزن کم زمان تولد دریافت می داد/فرایندبرون وزن زمان تولد مساوی و کمتر از (نسبت تمام نوزادان متولد شده در تسهیلات زایمانی با وزن کم زمان تولد .0 )11.18(. اندکه در اولین هفته زندگی مراقبت مداوم کانگروئی دریافت کرده )گرم 1116 که )گرم 1116وزن مساوی و کمتر از (نسبت همه نوزادان با علایم حیاتی ناپایدار و با وزن کم زمان تولد .6 بطور مناسب در یک محیط حرارتی خنثیکه ،توانند در تسهیلات زایمانی مراقبت کانگروئی دریافت کنندنمی )16.17(. قرار گرفته بودندهای تابشی یا انکوباتورها حتی زیر بخاری نسبت همه نوزادان متولد شده در تسهیلات زایمانی با وزن کم زمان تولد که مادرشان تحت حمایت مضاعف .1 )10.77(است. برای شروع شیردهی قرار گرفته پیامد متولد شده در )حاملگی 71-61های ، و هفته61-86های هفته، هفته 86زیر (نسبت همه نوزادان زودرس .0 )10.11(. *انددر هفت روز اول زندگی مرده تسهیلات زایمانی که نسبت همه نوزادان متولد شده در تسهیلات زایمانی با وزن کم زمان تولد که در طول اقامتشان در تسهیلات .6 )71.18(اند. زایمانی بصورت انحصاری با شیر مادر تغذیه شده مانند سندرم زجر (بیماری شدید نوزادی نسبت همه نوزادان زودرس زنده متولد شده در تسهیلات زایمانی که .1 )16.08(داشتند. )تنفسی، خونریزی داخل مغزی، انتروکولیت نکروزان نسبت مرگ همه نوزادان متولد شده در تسهیلات زایمانی با وزن کم زمان تولد که مرگشان به عفونت احتمالی .1 )11.18(باکتریال یا سپسیس نسبت داده شده است. های عفونت یا در معرض خطر عفونت، مطابق با دستورالعمل مبتلا بهالف: زنان 1.1کیفیت یهبیان سازمان جهانی بهداشت، در طول لیبر، زایمان یا دوره اولیه پس از زایمان سریعا مداخلات مناسب کنند.دریافت می دان سپسیس زودرس در نوزاتواند سبب شروع سپسیس زایمانی یکی از علل بیماری در مادر بوده و همچنین میمنطق: -صحیح و استفاده از آنتی و سریعکننده، انجام استریل تمام مداخلات و فرایندها، تشخیص شود. پیشگیری از عوامل مستعد ایجاد سپسیس در مادر و نوزاد و مرگ و میر و بیماری مرتبط را کاهش ،های مناسب برای درمان عفونت مادریبیوتیک خواهد داد. های پاره شده، در موارد خواسته یا اورژانسی قرار بگیرند، در لیبر طول کشیده با پردهه زنان تحت سزارین خوددر صورتی ک به زنان در معرض سازی دستی جفت، وم و چهارم پرینه یا قبل از خارجهای درجه سجفت محبوس شده، در موارد پارگی قبل از شروع بیوتیکی ها برای کشت و تعیین حساسیت آنتیونهنمشود. های پیشگیرانه داده میبیوتیکخطر عفونت آنتی درجه قبل از زایمان یا در طول زایمان، 81تب بالای (ها و علایم عفونت آیند. زنان با نشانهبه دست میبیوتیکی درمان آنتی و درد دشکمی و/یا ترشح یا مایع آمنیوتیک چرکیمایع آمنیون ساعت، بوی متعفن 80ها مساوی یا بیشتر از پارگی پرده بطور آنهاو اداره قرار گرفتهبررسی مورد ها درمان شده و دقیقا بیوتیکبا آنتی )واژینال ناخوشایند در دوره پس از زایمان شود.مرتب ارزیابی می های کیفیتگیریاندازه داددرون سیلین و سیلین یا پنیمانند آمپی(و تزریقی های خط اول و دوم خوراکی بیوتیکلات زایمانی ذخایری از آنتیتسهی .0 دارد که همیشه به تعداد کافی برای موارد مورد انتظار )جنتامایسین، کلیندامایسین، سفالوسپورین و مترونیدازول )10.61(. *موجود هستند یا در معرض خطر به عفونت روز برای درمان زنان مبتلاشده و بههای بالینی نوشتهتسهیلات زایمانی دستورالعمل .6 عفونت در طول لیبر، زایمان و دوره اولیه پس از ایمان در واحدهای زایمان و پس از زایمان از بخش مامایی دارد )17.01(. *دنباشهای سازمان جهانی بهداشت میدستورالعمل طبقکه کنند، س از زایمان کار میکارکنان مراقبت سلامتی در تسهیلات زایمانی که با زنان حامله و زنان در مرحله پ .1 های ضمن خدمت و جلسات منظم بازآموزی در مورد تشخیص و اداره عفونت ماه یکبار، آموزش 60حداقل هر )16.18(. کنندحول و حوش زایمان دریافت می اد/فراینددبرون های پیشگیرانه دریافت بیوتیکانی که قبل از جراحی سزارین آنتینسبت همه زنان سزارین شده در تسهیلات زایم .0 )71.11(. *اندکرده بیوتیک دریافت ها که آنتینسبت همه زنان زایمان کرده در تسهیلات زایمانی با پارگی زودرس و قبل از موعد پرده .6 )11.78(. اندکرده . اندهبیوتیک دریافت کردای درجه سه و چهار پرینه که آنتیهنسبت همه زنان در تسهیلات زایمانی با پارگی .1 )11.18( های عفونت که نسبت همه زنان در حال زایمان یا زنان در مرحله پس از زایمان در تسهیلات زایمانی، با نشانه .1 )11.18(. اندبیوتیک تزریقی دریافت کردهآنتی های عفونتدرجه یا سایر نشانه 81نسبت همه زنان زایمان کرده در تسهیلات زایمانی که دمای بدنی بالای .1 )78.68(بعد از زایمان را داشتند. )لوشیای بدبو یا چرکی( پیامد نسبت تمام زنان سزارین شده در تسهیلات زایمانی که عفونت سیستمیک شدید یا سپسیس بعد از جراحی سزارین .0 )21.28(. داشتند دوره پس از زایمان نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که عفونت سیستمیک شدید یا سپسیس در .6 )10.28(. داشتند های سازمان جهانی بهداشت، به نوزادان مشکوک به ب: مطابق با دستورالعمل1.1کیفیت یهبیان شود.بیوتک درمانی داده مییا در معرض خطر عفونت سریعا آنتیعفونت -عفونت هستند. عفونت در نوزادان می شان در معرض خطر زیادی براینوزادان بخاطر سیستم ایمنی تکامل نیافتهمنطق: بهداشت مناسب دست، مراقبت از بندناف و سایر شان شود. های طولانی مدت در زندگیتواند منجر به مرگ یا ناتوانی مناسب، غربالگری نوزادان از نظر سپسیس بر اساس حضور یک یا تعداد بیشتری عامل خطر، کردن عفونیتوجهات به ضد ها برای پیشگییری از سپسیس و مرگ و بیوتیکیس نوزادی و درمان مناسب با آنتیها و علائم سپسنهتشخیص زودتر نشا باشد. میر و بیماری مربوطه ضروری می بیوتیک آنتیهای عفونت، عوامل خطر عفونت یا با نشانه داراینوزادان های سازمان جهانی بهداشت، مطابق دستورالعمل ایمان یا در طول لیبر، پارگی زدرجه قبل از 81بالای امل خطر برای عفونت شامل تب مادرعوکنند. درمانی دریافت می های نشانه دارای. نوزادان باشندمیساعت قبل از زایمان و بوی بد یا مایع منیوتیک چرکی 80ها مساوی یا بیشتر از پرده تو ، )بار در دقیقه 12بالای (سریع ، لرز، تنفس )خوبیا توقف در تغذیه (با ناتوانی در تغذیه ،عفونت باکتریایی شدید حالی، حرکت فقط در بی ،)درجه 11زیر (یا دمای پائین بدن )درجه 81مساوی یا بالای (کشیدگی قفسه سینه شدید، تب های انهیا با نشعفونت نوزادان در معرض خطر از ،بیوتیکشوند. قبل از شروع آنتیموقع تحریک یا عدم حرکت مشخص می سپسیس یا مشکوک به درمان بیوتیک تزریقی تجربی برای یک آنتی با این نوزادانشود. عفونت، کشت خون گرفته می ری در مورد گیای برای تصمیمپایه ،شوند. نتایج کشتشوند و برای ارزیابی درمانشان دقیقا بررسی میسپسیس درمان می ل مدت درمان هستند.ها و طوبیوتیکهر نوع تغییر در نوع آنتی های کیفیتگیریاندازه داددرون های خط اول و دوم برای سپسیس بیوتیکحداقل آنتی(های تزریقی بیوتیکمانی ذخایری از آنتیتسهیلات زای .0 )10.61(. *انتظار موجود هستند قابلکه همیشه به تعداد کافی برای موارد دارد )نوزادی و مننژیت ن جهانی بهداشت، ازماهای سروز، مطابق با دستورالعملمکتوب و بههای بالینی دستورالعملتسهیلات زایمانی .6 )71.11(. *داردو اداره عفونت نوزادی در واحدهای زایمان از بخش مامایی سریعبرای تشخیص نوزادان مراقبت کارکنان مراقبت سلامتی در تسهیلات زایمانی که از زنان حامله و زنان در مرحله پس از زایمان و .1 های ضمن خدمت و جلسات منظم بازآموزی در مورد تشخیص و اداره ماه یکبار، آموزش 60کنند، حداقل هر می )11.18(. کنندهای مشکوک نوزادی دریافت میعفونت های سپسیس نوزادی و چگونگی درمان آن را، مطابق با کارکنان مراقبت سلامتی در تسهیلات زایمانی نشانه .1 )16.18(. دانندهای سازمان جهای بهداشت، میتورالعملدس داد/فرایندبرون . اندهای تزریقی دریافت کردهبیوتیکفونت در تسهیلات زایمانی که آنتیهای عنسبت همه نوزادان با نشانه .0 )11.28( های تزریقی بیوتیکتیفونت در تسهیلات زایمانی که آنهای عمادران با نشانهمتولد شده از نسبت همه نوزادان .6 )11.77(. انددریافت کرده پیامد . *)میزان کشندگی موردی( اندفوت کردهنسبت نوزادان درمان شده بعلت سپسیس در تسهیلات زایمانی که .0 )61.18( )21.28(. های نوزادی در تسهیلات زایمانی که بعلت سپسیس بوده استنسبت همه مرگ .6 )11.77(. در تسهیلات زایمانی که بعلت سپسیس نوزادی بوده است دید نوزادیبیماری شموارد نسبت تمام .1 مراقبتی که شامل توجهات استاندارد برای پیشگیری از ،: همه زنان و نوزادان8.1کیفیت یهبیان کنند.باشد، دریافت میهای بیمارستانی میعفونت د. ندهمراقبت و طول مدت اقامت در بیمارستان را افزایش میمیر، هزینه وهای بیمارستانی بیماری و مرگفونتعمنطق: های بیمارستانی ضروری هستند.توجهات استاندارد برای پیشگیری از عفونت آب و صابون یا مالش دست استفاده از بهداشت دست با رعایت شود که شامل ها مشاهده میتوجهات استاندارد در همه زمان و انهدام ایمن وسایل عفونی و ذخیره، نوزاد و استفاده مناسب از دستکشو بعد از معاینه زن یا با محلول بر پایه الکل قبل باشد. زدایی تجهیزات و سطوح زایمان میتیز، استفاده ایمن از تجهیزات مراقبت از بیمار و ملحفه آلوده، استریل و عفونت های کیفیتگیریاندازه داددرون یا محلول مالش دست بر )ترجیحا قابل انهدام(، صابون و حوله دسترسب قابل اعتماد در تسهیلات زایمانی منبع آ .0 )76.11(. *پایه الکل برای بهداشت دست دارد )81.11(. *مطمن است زائد عفونی، ذخیره و انهدام نهایی مواد نگهداریتسهیلات زایمانی از .6 . *باشده و انهدام نهایی وسایل دور ریختنی تیز مطمئن میتسهیلات زایمانی از کاربرد ایمن، نگهداری وسایل برند .1 )21.11( )11.61(. تسهیلات زایمانی امکانات استرلیزااسیون و ضدعفونی کردن مناسب تجهیزات را دارد .1 را سازی وسایل استفاده شده و عفونی های مناسب برای پاکسوز یا سایر روشتسهیلات زایمانی دستگاه زباله .1 )21.61(. دارد در مورد انتقال اتروز برای کنترل عفونت استاندارد و احتیاطمکتوب و بههای تسهیلات زایمانی دستورالعمل .2 )11.61(. عفونت دارد ماه یکبار، آموزش ضمن 60کارکنان مراقبت سلامتی در واحدهای زایمان و نوزادان از بخش مامایی، حداقل هر .7 )76.78(. در مورد انتقال عفونت دارند اتو احتیاطرد استانداخدمت در مورد کنترل عفونت داد/ فرایندبرون اجزا «درصد کارکنان مراقبت سلامتی در تسهیلات زایمانی که دستهایشان را بطور صحیح بر اساس ابزار بررسی .0 )87.78(کنند. تمیز می »گانه بهداشت دست سازمان جهانی بهداشتپنج )27.18(. کنندبیوتیکی مناسب دریافت مینت باکتریایی شدید که درمان آنتیونسبت نوزادان مشکوک به عف .6 )17.68(. مراقبت سلامتی از نقطه تولید تا نقطه انهداممرکز زائداداره ایمن وسایل .1 درصد کارکنان مراقبت سلامتی در تسهیلات زایمانی که استانداردهای ایمنی مواد شیمیایی را در زمان تجویز .1 )18.08(. کنندی غیرخوراکی رعایت میداروها پیامد شدید یا سپسیس ، عفونت سیستمیککرده در تسهیلات زایمانی که در دوره پس از زایماننسبت تمام زنان زایمان .0 )01.08(. اندزایمان بستری مجدد شده ازبعد وداشتند )11.87(. اندشدهمبتلا له از بیمارستانی کرده در تسهیلات زایمانی که به عفونت منتقنسبت تمام زنان زایمان .6 )11.87(. اندشدهمبتلا نسبت تمام نوزادان متولد شده در تسهیلات زایمانی که به عفونت منتقله از بیمارستانی .1 مورد هدف اعمال : هیچ زن و نوزادی در طول لیبر، زایمان و دوره اولیه پس از زایمان1.1کیفیت یهبیان گیرد.قرار نمی غیرضروری یا مضر این اعمال باید از تواند منجر به مشکلات و آسیب به مادران و نوزادانشان شود. ضروری یا مضر میاعمال غیر منطق: جلوگیری شده و با عملکردهای بر پایه شواهد جایگزین شوند. انمای روتین و اصلاح عمال شاملاین ا شوند.گیرند یا بکار گرفته نمیضروری یا مضر مورد استفاده قرار نمیاعمال غیر توسین ر، تقویت لیبر با اکسیو پرینه قبل از زایمان واژینال، فشار بر قله رحم برای تسهیل مرحله دوم لیب موهای پوبیس موارد ضروری، سزارین مگر در موارد ضروری و ساکشن ترشحات تومی مگر درازی، انجام اپیطول کشیده لیبر قبل از اثبات های شیر مادر یا داری نوزادان دور از مادر، تبلیغ و گسترش جایگزینارد ضروری، حمام فوری نوزاد، نگهگر در مونوزاد م .باشندمیتغذیه با بطری و استفاده از موادی برای تمیز کردن بند ناف های کیفیتگیریاندازه داددرون زا و مداخلات غیرضروری در طول لیبر، اعمال آسیب روز در موردمکتوب و بههای تسهیلات زایمانی دستورالعمل .0 )11.18(. *زایمان و دوره اولیه پس از زایمان دارد بر روی پوستر و پلاکارد تبلیغ را بطری و پستانکاستفاده از یا برای نوزادتسهیلات زایمانی استفاده از شیر خشک .6 )81.88(. *کندنمی اسیون طبی، و به دهد مگر در صورت اندیکشیر مادر غذا یا نوشیدنی نمیتسهیلات زایمانی به نوزادان، غیر از .1 )10.18(. دهدنمی )شودکه پستانک هم نامیده می(کن کودکان شیرمادرخوار آرام ماه یکبار، آموزش ضمن خدمت و جلسات منظم بازآموزی در 60سلامتی در تسهیلات، حداقل هر کارکنان مراقب .1 )11.18(. کنندو اعمال مضر دریافت میزا مورد مداخلات آسیب بین مادران یا کارکنان پخش ها و نمونه کندتشویق نمیها شیرخشک را در بخشاستفاده از تسهیلات زایمانی .1 )11.68(. شوندنمی نظارت حمایتی و مشاوره در مورد مداخلات غیرضروری و هر ماهکارکنان مراقبت سلامتی در تسهیلات زایمانی .2 )81.17(. کنندزا دریافت میآسیب اعمال داد/فرایندبرون تومی انجام شده ازیهای واژینال خودبخود و بدون مشکل در تسهیلات زایمانی که با برش اپینسبت تمام زایمان .0 )821.0(. *است )6.18(. اندسزارین شده nosboRبندی های طبقهنسبت تمام زنانی که در تسهیلات زایمانی مطابق با گروه .6 تقویت لیبر دریافت ،تاخیر در پیشرفت لیبرداشتن کرده در تسهیلات زایمانی که بدون نسبت تمام زنان زایمان .1 )01.18(اند. کرده دریافت هنگام رف شش ساعت از تولدشان، حمام زودنسبت تمام نوزادان متولد شده در تسهیلات زایمانی که ظ .1 )11.17(. شان پاک شده استو ورنیکساند کرده کرده در تسهیلات زایمانی که بطور روتین قبل از زایمان واژینال اصلاح موهای ناحیه نسبت تمام زنان زایمان .1 )11.77(. اندپوبیس و پرینه داشته 2. مامت تبسندلوتم نادازون رارق نشکاس تحت نیتور روطب هک نشور کیتوینمآ عیام اب ینامیاز تلایهست رد هدش هتفرگدنا .(77.11) 7. نامیاز نانز مامت تبسن تفایرد نیتور یامنا لانیژاو نامیاز زا لبق ینامز ره رد هک ینامیاز تلایهست رد هدرک هدرک دنا .(72.16) درادناتسا رد هدافتسا دروم عبانم1  Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014;384:347–370.  Boulkedid R, Sibony O, Goffinet F, Fauconnier A, Branger B, Alberti C. Quality indicators for continuous monitoring to improve maternal and infant health in maternity departments: a modified Delphi survey of an international multidisciplinary panel. PLoS One 2013;8:e60663.  Gülmezoglu MA, Lawrie TA. Impact of training on emergency resuscitation skills: impact on Millennium Development Goals (MDGs) 4 and 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10.1016/j.bpobgyn.2015.03.018.  Hussein J, Mavalankar DV, Sharma S, D’Ambruoso L. A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality. Globalization Health 2011;7:14.  Khaskheli MN, Baloch S, Sheeba A. Risk factors and complications of puerperal sepsis at a tertiary healthcare centre. Pak J Med Sci 2013;29:972–976.  National Institute for Health Care Excellence. NICE guidelines on routine intrapartum care (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth- pdf).  Polin RA, Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Paediatrics 2012;129:1006 –1015.  Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet 2011;114:4–9.  Schuchat A, Zywicki SS, Dinsmoor MJ, Mercer B, Romaguera J, O’Sullivan MJ, et al. Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicentre case-control study. Pediatrics. 2000;105:21–26.  Sibanda T, Fox R, Draycott TJ, Mahmood T, Richmond D, Simms RA. Intrapartum care quality indicators: a systematic approach for achieving consensus. Eur J Obstet Gynecol Reprod Biol 2013;166:23–29.  Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, et al. Improving quality of care for maternal and newborn health: prospective pilot study of the WHO safe childbirth checklist program. PLoS One 2012;7:e35151.  Tietjen L, Bossemeyer D, McIntosh N. Infection prevention guidelines for healthcare facilities with limited resources. Baltimore, Maryland: JHPIEGO; 2003.  World Health Organization. International code of marketing of breast-milk substitutes. Geneva; 1981 (http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/).  World Health Organization. Standard precautions in health care: aide-memoire. Geneva; 2007 (http:// www.who.int/csr/resources/publications/EPR_AM2_E7.pdf).  World Health Organization. WHO guidelines on hand hygiene in health care. Geneva; 2009 (http://www.who.int/gpsc/information_centre/hand-hygiene-2009/en/).  World Health Organization. Evaluating the quality of care for severe pregnancy complications. The WHO near-miss approach for maternal health. Geneva; 2011 (http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf).  World Health Organization. WHO recommendations for the prevention and treatment of pre-eclampsia/eclampsia. Geneva; 2011 (http://apps.who.int/iris/bitstream/10665/44703/1/9789241548335_eng.pdf).  World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva; 2012 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241 548502/en/).  World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines recommendationsnewborn-health.pdf).  World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on maternal and perinatal health. Geneva; 2013 (http://www.who.int/maternal_child_adolescent/documents/guidelinesrecommendations- maternal-health.pdf?ua=1).  World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva, 2013 (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/).  World Health Organization. Safe management of wastes from health-care activities Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1).  World Health Organization. WHO recommendations for augmentation of labour. Geneva; 2014 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmenta tion-labour/en/).  World Health Organization. The role of WHO in public health. Geneva; 2015 (http://www.who.int/about/role/en/).  World Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. Geneva; 2015 (http://who.int/reproductivehealth/publications/maternal_perinatal_health/preterm-birth- guideline/en/).  World Health Organization, Partnership for Maternal, Newborn and Child Health. Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities. Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf).  World Health Organization, UNICEF. Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva; 2009 (http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse/en/).  World Health Organization, UNICEF. Indicators for assessing health facility practices that affect breastfeeding. Geneva; 1993 (http://apps.who.int/iris/handle/10665/62140).  World Health Organization Regional Office for Europe. Making pregnancy safer: assessment tool for the quality of hospital care for mothers and newborn babies. Copenhagen; 2009 (http://www.euro.who.int/__data/assets/pdf_file/0008/98792/E93128.pdf).  World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn- health/publications/2014/hospital-care-formothers-and-newborn-babies-quality- assessment-andimprovement-tool.pdf?ua=1). تفاده از اطلاعات برای اطمینان از : سیستم اطلاعاتی سلامت ما را به اس1استاندارد سازد.و مناسب برای بهبود مراقبت از هر زن و نوزادی قادر می سریعواکنش : هر زن و نوزادی در طول لیبر، زایمان و دوره اولیه پس از زایمان، ثبت پزشکی 1.1کیفیت یهبیان کامل، صحیح و استاندارد دارد. سریع درست، تعیین لیبر، برای مراقبت ثبت شده، پیگیری بالینی، تحویل ثبت پزشکی کامل و صحیح در طول منطق: کند.فراهم می طلاعاتی برای تشخیص نواحی نیازمند بهبودمشکلات و پیامدهای سلامتی مهم است و ا از زمان د، که صحیح، کامل و قابل دستیابی هستنشود و اسناد بالینی مادران و نوزادان مراقبت استاندارد از بیمار ثبت می مانند یادداشتهای ارجاع، اسناد مراقبت قبل از (. مراقبت ثبت شده مداوم مانندپذیرش تا زمان ترخیص در محل باقی می اجتماعی، زمان پذیرش، زایمان و ترخیص، پیشرفت لیبر، اعمال -موجود هستند. اطلاعات فردی )زایمان و هنگام زایمان شوند. جزئیات اطلاعات نوزادی مانند تعیین هویت، مرگ هنگام تولد بطور مناسبی ثبت می انجام گرفته و پیامد زایمان مانند هاپروندهدر همه را زنان و نوزادانشان ارتباطشوند که های معاینه در سیستمی ثبت میسن حاملگی، وزن زمان تولد و یافته گیرد.مورد استفاده قرار میای تشخیص کد بر )DCI( هابندی بین المللی بیماری. طبقهسازندپذیر میامکان های کیفیتگیریاندازه داددرون ،هازمان یدر تمام ،ایهای بالینی و مشاهدهآوری اطلاعات، منحنیها و جمعنامهای ثبتفرمتسهیلات زایمانی .0 )11.11(. *داردرا از زنان و نوزادان و بررسی همه فرایندهای مراقبت برای ثبت روتین )11.18(. *ها به سیستم ثبت ملی وصل استزمان همهتسهیلات زایمانی سیستم ثبت تولد و مرگ دارد که در .6 DCIکه همسو با از جمله مرگ داردها و پیامدهای تولد بندی بیماریسهیلات زایمانی سیستمی برای طبقهت .1 )11.28(. باشدمی داد/فرایندبرون . *طبی فردی دارند-بالینی و سند شناسه بیماریک د در تسهیلات زایمانی که نسبت همه نوزادان اخیرا موجو .0 )10.18( ساعت گذشته که یک ثبت اخیر کامل از فرایندهای 16نسبت همه نوزادان ترخیص شده از تسهیلات زایمانی در .6 )86.18(داشتند. )DCIبر اساس کد (ها مراقبت، درمان، پیامدها و تشخیص ساعت گذشته که یک ثبت اخیر کامل از فرایندهای 16شده بعد از زایمان در طول ترخیص نسبت همه زنان .1 )88.68(داشتند. )DCIبر اساس کد (ها مراقبت، درمان، پیامدها و تشخیص آوری هایش مکانیسمی برای جمع: هر تسهیلات زایمانی بعنوان بخشی از فعالیت1.1کیفیت یهبیان در مرحله حول و حوش زایمان شو بازخورد برای بررسی و بهبود عملکردتحلیل -اطلاعات، تجزیه دارد. تواند مورد تجزیه تحلیل قرار بگیرد و بطور مناسب کردن اطلاعاتی است که میها، فراهمآوری دادههدف از جمع منطق: برای ایجاد بازخورد و بهبود پیامدهای سلامتی مورد استفاده قرار گیرد. ریزی و بهبود خدمات بالینی جهت ایجاد یل شده و بطور روتین برای برنامهتحل-آوری، تائید و تجزیهعاطلاعات، جم گیرند. اطلاعات موجود هستند و توسط کارکنان تسهیلات برای بهبود مداوم تصمیمات بالینی و اداره مورد استفاده قرار می زشکان، ماماها، پرستاران، سرپرستان و مربیان برای طراحی و بهبود گیرند و توسط پفرایندهای مراقبت مورد استفاده قرار می -می ارسالسطوح مناسب بهزمان گیرند. اطلاعات صحیح و کامل به مرور ها و خدمات بالینی مورد استفاده قرار میفعالیت د. گیرنای بیماری و مرگ و میر جهت بهبود کیفیت مورد استفاد قرار میدوره بررسیشوند و برای های کیفیتگیریاندازه داددرون شرایط نزدیک به مربوط به مرگ وهای در طی شش ماه گذشته حداقل یکبار در ماه بررسیتسهیلات زایمانی .0 بررسی های توصیه برای ایجاد مکانیسمیدارای و را انجام داده استمادری و دوره حول و حوش زایمان مرگ )16.88(. *باشدمی اطلاعات گزارش هایی برای بررسی، تائید و یمانی همیشه فرایندهای عملی استاندارد و دستورالعملتسهیلات زا .6 )11.28(. دارد تواند های مربوطه دارد و میتحلیل اندیکاسیون-آوری و تجزیهعاتی برای جمعتسهیلات زایمانی یک سیستم اطلا .1 . شوندگزارش میوی کاغذ و همیشه بصورت دیجیتالی بر ر هر از گاهیدادهای قابل مشاهده ایجاد کند که برون )17.18( مدیران و کارکنان مراقبت سلامتی در تسهیلات زایمانی حداقل یکبار در ماه در طول شش ماه گذشته برای .1 )60.18(. بازنگری فرایند و اطلاعات پیامد جلسه داشتند های اطلاعات برای اتخاذ ها را در مورد بازنگرییهتوص ،مدیران و کارکنان مراقبت سلامتی در تسهیلات زایمانی .1 )10.18(. تصمیم و برای مشاوره جهت بهبود عملکرد در شش ماه گذشته مورد استفاده قرار دادند داد/فرایندبرون های رخ داده در زمان حول و حوش زایمان در تسهیلات زایمانی که با ابزارهای بررسی استاندارد نسبت همه مرگ .0 )26.11(. *د بازنگری قرار گرفته بودندمور که با ابزارهای بررسی استاندارد مورد مرگ در تسهیلات زایمانیبه های مادری و شرایط نزدیک نسبت همه مرگ .1 )16.88(. *بازنگری قرار گرفته بودند )18.28(. ودندب اطلاع داده شدهکه مرگ در تسهیلات زایمانیبه های مادری و شرایط نزدیک نسبت همه مرگ .1 پیامد آوری شده و بصورت در طول لیبر، زایمان و دوره بعد از زایمان جمع بطور روتین در تسهیلات زایمانی اطلاعات .0 )81.18(. گیرندمنظم برای اتخاذ تصمیم جهت بهبود کیفیت مورد استفاده قرار می مان در تسهیلات زایمانی که بطور کامل های دوره حول و حوش زایمرگ بررسیها در مورد نسبت همه توصیه .6 )01.08(. انداجرا شده )71.08(. اندمرگهای مادری در تسهیلات زایمانی که بطور کامل اجرا شده بررسیها در مورد نسبت همه توصیه .1 1استاندارد قسمتمنابع مورد استفاده در gnipocs lamrof a fo weivrevO .WA ilahG ,J ydenneK ,S siweL ,DL ittezneroL ,SE neirB  .2:5;0102 icS noitatnemelpmI .sdrac troper metsys htlaeh no weiver deM icS coS .part tnemerusaem eht dna htlaeh lanretaM .MO llebpmaC ,JW maharG  .779–769:53;2991 noitamrofni htlaeh fo noitatnemelpmi dna ngiseD .C tradoB ,R nrobreuaS ,T dleveppiL  .0002 ;noitazinagrO htlaeH dlroW :aveneG .smetsys fo ssenevitceffe eht gnirotinom rof slooT .Y demhA ,KR irihP ,S seivaD ,FS yarruM  .163–353:61;1002 nalP yciloP htlaeH .smetsys larrefer ytinretam tcirtsid aveneG .9002 nerdlihc s’dlrow eht fo etats ehT .FECINU  .)fdp.NE-tropeRlluF-90CWOS/scod/90cwos/gro.fecinu.www//:ptth( nA .)ARAS( tnemssessa ssenidaer dna ytilibaliava ecivreS .noitazinagrO htlaeH dlroW  ;aveneG 2.2 noisrev ,launam ecnerefeR .yreviled ecivres rof metsys gnirotinom launna .)/ne/eriannoitseuq_srotacidni_aras/smetsys/ofnihtlaeh/tni.ohw.www//:ptth( 5102 .knaB dlroW ,FECINU ,dnuF noitalupoP snoitaN detinU ,noitazinagrO htlaeH dlroW  dr3 ,ecitcarp laitnesse rof ediug a :erac nrobwen dna mutraptsop ,htribdlihc ,ycnangerP .5102 ;noitazinagrO htlaeH dlroW :aveneG .noitide : هر زن و نوزادی بطور مناسب در زمان پذیرش، در طول لیبر و دوره اولیه پس از 1.1کیفیت یهبیان ارجاع مورد نیاز است یا نه و تصمیم برای ارجاع بدون تاخیر اتخاذ زایمان برای تعیین اینکه آیا .گیردمورد ارزیابی قرار می ،شده یا نه این موارد برای تشخیص مواردی که نیاز به ارجاع سریع دارد، برای اطمینان از اینکه هر بیمار مراقبت به موقع منطق: .هستندحیاتی کند و برای پیشگیری از مشکلات غیرضروری و مناسب دریافت می تسهیلات زایمانی و منابع را تسهیلات، قابل دستیابی هستند و توانایی روز شده موجود درهای ارجاع بهدستورالعمل های بستری برای ارزیابی، تشخیص و پاسخ به د. یک سیستم تریاژ در پذیرش و یک مکانیسم در بخشندهنشان می قبل از ارجاع و ثابت. امکانات برای ایجاد مراقبت بصورت فوریتی وجود دارددر تسهیلات زایمانی یاورژانسموارد درمان موجود هستند. های کیفیتگیریاندازه داددرون و )مانند مراقبت قبل از ارجاع(روز برای تشخیص، اداره مکتوب و بههای بالینی تسهیلات زایمانی دستورالعمل .0 )11.18(. *داردرا ارجاع زنان با مشکلات مربوط به حاملگی و زایمان و مشکلات نوزادان اع زنان و نوزادان رای تثبیت وضعیت و درمان قبل از ارجتسهیلات زایمانی با منابع مناسب دارویی و پزشکی ب .6 )16.18(. *تجهیز شده است های ضمن خدمت و جلسات ماه یکبار، در بخش مامایی آموزش 60کارکنان مراقبت سلامتی حداقل هر .1 )11.18(. *کنندهای ارجاع دریافت میمنظم بازآموزی در مورد دستورالعمل داد/فرایندبرون های ان و نوزادان مشاهده شده در تسهیلات زایمانی در سه ماه گذشته که واقعا ارجاع شده و شاخصنسبت زن .0 )17.08(. اندتسهیلات برای رجاع را پر کرده نسبت تمام زنان حامله یا زنان در مرحله پس از زایمان که نتوانستند در تسهیلات زایمانی اداره شوند و بدون .6 ص مراقب سلامتی و یک یادداشت کامل و استاندارد ارجاع به مرکزی با سطح تاخیر، همراه با یک متخص )71.08(. اندامکانات بالا برای زایمان و اداره بیشتر انتقال داده شده همه نوزادان مریض، زودرس و کوچک که نتوانستند در تسهیلات زایمانی اداره شوند و بدون تاخیر، نسبت .1 در عرض یک ساعت از تصمیم ،متی و یک یادداشت کامل و استانداردهمراه با یک متخصص مراقب سلا )11.17(. اندبه مرکزی با سطح مراقبتی مناسب بیشتر انتقال داده شدهبرای ارجاع، پیامد رسیدن به تسهیلات زایمانی اند که در زماننسبت تمام زنان پذیرش شده در واحد لیبر که گزارش کرده .0 )18.68(. اندردهمداخله فوری دریافت ک : برای هر زن و نوزادی که نیاز به ارجاع دارد، ارجاع بصورت یک طرح از قبل 1.1کیفیت یهبیان تواند بدون تاخیر در هر زمانی اجرا شود.شود که میتثبیت شده دنبال می و منجر به مراقبت بهتر و کرده طرح از قبل تثبیت شده برای تسریع فرایند ارجاع، از تاخیر غیرضروری ممانعت منطق: شود.موقع از بیماران میب ساعت روز و هفت روز هفته قدرت عملکرد دارند، برای 16کافی که در تمام و دهنده مجهز های انتقالوجود سرویس های آنها در محل د. لیستی از تسهیلات اینترنتی شناخته شده و شماره تلفننباشانتقال زنان و نوزادان ضروری می که از زنان در مقابل موانع مالی برای است باشد، ب سیاستی می تحت نظارت و پاسخگو، . سیستم ارجاعهستندوجود م کند، و فرایندی برای بررسی و ارزیابی سیستم وجود دارد. ارجاع حمایت می های کیفیتگیریاندازه داددرون وسایل نقلیه برای انتقال اورژانسی زنان و نوزادان تسهیلات زایمانی دسترسی به یک آمبولانس آماده یا سایر .0 )11.11(. *به تسهیلات ارجاعی دارد جغرافیایی وجود دارد که مراقبت ارجاعی برای زنان و همان منطقهدر امکانات شبکهاز یروزلیست به .6 )16.18(. *کنندفراهم میرا کودکان توانند در تسهیلات زایمانی ز اینکه زنان و نوزادانی که نمیمحلی دارد برای اطمینان ا تدابیرتسهیلات زایمانی .1 ساعت روز و هفت روز هفته، به یک سطح مناسبی از مراقبت ارجاع داده 16اداره شوند بدون تاخیر، در طول )00.78(. شوند داد/فرایندبرون . *اندبیشتر مرده مدیریتی نسبت تمام نوزادانی که قبل و در طول انتقال به تسهیلاتی با سطح بالاتر برا .0 )17.78( نسبت تمام زنان حامله و زنان در مرحله پس از زایمانی که قبل و در طول انتقال به تسهیلاتی با سطح بالاتر .6 )11.78(. اندبیشتر مرده مدیریتجهت زایمان برای ال اورژانسی مناسب ارجاع داده نسبت تمام زنان حامله و زنان در مرحله پس از زایمان و نوزادانی که بدون انتق .1 )62.17(. شده بودند . نسبت همه زنان ارجاع شده از تسهیلات زایمانی که به جامعه یا به سیستم انتقال کمک مالی کرده بودند .1 )11.82( پیامد )71.18(. شده از تسهیلات زایمانی که ارجاع آنها کامل شده استداده نسبت همه زنان ارجاع .0 )11.18(. شده از تسهیلات زایمانی که ارجاع آنها کامل شده استداده زادان ارجاع نسبت همه نو .6 جاعی ار تسهیلات ی بدنشده از تسهیلات زایمانی که بدون کاهش دماداده نسبت همه نوزادان ارجاع .1 )11.27(. انددریافت کرده تبادلمانی ارجاع شده است، : برای هر زنان و نوزادی که در یا بین تسهیلات زای1.1کیفیت یهبیان و بازخورد برای کارکنان مراقبت سلامتی مربوطه موجود است.مناسب اطلاعاتی و بازخوردی در و بین تسهیلات زایمانی، مراقبت از بیمار را بهبود بخشیده، انگیزه تبادل شدهاطلاعات مناسب منطق: -منجر به مراقبت پیشرفته از بیمار میاز تجربیات کرده و کارکنان مراقبت سلامتی را افزایش داده، کمک به یادگیری شود. رسمی و قراردادهایو همیشه در شبکه ارجاعی در حال انجام است )مانند رادیو و تلویزیون( سیستم عملکردی جامعه رجاع و بازخوردی در مورد ادستورالعملهای و تبادل اطلاعاتتنظیمات برای جامعه و جلسات در محل موجود هستند. موجود هستند. ،نیازمورد ارجاع استاندارد و فرمهای ارجاعی پیشخوان در زمان گیری کیفیتاندازه داددرون بالینی مربوطه اجتماعی و-فردی مستندسازی اطلاعاتتسهیلات زایمانی یک فرم ارجاع استاندارد شده برای .0 -از ارجاع یا درمان داده شده و دلیل ارجاع می ها، مداخلات قبلهای بالینی، تشخیصدارد که شامل یافته )10.18(. *باشد باشد که های ارتباطی قابل اعتماد دارد که شامل تلفن همراه، خط زمینی یا رادیو میتسهیلات زایمانی روش .6 )10.78(. *باشد دار قابل عمل میها برای ارجاعات و مشاوره در مورد موارد مشکلزمان تمامیدر با مراکز ارجاعی تدابیر ارتباطی و سیستم بازخوردکه تسهیلات زایمانی توافقات رسمی، دهندنشان میشواهد .1 )11.18(. *دارد داد/فرایندبرون شده در تسهیلات ارجاعی که برای آنها اطلاعات کامل بازخوردی ارجاعی دیدهنسبت همه زنان ارجاع شده .0 )12.18(. پیشخوان موجود بود و نوزادان ارجاع شده مشاهده شده در تسهیلات ارجاعی که برای آنها اطلاعات کامل بازخوردی نسبت همه .6 )60.18(. ارجاعی پیشخوان موجود بود موقع در تسهیلات ارجاعی جاعی که مراقبت بشده در تسهیلات ار دیدهنسبت همه زنان و نوزادان ارجاع شده .1 )71.17(. انددریافت کرده 1استاندارد قسمتاده در منابع مورد استف margorp rof launam ecnerefer a :nrobwen yhtlaeh ehT .R ssoR ,JB yhtraCcM ,J nwaL  .1002 ;lanoitanretnI ERAC ,lortnoC esaesiD rof sretneC :aigroeG ,atnaltA .sreganam gnimmargorp :yawflah ytinummoc eht gniteeM .HA rihatiE ,V draW ,D eniaM  :kroY weN ,ytiC kroY weN .ytilatrom lanretam fo noitcuder eht rof senilediug .3991 ;FECINU tnerruc :seirtnuoc gnipoleved ni smetsys larrefer ytinretaM .S nosraeP ,FS yarruM  .5122–5022:26;6002 deM icS coS .sdeen hcraeser erutuf dna egdelwonk fo ssenevitceffe eht gnirotinom rof slooT .Y demhA ,KR irihP ,S seivaD ,FS yarruM  .163–353:61;1002 nalP yciloP htlaeH .smetsys larrefer ytinretam tcirtsid .level larrefer tsrif ta erac cirtetsbo fo stnemele laitnessE .noitazinagrO htlaeH dlroW  .1991 :aveneG .)ARAS( tnemssessa ssenidaer dna ytilibaliava ecivreS .noitazinagrO htlaeH dlroW  .2.2 noisrev ,launam ecnerefeR .yreviled ecivres rof metsys gnirotinom launna nA 5102 ;aveneG .)/ne/eriannoitseuq_srotacidni_aras/smetsys/ofnihtlaeh/tni.ohw.www//:ptth( htlaeh tcirtsiD .cificaP nretseW eht rof eciffO lanoigeR noitazinagrO htlaeH dlroW  .8991 ;alinaM .snoitarepo dna tnempoleved rof senilediuG :seitilicaf هایشان موثر است و به نیازها و ترجیحات آنها پاسخ . ارتباط با زنان وخانواده1استاندارد دهد.می کنند و تعامل هایشان اطلاعاتی درباره مراقبت دریافت مین و خانواده: همه زنا1.1کیفیت یهبیان موثری با کارکنان دارند. بیشتری در مراقبتشان داشته باشند، یکند تا احساس درگیرهایشان به آنها کمک میارتباط موثر با زنان و خانوادهمنطق: دهد کند و به آنها احساس کنترل شرایطشان را میی میمورد جلوگیراز اضطراب غیرضروری، فهم نادرست و انتظارات بی شود.میبرای آنها که منجر به تجربه مثبت مثبت، نگرشدسترس هستند. آنها درسریعا ودارند ایهای مشاورهکارکنان مراقبت سلامتی ارتباط بین شخصی و مهارت -تشخیص میبفهمند و را خود همه زنان تحت مراقبت نیازهای ارتباطی و ترجیحاتتوانند میشفاف دارند که ساده و زبان دهند. های کیفیتگیریاندازه داددرون که به زبان همان جامعه یک نوشته قابل دستیابی یا با فرمت مصور با قابلیت فهم آسان بصورت موارد آموزشی .0 )01.01(. *ست، موجود استتوسط تسهیلات زایمانی تهیه شده ا ماه یکبار آموزش ضمن خدمت برای بهبود 60و حداقل هر هستندمتی در بخش مامایی آگاه کارکنان مراقبت سلا .6 )17.18(. *کنندو صلاحیت فرهنگی دریافت می ایهای مشاورهارتباط بین شخصی و مهارت و کنداهداف روشن و طرحهای عملیاتی را مشخص می ای دارد کهروز نوشته شدهسیاست به تسهیلات زایمانی .1 . کندمی ها را بررسیمکانیسم ای کارکنان مراقبت سلامتیهای مشاورهبرای پیشبرد ارتباط بین شخصی و مهارت )12.18( فردی، مشاوره و باط بیندر مورد ارت حمایت شدهکارکنان مراقبت سلامتی در بخش مامایی، هر سه ماه، نظارت .1 )60.18(کنند. صلاحیت فرهنگی دریافت می یندداد/فرابرون شده از واحد لیبر و زایمان در تسهیلات که قبل از ترخیص اطلاعات نوشته شده و نسبت تمام زنان ترخیص .0 و پیشگیری از هاگذاری بین زایماناند: تغذیه و بهداشت، فاصلهکلامی و مشاوره در موارد زیر دریافت کرده یز نگه داشتن بچه، ارتباط و بازی با کودک، بارداری، شیردهی انحصاری با پستان و انجام شیردهی، گرم و تم )18.18(. *که باید در موارد مشکل مراجعه کنند محلیهای خطر در مادر و نوزاد و نشانه اند که به آنها فرصتی داده شده بود تا در مورد نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که گزارش کرده .6 )17.68(حث کنند. ب هایشاناولویتها و نگرانی اند: گوش کردن فعال، های زیر را انجام دادهنسبت تمام کارکنان مراقبت سلامتی در تسهیلات زایمانی که مهارت .1 هایشان و حمایت از زنان در حل سوال پرسیدن، پاسخ دادن به سوالات، مشخص کردن درک زنان و خانواده )72.27(مشکلات . پیامد اند که بطور کافی توسط کارکنان مراقبت در مان کرده در تسهیلات زایمانی که احساس کردهنسبت تمام زنان زای .0 )81.18(اند. و تصمیماتی که برای مراقبت از آنها گرفته شده است، آگاه شده عملیاتمورد معاینات، در طول لیبر، هایشانتاولویاند که نیازها و نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که گزارش کرده .6 )72.18(زایمان و دوره پس از زایمان در نظر گرفته شده بود. اند. داشتهرضایت خود را در مورد خدمات سلامتی ابراز نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که .1 )22.18( بهداشتی در مورد اطلاعات و آموزش اند که نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که گزارش کرده .1 )16.27(اند، راضی بودند. کنندگان دریافت کردهکه از مراقبت و صحیح دقیق به همراه اطلاعات هماهنگهایشان مراقبت : همه زنان و خانواده1.1کیفیت یهبیان اند.میان متخصصان سلامتی مربوطه و متخصصان مراقبت اجتماعی تجربه کرده تبادلی و اطلاعات دقیق میان مراقبان سلامتی برای ایجاد مراقبت مداوم از بیمار و پیشگیری از تاخیر هماهنگمراقبت ق:منط غیرضروری در درمان ضروری است. مانند میان کاکنان در زمان تعویض شیفت و ارجاعات با خدمات (فرمت استانداردی برای اطلاعات تبادلی بین مراقبان یا تلفنی میان دریافت و ارتباط موثر کلامی و/گیرد مورد استفاده قرار می )ستادن نتایج آزمایشگاهمراقبت اجتماعی، فر وجود دارد.حیاتی های تشخیصی موقع نتایج تستشود. گزارش بکنندگان مراقبت استفاده می های کیفیتگیریاندازه داددرون ، تولد )پارتوگراف(یر بالینی و ارزیابی حوادث در طول لیبر های ستسهیلات زایمانی فرم استانداردی برای یادداشت .0 )17.01(. *نوشته دارد ی تحویلو بعد از تولد برای آسان کلامی و نوشته شده زنان و نوزادان در تحویل روز برای های بالینی نوشته شده و بهتسهیلات زایمانی دستورالعمل .6 )10.18(. *، ارجاع به سایر تسهیلات و در زمان ترخیص داردزمان تعویض شیفت، در طول انتقال بین تسهیلات آموزش ضمن خدمت و جلسات ماه یکبار 60کارکنان مراقب سلامتی در بخش مامایی آگاه بوده و حداقل هر .1 ، ارجاع یا ترخیص دریافت انتقال و ارتباط اطلاعات مهم برایدادن تحویلمنظم بازآموزی در مورد سیاست بالینی )11.08(د. کنمی کنندگان خدمات برای تبادل اطلاعات میان فراهم تسهیلات زایمانی یک سیستم ارتباطی عملکردی و قابل اعتماد .1 )26.87(مربوطه دارد. داد/فرایندبرون )78.08(در طول لیبر و زایمان برای آنها پارتوگراف کامل شده است. که حاضر نسبت زنان .0 اند که کارکنان مراقب سلامتی خودشان را ده در تسهیلات زایمانی که گزارش کردهنسبت تمام زنان زایمان کر .6 اند. اند، نشان دادهزنان و مراقبتی که تا آن زمان دریافت کرده حالشرحاند و اطلاعات خوبی در مورد معرفی کرده )71.17( دمایپ 0. تامدخ زا هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسنهدرک یدنمتیاضر زاربا یتملاسدنا* .(81.11) 6. هک یعامتجا ناصصختم و رداک لماش یتملاس بقارم نانکراک تبسن ینامیاز تلایهست ردزا لوط رد طابترا لیوحت یتملاس تبقارم میت یاضعا نایم ینیلابهدوب یضاردنا .(28.18) رد هدش هدافتسا عبانمتمسق درادناتسا1  de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1).  Anderson L, Scrimshaw S, Fullilove M, Fielding J, Normand H. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003;24:68–79.  Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267.  Fealy G, Riordan F. Communication and clinical handover practices: a systematic review. Dublin: University College Dublin and Health Service Executive; 2014.  Iedema R, Manidis M. Patient–clinician communication: an overview of relevant research and policy literatures. In: Communication (clinical handover) in maternity services. Sydney: Australian Commission on Safety and Quality in Health Care and UTS Centre for Health Communication; 2014 (National clinical guideline No. 5) (http://health.gov.ie/wp-content/uploads/2015/01/ National-Clinical-Guideline-No.-5- Clinical-Handover-Nov2014.pdf).  Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003;4:CD003716.  Kongnyu E, van den Broek N. Criteria for clinical audit of women friendly care and providers’ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28.  National Institute for Health Care Excellence. Patient experience in adult NHS services. London; 2012 (https://www.nice.org.uk/guidance/qs15/chapter/ quality-statement-2- demonstrated-competency-in-communication-skills#quality-statement-2).  The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. Oakbrook Terrace, Illinois; 2010 (http://www. jointcommission.org). کنند.دریافت می کرامتشان: زنان و نوزادان مراقبت همراه با احترام و حفظ 5استاندارد : همه زنان و نوزادان در زمان لیبر و زایمان خلوتی دارند و حریم خصوصی آنها مورد 1.5کیفیت یهبیان .گیردقرار میاحترام ها مورد دهد که در همه زمانهایشان این احساس را میبه زنان و خانوادهطلاعات بودن اداشتن خلوت و محرمانه منطق: کنندگان مراقبت سلامتی کند و به ارائهدر ارتباط با مشکلات آنها حمایت می مشکلیهر باشند، از آنها در مورداحترام می .کنندمیاعتماد ها برای ها و دیوارهدهند. ملحفه، پردهه را مورد احترام قرار میکارکنان مراقبت سلامتی خلوت، اطلاعات و مراقبت محرمان و کلامی از شرایط زنان و نوزادان بصورت محرمانه مکتوباطمینان از حریم خصوصی موجود هستند و گزارشات ثبت شده شوند.نگهداری می های کیفیتگیریاندازه داددرون که محرمانه همراه با احترام احتیاطی و ریم خصوصی، مراقبت امکان حفظ حمحیط فیزیکی تسهیلات زایمانی .1 )18.11(. *دهدمی ، راباشدها و ظرفیت کافی تخت میبندیدیواره، صفحاتها، شامل وجود پرده روز برای اطمینان از خلوت و حریم خصوصی برای تمامی زنان و مکتوب و بههای تسهیلات زایمانی دستورالعمل .1 )76.18(. *های مراقبت داردزمینه میتمانوزادان در -رضایتو محرمانه بودن، حریم خصوصی ضنق صورتبرای جبران در پاسخگوهای تسهیلات زایمانی مکانیسم .1 )20.18(دارد. مندی داد/فرایندبرون ن وجود که نیاز به رضایت کتبی دارند که برای آنها ثبت مربوط به رضایت زنسبت فرایندهای تسهیلات زایمانی .0 )11.28(. * دارد اند که قبل از معاینه یک فرایند قرار گرفته در تسهیلات زایمانی که گزارش کردهتحت نسبت زنان تحت معاینه یا .6 )01.18(. ه بودیا فرایند از آنها اجازه گرفته شد پیامد ل اقامتشان در بخش لیبر و در طو حریم خصوصینسبت تمام زنان زایمان کرده در تسهیلات زایمانی که از میزان .0 )12.18(زایمان ابراز رضایت کرده بودند. در زمان حریم خصوصیدرمان قرار گرفته در تسهیلات زایمانی که از میزان تحت نسبت تمام زنان تحت معاینه یا .6 )81.18(اند. معاینات یا درمان ابراز رضایتمندی کرده )11.08(اند. ایمانی که از خدمات سلامتی ابراز رضایتمندی کردهنسبت تمام زنان زایمان کرده در تسهیلات ز .1 : هیچ زن و نوزادی نباید مورد درمان نامناسب مانند سوء استفاده فیزیکی، جنسی یا 1.5کیفیت یهبیان کلامی، تبعیض، اهمال، معطلی، تهدید یا خودداری از ارائه خدمات قرار بگیرد. بیشترین میزان استاندارد مراقبت سلامتی بدون تبعیض یا درمان دارا بودن از ی برای هر زنی حقوق اساسی انسان منطق: نامناسب دارد. آنها را کرامتدهند و مورد درمان قرار می صداقتکارکنان مراقبت سلامتی همه زنان را با مهربانی، نزاکت، احترام، درک و از عواقب آن، آزاد هستند و محدودیتی در مورد ورود یا ترک کنند. زنان در مورد شکایت کردن بدون داشتن ترسحفظ می تسهیلات زایمانی ندارند. های کیفیتگیریاندازه داددرون مان نامناسب زنان و نوزادان روز، بدون تحمل هیچ تبعیضی در زمینه درمکتوب، بههای تسهیلات زایمانی سیاست .0 )10.01(. *دارد توانند به نوزاد و پرستار نوزادان کوچک و بیمار می دارای که از طرق آن مادران تسیهلات زایمانی سیستمی دارد .6 )11.18(. *هایشان نزدیک باشندبچه )71.18(. *اندقابل پرداخت بوده و به وضوح نشان داده شده راقبت از زنان و نوزادان منصفانه وهای مساختار هزینه .1 )11.88(درمان نامناسب دارد. ی جبران در موردهای پاسخگو براسمتسهیلات زایمانی مکانی .1 درباره هایشان حق شکایتزنان و خانواده دارد که بهروز مکتوب و بهها و سیاست تسهیلات زایمانی دستورالعمل .1 شکایات دارد. ارسالبرای )مانند یک جعبه(و یک مکانیسم قابل دستیابی آسان دهد میشان مراقبت دریافت کرده )11.88( حمایتی در مورد احترام به حقوق نظارتکارکنان مراقبت سلامتی در بخش مامایی، آموزش ضمن خدمت و .2 کارکنان جدید بهکنند. این آگاهی دریافت می پاسخگوهای مادران و نوزادان، مراقبت همراه با احترام و مکانیسم )21.78(. ارائه شده است -بخاطر عدم پرداخت می یک زن یا کودکاز بازداشت ور خاص مانعبطسیاست تسهیلات زایمانی برای پرداخت .7 )11.28(شود. -هایشان است، و بطور دورهدارد که به آسانی قابل دستیابی برای زنان و خانواده یتسهیلات زایمانی جعبه شکایات .8 )66.77(شود. ای خالی شده و محتوای آن بازنگری می داد/ فرایندبرون زایمانی که گزارش خشونت فیزیکی، کلامی یا جنسی نسبت به تزایمان کرده در تسهیلانسبت تمام زنان .0 )82.28(اند. خودشان یا نوزادانشان در طول لیبر، زایمان یا بعد از زایمان کرده برآوردن نیازهای فرهنگی و بخاطرنسبت تمام زنان زایمان کرده در تسهیلات زایمانی که از تسهیلات زایمانی .6 )10.87(اند. مندی کردهابراز رضایت شانبیمذه آنها بدلیل عدم توانایی پرداخت خودداری شده از در تسهیلات زایمانی که از مراقبت حضور یافتهنسبت تمام زنان .1 )71.27(است. )71.17(هایشان دریافت شده است. زنان و خانواده کرامتنسبت شکایاتی که درباره احترام و حفظ .1 ام زنان زایمان کرده در تسهیلات زایمانی که از وجود و محل جعبه شکایات در تسهیلات زایمانی آگاه نسبت تم .1 )11.17(بودند. پیامد اند. ابراز رضایتمندی کرده دریافت کرده نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که از خدمات سلامتی .0 )11.18( کرامتتوام با احترام و حفظ درمان آنها اند که تسهیلات زایمانی که گزارش کرده نسبت تمام زنان زایمان کرده در .6 )10.18(. بوده است بدون در نظر گرفتن اند و به شکایت آنهاداشتهنسبت تمام زنان زایمان کرده در تسهیلات زایمانی که شکایتی .1 )68.67(است. عواقب آن، رسیدگی شده کنند، داشته باره خدماتی که دریافت میتوانند انتخابهای آگاهانه درن می: همه زنا1.5کیفیت یهبیان اند.بیان شدهبرایشان مداخلات یا پیامدها به روشنی دلیلباشند و درمان و مراقبتشان داشته باشند و برای بهبود پذیرش و رضایت از دخیل بودن درضروری است که زنان احساس منطق: گاهانه داشته باشند.های آانتخاب شاندرمان آنها از . شوند که سوالاتشان را مطرح کنندتشویق میشود و می مطلعهایشان برای مراقبت گزینه به زنان در مورد حقوق و د، ارزش انسانی و اعتقاداتشان مورد حمایت شوهای مراقبت و درمانشان حمایت میتمامی زمینهمورد در گیریدر تصمیم شود.آنها قبل از انجام فرایندها رضایت گرفته میگیرد و از قرار می های کیفیتگیریاندازه داددرون . *روز برای گرفتن رضایت آگاهانه از زنان قبل از معاینات و فرایندها داردمکتوب و بهتسهیلات زایمانی سیاست .0 )81.11( اطلاعات در فراهم آوردنمراقبت سلامتی تسهیلات زایمانی فرم رضایت آگاهانه استانداردی دارد که به کارکنان .6 )11.11(. *کند کمک میاز آنها فهم برای زنان، جهت گرفتن رضایت کاملا آگاهانه قابل حمایتی در مورد فرایندهای نظارتهای ضمن خدمت و کارکنان مراقبت سلامتی در تسهیلات زایمانی آموزش .1 آگاهی به کارکنان جدید این کنند. زمان زایمان دریافت می زنان برای انتخاب مراقبت در حقرضایت آگاهانه و )01.87(. *شودارائه می دارد خسارت در صورت عدم انتخاب آگاهانه زنان برای جبران مکتوب های پاسخگوی تسهیلات زایمانی مکانیسم .1 )01.08(مکانیسم مشخص شده است. این و داد/فرایندبرون -نامهکه برای آنها رکورد مربوط به رضایت ،دندار کتبیت زایمانی نیاز به رضایت در تسهیلا یی کهنسبت فرایندها .0 )61.18( ای که توسط زن یا یکی از اعضای خانواده امضا شده است وجود دارد. درباره اند که کارکنان مراقبت سلامتی نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که احساس کرده .6 )68.18(اند. ها دادهنبه آآگاهی کافی ،مراقبتشان در موردته شده های گرفتصمیم دریافت یا خودداری از حق داشتندر تسهیلات زایمانی که به آنها در مورد قرار گرفتهمراقبت مورد نسبت زنان .1 .دوب هدش هداد یهاگآ نامرد تفایرد(78.11) دمایپ 0. نانز تبسنهدش نیرازس رد تلابهستینامیاز هک دروم رد اهنآ هب هاگآ نیرازس لیلدی هداددشوب ه .د(87.01) 6. تیاضر زاربا یتملاس تامدخ زا هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسنهدرک یدنم .دنا(86.71) 1. هدرک ساسحا هک ینامیاز تلایهست رد هدرک نامیاز نانز تبسن هدش هتفرگ تامیمصت دروم رد هک دنااهنآ یارب رد بیلنامیاز زا سپ هرود و نامیاز ،ر هدش هداد تکراشم .دنا(71.82) رد هدش هدافتسا عبانم تمسق درادناتسا5  Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015;12:e1001847.  de Silva A. A framework for measuring responsiveness. Geneva: World Health Organization; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1).  Dwamena F1, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267.  International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99.  Kongnyuy E, van den Broek N. Criteria for clinical audit of women friendly care and providers ‘ perception in Malawi. BMC Pregnancy Childbirth 2008;8:28.  Lothian JA. Do not disturb: the importance of privacy in labor, J Perinat Educ 2004;13:4– 6.  National Institute for Health and Care Excellence. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. London; 2012 (http://www.nice.org.uk/guidance/cg138).  Reader TW, Gillespie A. Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC Health Serv Res 2013;13:156. metsys htlaeH .BD snavE ,LJC yarruM ,C ybraD ,K atabawaK ,A avliS ed ,BN enitnelaV  ,BD snavE ,LJC yarruM :nI .tnemerusaem dna sniamod ,stpecnoc :ssenevisnopser .msiciripme dna sdohtem ,setabed :tnemssessa ecnamrofrep smetsys htlaeH ,srotide .3002 ;noitazinagrO htlaeH dlroW :aveneG fo noitanimile dna noitneverp eht no tnemetats OHW .noitazinagrO htlaeH dlroW  5102 ;aveneG .htribdlihc desab-ytilicaf gnirud esuba dna tcepsersid au&1=au?fdp.gne_32.41_RHR_OHW/1/885431/56601/maertstib/siri/tni.ohw.sppa//:ptth( .)1= -اش حمایت عاطفی دریافت میاش یا همراه انتخاب کرده: هر زن و خانواده6استاندارد دهد.را افزایش می کنند که این حمایت به نیازهای آنها حساس بوده و توانایی زن لیبر و زایمان را به انتخاب خودش تجربه شود تا ای پیشنهاد می: به هر زنی گزینه1.6کیفیت یهبیان .داشته باشد که اثر مثبتی بر کنندلیبر و زایمان حمایت روحی، عاطفی و فیزیکی فراهم میبرای زن در طول یهمراهان زایمان منطق: بخشند.را بهبود می انزایمداشته و پیامدهای زن د. همراه نحاضر باش تا در طول لیبر و زایمان انتخاب کنند شوند یک همراه زایمانیشود و تشویق میبه زنان اجازه داده می -تشویق میفعالانه همراهش به تمرین مراقبتهم زن و هم باشد،میزایمانی به حمایت از زن در طول لیبر و زایمان آگاه شوند. های کیفیتگیریاندازه داددرون اند که یک محیط فیزیکی خصوصی برای زن و همراهش در زمان واحدهای لیبر و زایمان چنان تنظیم شده .0 )11.01(. *کنندزایمان ایجاد تا هایشان توضیح داده شده است روز دارد که به زنان و خانوادهمکتوب و بهتسهیلات زایمانی یک دستورالعمل .6 در طول لیبر، زایمان )بر اساس فرهنگشان( قل یک شخص همراه به انتخاب خودشحدا را به داشتنهمه زنان )16.01(. *تشویق بکندو دوره بلافاصله پس از زایمان ماه یکبار جلسات منظم بازآموزی 60و حداقل هر هستندکارکنان مراقبت سلامتی در تسهیلات زایمانی آگاه .1 . کننداثر مثبت حضور یک همراه زایمانی در طول لیبر و زایمان دریافت می ضمن خدمت در مورد شواهد و )12.18( در مورد نقش او در حمایت از زن آگاه کردن همراه جهت )نوشتاری یا تصویری( اطلاعات ی برای دادنجلسات .1 )11.18(زن در طول لیبر و زایمان موجود است. داد/فرایندبرون کرده در تسهیلات زایمانی که یک همراه به انتخاب خودشان در طول لیبر و زلیمان نسبت تمام زنان زایمان .0 )27.01(. *اندداشته داده شده بود، ابراز به آنها نسبت تمام همراهانی که از آگاهی که در مورد نقش آنها در طول لیبر و زایمان .6 )10.17(. *مندی کرده بودندرضایت پیامد . اندکرده مندیابراز رضایت ارائه شده کرده در تسهیلات زایمانی که از خدمات سلامتی نسبت تمام زنان زایمان .0 )18.18( کند.در طول زایمان حمایت دریافت می اشتقویت توانایی: هر زنی برای 1.6کیفیت یهبیان مادر و کودک باید برای بهبود پیامدهای سلامتی کلابهبود سلامت روان، داشتن نگرش مثبت و جهتهر زنی منطق: .قرار گیردحمایت عاطفی مورد دهد. را افزایش میزنان ، سلامت بیولوژیکی، فیزیولوژیکی، اجتماعی و فرهنگی زایمانی در تسهیلاتانجام یافته مراقبت آشامیدنو و خوردن لیبر راه رفتن در مرحله اول آزادانه در مورد ،در طول لیبر منتخبشانبا موقعیت برای سازگاریزنان نند مرگ نوزاد قبلی، تجربه ما(شوند. زنان با نیازهای عاطفی پیچیده برای اطمینان از تغذیه و هیدراسیون کافی تشویق می . در صورت مرگ مادر و کودک گیرندقرار میحمایت مورد و مشخص شده )در مادرمشکلات سلامتی خشونت، تجاوز و شود. می انجام هااندوه برای خانوادهغم و از حمایت های کیفیتگیریاندازه داددرون های تسکین درد غیر دارویی کارکنان مراقبت سلامتی در واحدهای لیبر و زایمان از بخش مامایی در مورد روش .6 . *کنندو آموزش ضمن خدمت دریافت می داشته ماه یکبار جلسات آموزشی 60ته و حداقل هر آگاهی داش )71.78( کاهش در موردهایشان دارد که به زنان و خانواده ایشده روزمکتوب و بهیمانی دستورالعمل تسهیلات زا .1 حساس بنابراین زن ا ،شودمداخلات غیرضروری، حمایت نرمال در لیبر و افزایش ظرفیت زن توضیح داده می )06.18(. دارد کنترل در مورد تجربه زایمان ماه یکبار، 60و حداقل هر ر و زایمان از بخش مامایی آگاهی داشتهبکارکنان مراقبت سلامتی در واحدهای لی .1 حمایت مورد ارائهآموزش ضمن خدمت و جلسات منظم بازآموزی برای افزایش ظرفیت شخصی و فرهنگی در )11.68(. کنندعاطفی دریافت می واحدهای ده دارد و آنها را به های با نیازهای عاطفی پیچیبرای زنان و خانواده تسهیلات زایمانی فرایند ارجاع .1 یارادیم عاجرا هژیو تبقارمدهد .(71.70) نوربدنیارف/داد 0. نامیاز نانز مامت تبسن هک ینامیاز تلایهست رد هدرکتیعضو تسا هدوب ناشدوخ باختنا هب ناشربیل .(86.16) 6. نانز مامت تبسنبیسآ ای هدیداب ح ینامیز تلایهست نانکراک زا هک دب دمایپ تفایرد یفاضا یفطاع تیام هدرکدنا .(81.21) 1. نامیاز نانز مامت تبسن هدرک شرازگ هک ینامیاز تلایهست رد هدرک ربیل لوط رد یفاک یندیشون و اذغ هک دنا هتشاددنا .(81.01) 1. ربیل لوا هلحرم لوط رد هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسنکرحتم دوبهادن .(77.11) دمایپ 0. هدرک تیاضر زاربا یتملاس تامدخ زا هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسندنا* .(81.21) 6. اهنآ هب هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسن داهنشیپ رد نامیاز نآ تلایهستهداد تسا هدش* . (81.12) 1. ز تلایهست رد هدرک نامیاز نانز مامت تبسن هک ینامیانامیاز زا تبثم هبرجت نتشاد ارهدرک شرازگ .دنا (81.61) 1. باختنا و تاحیجرت هکنیا زا هک ینامیاز تلایهست رد هدرک نامیاز نانز مامت تبسن عقاو مارتحا دروم اهنآ یاه تیاضر زاربا ،دوب هدشیدنم .دندوب هدرک(86.12) رد هدافتسا دروم عبانمتمسق درادناتسا6  Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013;7: CD003766.  International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother–baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128:95–99.  National Institute for Health Care Excellence. Using organisational change to enhance the experience of women giving birth by focusing on normalising births. London; 2013 (https://www.nice.org.uk/ sharedlearning/using-organisational-change-to-enhance-the- experience-of-women-giving-birthby-focusing-on-normalising-births).  National Institute for Health Care Excellence. NICE guidelines on routine intrapartum care (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/guidance-intrapartum-care-care-of- healthy-women-and-their-babies-during-childbirth-pdf). dna shtribllits gnitneverp ot yrefiwdim fo noitubirtnoc eht gnisimitpO .JM werfneR  yrefiwdiM .dedeen noitca labolg detanidro-oc :erac fo ytilauq llarevo eht gnivorpmi .101–99:63;6102 a ,tnempoleved tnafni dna gniebllew lanoitome lanretaM .seviwdiM fo egelloC layoR  2102 ;nodnoL ,seviwdim rof ediug ecitcarp doog .)fdp.BEW_ediuG_gnieblleW.2%lanoitomE/selif/tluafed/setis/ku.gro.mcr.www//:sptth( sledom ytiunitnoc del-efiwdiM .D ,enaveD ,A ,nannehS ,S setaG ,H inatloS .J lladnaS  veR tsyS esabataD enarhcoC .nemow gniraebdlihc rof erac fo sledom rehto susrev .766400DC :8;3102 dna rehtom eht fo erac latantsop no snoitadnemmocer OHW .noitazinagrO htlaeH dlroW  3102 ;aveneG .nrobwen -erac-latantsop/stnemucod/tnecseloda_dlihc_lanretam/tni.ohw.www//:ptth( .)/ne/snoitadnemmocer .ruobal fo noitatnemgua rof snoitadnemmocer OHW .noitazinagrO htlaeH dlroW  4102 ;aveneG tatnemgua/hlaeh_latanirep_lanretam/snoitacilbup/htlaehevitcudorper/tni.ohw.www//:ptth( .)/ne/ruobal-noi برای بهبود باانگیزهو دارصلاحیت: برای هر زن و نوزادی، همیشه، کارکنان 1استاندارد مراقبت روتین و اداره مشکلات موجود هستند. زمانها حداقل به یک متخصص زایمانی ماهر و کارکنان ی: هر زن و کودکی در تمام1.1کیفیت یهبیان ی دارد.مراقبت روتین و اداره مشکلات دسترس جهتحامی موقع اورژانسی از بیماران و اداره به ها برای مراقبت بهینه روتین ووجود کارکنان مراقبت سلامتی در همه ساعتمنطق: مشکلات ضروری است. مشخص کردن ورت نیاز بطور منظم جهتاست که در ص موجوددر تسهیلات کارکنان مراقبت سلامتی برای مشیخط تعداد متضمن وجود تا شودرسانی میروزو بهقرار گرفته بازبینی مورد ،کارکنان تگی مورد نیازشایسوع و ن، کارکنان تعداد در روز و هفت روز در ساعت 16های چندگانه کارکنان مراقبت سلامتی برای حجم کاری مهارتترکیب کافی کارکنان و -ئولیتشان در تسهیلات یا واحدی که در آن کار میو مس های ویژه. کارکنان بالینی و غیربالینی نسبت به نقشباشد هفته روز همیشه بههایی که کارکنان در آن زمان کار خواهند کرد و زمانیک کارمند شده فهرستوظایف . شوندکنند، آگاه می ی ها نواحی کلیددر مورد چگونگی دستیابی به خدمات موجود است و نشانه مکتوباطلاعات . شودنمایش داده میو بوده بندی بر نند. زنان برای اولویتکاورژانسی را مشخص می مواقعو چگونگی انجام کارها در )مانند بخش اورژانس(خدمت شوند. تریاژ می شاناساس شرایط اورژانسی های کیفیتگیریاندازه داددرون نظر جام بار کاری مورد به تعداد کافی برای ان همیشه وتسهیلات زایمانی متخصصان زایمانی ماهر دارد که .0 )11.18(. *موجود هستند را کارکنان صلاحیت کاریتعداد، نوع و دارد کهبرای کارکنان روز مکتوب و بهتسهیلات زایمانی سیاست .6 )11.18(. *شودبر اساس بار کاری بازبینی می مدامکه کندفهرست می آنها و کاری شته، وظیفه کارکنان، زمان شیفتدا وجوددارد که در همه واحدها فهرستیتسهیلات زایمانی .1 )11.28(کند. هایشان را مشخص میویژه و مسئولیت وظایف اورژانسی هایها و درمانمشاورهبرای انتظارروز در مورد تریاژ و زمان مکتوب و بهتسهیلات زایمانی سیاست .1 )61.28(و غیراورژانسی دارد. زمانها دارد. همهکارکنان به وظایفشان در دسترسیطی شفاف برای ای ارتباهتسهیلات زایمانی کانال .1 )78.68( داد/فرایندبرون تکمیل کار توصیف برای شایستگی لازمهای موجود در تسهیلات زایمانی که توسط کارکنان با نسبت پست .0 )67.18(. را فراهم کند ساعته در تسهیلات 16خدمات شده بود تا امکان انجام کنند ها و مسئولیتشان در تسهیلات یا واحدی که در آن کار می، نقشدر مورد عملکردکارکنانی که نسبت .6 )17.87(آگاهی داده شده است. بعنوان نسبت به وضعیتشاناند که در زمان مناسب در تسهیلات زایمانی که گزارش کرده موجودنسبت زنان .1 )81.17(. اندقرار گرفتهتوجه مورد ،تریاژ یا زمان انتظارمورد در ،تسهیلات مشیخط پیامد گونه که تعریف همان(نسبت زنان و نوزادان موجود در تسهیلات زایمانی که توسط متخصص زایمانی ماهر .0 )00.11(. *در طول زایمان یا بعد از زایمان تحت مراقبت قرار گرفته بودند )شده است در مورد خود های خطر اند که درباره نشانهکه گزارش کرده نسبت زنان زایمان کرده در تسهیلات زایمانی .6 )76.18(. بودند اورژانسی آگاه شدهبرای شرایط و آمادگی نوزاد خود ، گرفته بودندسلامتی از در تسهیلات زایمانی که در مورد خدماتی که درباره مراقبت حضور یافتهنسبت زنان .1 )78.18(مندی کرده بودند. ابراز رضایت ، ظرفیت مناسب و مهارت برای انجام صصان ماهر زایمانی و کارکنان پشتیبان: متخ1.1کیفیت یهبیان هایشان در طول لیبر، زایمان و دوره اولیه پس از زایمان دارند.نیازمندی بخشد.بهبود می های خودها و مسسئولیتنقش از، آموزش و آگاهی کارکنان عملکردشان را صلاحیتمنطق: مورد نظر و سایر هایبا صلاحیترا هاها و مسئولیتضروری، نقش هایشایستگیکار دارند که ی ازکارکنان تعریفهمه نامه یا استخدام و سایر صدور گواهی، آموزش کارکنان مراقبت سلامتی، ی. برای تمامدهدقرار میحمایت مورد الزامات نام، نگهداری، ارتقا های ثابتی برای ثبت. برنامهاستنگهداری حالو در مقررات تائید شدهیا توسط قانونمدارک مورد نیاز تخصص و ادامه تحصیل تمام کارکنان موجود است. های ارتقا تخصصی به همراه ها، آمادگی حمایتی و فعالیتها و مسئولیتدر مورد دستورالعمل مستمرهمه کارکنان آگاهی های موثر و کافی اداره موارد برای اطمینان از اینکه. سیستمدارندرد خوب ارزشیابی عملکرد سالانه و تشخیص عملک عملکرد توانند کنند و برای اطمینان از اینکه کارکنان مراقبت سلامتی میموقع دریافت میبیماران مراقبت کافی، ایمن و به موجود هستند. تسهیلاتهند، در مراقبت روتین و اداره مشکلات برای مادران و نوزادان نشان د ارائهدر یمناسب های کیفیتگیریاندازه داددرون ها برای تمام متخصصان زایمانی ماهر و ای برای ادامه ارتقا تخصصی و ارتقا مهارتتسهیلات زایمانی برنامه .1 )62.28(. *دهدترتیب میدارد و آموزش منظم پشتیبان سایر کارکنان و )پاداش طرحتشخیص و (نام، ارتقا، انگیزش هایی برای ثبتدارد و طرحتسهیلات زایمانی فرایندهای استان .1 )06.18(. *تمامی کارکنان دارد حفظ کند و مکانیسمی برای تشخیص عملکرد خوب ای همه کارکنان را ارزشیابی میتسهیلات زایمانی بطور دوره .2 )72.68(دارد. متخصصان ، باانگیزهدار، موزش دیده، باکفایت، مدرکتسهیلات زایمانی تعداد کافی از متخصصان زایمانی آ .7 کنند، های چندگانه کار میبا حرفه هایتیمهای چندگانه مناسب که در مهارتداشتن همراه زایمانی ماهر به )18.08(دارد. صصی به همراه مشاوره و نظارت پشتیبان برای پیشرفت کارکنان تختسهیلات زایمانی یک محیط مناسب و .8 )16.17(کند. تی منظم ایجاد میحمای های مشخص بر اساس ها و مسئولیتشود، با نقشای میسبب تسهیل همکاری بین حرفهتسهیلات زایمانی .1 )68.17(لیبر، زایمان و دوره اولیه پس از زایمان. ای و نیازهای مراقبت در طولمحدوده حرفه داد/فرایندبرون از کار در مورد توسعه تسهیلات دریافت مکتوبیسهیلات زایمانی که تعریف نسبت کارکنان زایمانی ماهر در ت .0 )08.18(. *اندکرده ماه گذشته، آموزش ضمن خدمت، جلسه بازآموزی 60نسبت اساتید زایمانی ماهر در تسهیلات زایمانی که در .6 )18.08(اند. یا مشاوره دریافت کرده )18.18(انایی بالینی و توسعه عملکرد در سه ماه گذشته. های نظارتی برای حمایت از توتعداد ویزیت .1 )11.77(ماه گذشته ارزیابی شده بودند. 60نسبت کارکنان تسهیلات زایمانی که حداقل یکبار در .1 )11.27(. کندبررسی را کیفیت صحیح و بهبودعملکرد شود تا برگزار میکه هر ماه تیم تعداد جلسات .1 )70.17(ان متخصص در هر ماه برای اطمینان از توانایی بالینی و بهبود عملکرد. تعداد تعاملات با مشاور .2 کیفیت فعال و بهبود ینسبت تمام کارکنان تسهیلات زایمانی که در شش ماه گذشته، حداقل در دو جلسه تیم .7 )17.17(. *کیفیت شرکت کرده بودند بهبودهای فعالیت پیامد تسهیلات زایمانی که از مراقبت و حمایت کارکنان تسهیلات ابراز رضایت نسبت تمام زنان زایمان کرده در .0 )01.68(کرده بودند. شان رضایت در تسهیلات زایمانی که ارزشیابی عملکرد قبلی پشتیباننسبت کارکنان زایمانی ماهر و کارکنان .6 بخش بود. )11.27(د. انشتهرضایت زیادی دااند که از کارشان نسبت تمام کارکنان تسهیلات زایمانی گزارش کرده .1 نسبت همه کارکنان تسهیلات زایمانی که در شش ماه گذشته، توانستند حداقل یک فعالیت توسعه بالینی که .1 )71.17(آنها شخصا در آن درگیر بودند، تشخیص و گزارش کنند. )26.12(نسبت تمام کارکنان تسهیلات زایمانی که فعالانه به دنبال کار جدیدی بودند. .1 تحققبه : مدیران و رهبران بالینی در تسهیلات زایمانی مسئول برای ایجاد و 1.1کیفیت یهبیان مداوم کیفیت حمایت بهبودمحیطی که از کارکنان تسهیلات در حفظهای مناسب و سیاست رساندن باشد.کند، میمی یو محیطبخشند بهبود مین جهت و ترغیب کارمندان عملکرد را بوسیله نشان داد ،بالینیمدیران خوب و رهبرانمنطق: .کنندایجاد میمداوم کیفیت بهبودکارکنان برای برای حمایت از های حکومتی مناسب، فرایندها و محیطی که از کارکنان برای ایجاد مدیران و رهبران بالینی، مسئولیت چندگانه، سیاست کیفیت بهبودتار مدیریتی تعریف شده و قدرت، خطوط مشخص و تیم مداوم کیفیت حمایت کند، وجود دارد. ساخ بهبود های ایمنی بیمار را ایجاد کرده و توسعه کیفیت و برنامه بهبودتعریف شده به همراه منابع وجود دارد. در مجموع، کارکنان، کنند.دهند و حمایت، نظارت و مشاوره دریافت میمی حول و حوش های های مادری، مرگمرگ(های منظم تسهیل حسابرسی برای اداره خطرات مالی و یسیاست و طرح ل برای هایی برای بهبود کیفیت در محل وجود دارند. سیستمی در محبه همراه توصیه )زایمان و شرایط نزدیک مرگ گیری و مآوری شده و گزارش و ارتباط با موضوعات اداره کیفیت برای راهنمایی جهت تصمیبازبینی منظم اطلاعات جمع شود.اداره عملکرد موجود است. مراقبت از بیمار و رضایت بطور منظم بازبینی شده و وضعیت پیشرفت کیفیت ثبت می های کیفیتگیریاندازه داددرون )81.88(. *روز برای پیشبرد کیفیت مراقبت و برنامه ایمنی بیمار داردمکتوب و بهتسهیلات زایمانی یک طرح .0 ها و خطوط مشخص های تعریف شده و مسئولیتهمراه نقشروز بهمکتوب و بهانی ساختار مدیریتی تسهیلات زایم .6 )10.78(. *برای گزارش کردن دارد )81.18(. *کیفیت مشخص و کارکنان مسئول دارد بهبودتسهیلات زایمانی تیم .1 )81.18(رضایت دارد. کردنفراهم بیمار و اطلاعات از آوری منظم هیلات زایمانی مکانیسمی برای جمعتس .1 کیفیت دارد که بهبودای برای بازبینی اطلاعات و بررسی عملکرد تسهیلات زایمانی حداقل ماهی یکبار جلسه .1 -کند، افرادی را که عملکرد خوب دارند مورد احترام قرار میمی ارائههایی برای تشخیص هر نوع مشکلی توصیه )10.18(کند. کنند، تشویق میلاش میدهد و کارکنانی را که برای پیشرفت ت جود بوده و برای همه در تسهیلات مو )هاها و دستورالعملسیاستشامل (امی فرایندهای حکومتی استاندارد تم .2 )02.68(باشد. کارکنان مربوطه قابل دستیابی می کننده، آموزش ، رفتارهای توانافاده از اطلاعاتاست(نسبت تمام مدیران تسهیلات زایمانی که در زمینه بهبود کیفیت .7 )71.08(. اندآموزش دیده بودند و منجر به تغییر شده )مداوم برای )کنندگان از خدمات، شرکامانند جامعه، استفاده( سالانه دو جلسه با سایر افراد ذینفع تسهیلات زایمانی حداقل .8 ها به بهبود کیفیت دارد.تن فعالیتهایی برای پیوستوصیه ارائهبازبینی عملکرد خود، تشخیص مشکلات و )18.18(های مدیریتی و رهبری آموزش دیده بودند. نسبت مدیران تسهیلات زایمانی که در زمینه مهارت .1 در جهت بهبود کیفیت و عملکردشانبازخورد برای اداره تسهیلات گرفتنبرای کارکنان جهت مرکزسیاستی در .10 )68.18(وجود دارد. ایندداد/فربرون -گیریمانند اندازه(های ثابت شده جهت بررسی مکانیسم از طریقمدیران تسهیلات زایمانی عملکرد تسهیلات را .0 )17.17(اند. داده گزارشبرای همه کارکنان مربوطه )های کلیدی سیاست )12.27(ماه گذشته تشکیل شده بود. 60نسبت جلسات ماهانه در مورد کیفیت مراقبت که عملا در .6 پیامد نسبت تمام زنان زایمان کرده در تسهیلات زایمانی که از مراقبت و حمایت کارکنان تسهیلات راضی بودند. .0 )11.18( )11.68(. )های تسهیلاتمطابق با سیاست(شواهد عملکرد بهبود یافته سیستم .6 1بع مورد استفاده در قسمت استاندارد امن :slliks noitaticsuser ycnegreme no gniniart fo tcapmI .AT eirwaL ,AM ulgozemlüG  tetsbO nilC seR tcarP tseB .5 dna 4 )sGDM( slaoG tnempoleveD muinnelliM no tcapmi .810.30.5102.nygbopb.j/6101.01 :iod ;)5102 loceanyG  ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014;384:1226–1235.  International Confederation of Midwives. Essential competencies for basic midwifery practice. The Hague; 2011 (http://www.internationalmidwives.org).  Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129–1145.  The Lancet. Midwifery. An executive summary for The Lancet’s series. London; 2014 (http://www.thelancet.com/pb/assets/raw/Lancet/stories/series/midwifery/midwifery_exe c_summ.pdf).  United Nations Population Fund. The state of the world’s midwifery: delivering health, saving lives. NewYork; 2011.  Whittaker S, Shaw C, Spieker N, Linegar A. Quality standards for healthcare establishments in South Africa. In: Padarath A, English R, editors. South African Health Review. Pretoria: National Department of Health; 2011:59–68 (http://www.cohsasa.co.za/sites/cohsasa.co.za/files/publication_pdfs/ chap_5_quality_standards_pgs_59-_68_0.pdf).  World Health Organization. Making pregnancy safer: the critical role of the skilled attendant – a joint statement by WHO, ICM and FIGO. Geneva; 2004 (http://www.who.int/maternal_child_adolescent/documents/9241591692/en/).  World Health Organization. World health report 2005. Make every mother and child count. Geneva;2005 (http://www.who.int/whr/2005/whr2005_en.pdf).  World Health Organization. World health report 2006. Working together for health. Geneva; 2006 (http://www.who.int/whr/2006/en/).  World Health Organization. District planning tool for maternal and newborn health strategy implementation: a practical tool for strengthening health management system. Geneva; 2011.  World Health Organization. Guidelines on maternal, newborn, child and adolescent health, approved by the WHO Guidelines Review Committee. Recommendations on newborn health. Geneva;2013 (http://www.who.int/maternal_child_adolescent/documents/guidelines- recommendationsnewborn-health.pdf).  World Health Organization Regional Office for Europe. Hospital care for mothers and newborn babies: quality assessment and improvement tool. Copenhagen; 2014 (http://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn- -ytilauq-seibab-nrobwen-dna-srehtomrof-erac-latipsoh/4102/snoitacilbup/htlaeh .)1=au?fdp.loot-tnemevorpmidna-tnemssessa : تسهیلات زایمانی محیط فیزیکی مناسب به همراه آب کافی، بهداشت و 8استاندارد ذخایر انرژی، داروها، منابع و تجهیزات متداول برای مادر و نوزاد و اداره مشکلات دارد. ، قابل اعتماد، زبالهامکانات انهدام بهداشت دست و امکانات ، : آب، انرژی، بهداشت1.8کیفیت یهبیان های آنها هستند.ایمن و کافی برای نیازهای کارکنان، زنان و خانواده ، زباله آب تمیز و الکتریسیته، بهداشت مناسب و انهدام ایمن همیشگیمحیط ایمن، تمیز و بهداشتی به همراه ذخایر منطق: .موجود هستندبیماران برای انجام همه فرایندها و مداخلات و کنترل عفونت بر اساس مراقبت مناسب از های بالینی یک منبع دائمی از آب سالم مستقر در محل، همیشه برای آشامیدن، تمیز کردن و شستن دست در تمام بخش بر اساس جنس، کاملا مجزا بهداشتی موجود بوده و هایتوالتشامل لیبر، زایمان، بخش نوزادان و اتاق عمل موجود است. کارکنان وبه آن باشد. تسهیلات زایمانی و تسهیلات وابستههایشان و کارکنان میو قابل دستیابی برای همه زنان، خانواده دارند. ها در تمامی زمان )مانند سیستم خورسیدی، ژنراتور یا شبکه برق(الکتریسیته محلی دسترسی قابل اعتمادی به منبع و تسهیلات وجود دارد. تسهیلات بودجه در زبالهو انهدام ایمن برخوردآوری، انتقال، ی برای تفکیک، جمعمکانیسم های بهداشتی دارد.دستورالعملی برای اجرا و نگهداری انرژی، آب سالم و سرویس های کیفیتگیریاندازه داددرون اختمان دارد که برای همه مصارف مانند آشامیدن، از آب سالم مستقر در س کارکردیتسهیلات زایمانی یک منبع .0 بهداشت کارکنان، مداخلات پزشکی، تمیز کردن، شستشو و پخت و پز برای استفاده توسط کارکنان، زنان، نوزادان )11.11(. *یاشدهای آنها کافی میو خانواده نگهداری اجسام تیز دارد که در دار، بدون نشتی و ظروف دار، پوششهای زباله برچسبتسهیلات زایمانی سطل .6 -زبالهاجسام تیز، مواد عفونی بدون تیزی، هستند که شاملبه چهار گروه موجود هازبالهمحل درمان برای تفکیک )88.11(. *باشندمی آناتومیکی مانند جفت هایزبالهها و عفونی عمومی مانند غذا و پک های یک ایستگاه بهداشت دست به همراه آب و تخت 10برای هر ها، حداقل بخش تمامیتسهیلات زایمانی در .1 )11.18(. *مالش دست داردالکلی صابون یا محلول همراه یک منبع انرژی بهدارد که )مانند سیستم خورشیدی، ژنراتور، شبکه برق(تسهیلات زایمانی منبع انرژی .1 برآورده کند. ها زمان تمامیابسته را در تسهیلات و ساختارهای و کیهمه نیازهای الکتریتواند پشتیبان می )01.18( و ضدعفونی نظافتدر مورد )پوستر(افزایش آگاهی ابزارروز و مکتوب و بههای تسهیلات زایمانی دستورالعمل .1 دارد که این هازبالهایمن مدیریتنظافت و ،و نگهداری آب، تجهیزات بهداشت مدیریتکردن، بهداشت دست، )11.88(اند. ، نصب شدهگیرندها انجام میهایی که فعالیتشموارد در بخ روشن در شب، قابل دسترس ر مناسبساختمان دارد که قابل استفاده، بطو ت زایمانی، امکانات بهداشتی درتسهیلا .2 باشد که شامل حداقل یک برای مردم با محدودیت حرکتی و مجزا براساس جنسیت برای کارکنان و بیماران می حداقل یک (صابون و آب به همراههای شستشوی دست لت برای اداره نیازهای بهداشت قاعدگی با ایستگاهتوا )21.78(باشد. می) های بستریپرستار در بخش 16لیتر برای هر هایشان همراه با تعاریف واضح در مورد مسئولیت دارد کهو کاملا آموزش دیده باانگیزه تسهیلات زایمانی کارکنان .7 در زمان مورد نیاز ،هامراقبت بهداشتی از زبالهو نگهداری آب، نظافت، بهداشت و امکانات مدیریت جهت تمیزی، )11.28(. در تسهیلات حاضر هستند آب، نظافت، بهداشت و خدمات از ذخیرهتسهیلات زایمانی بودجه کافی برای توانبخشی، بهبود و اداره مستمر و .8 )10.18(دارد. هامراقبت بهداشتی از زباله برای تمامی نیازهای ها در همه زمانمحلی دارد که ذخیرهو سوخت مدیریت ی برایتسهیلات زایمانی طرح .1 با بودجه کافی مورد )صورت مربوط بودن و در صورت نیاز در(وسایل نقلیه، پخت و پز و گرمایش مانندسوختی )61.18(است. قرار گرفتهحمایت های بهداشتی جهت پیشگیری نی طرح پیشگیری از خطر برای اداره و بهبود آب، نظافت و سرویستسهیلات زایما .10 )11.08(. *و کنترل عفونت دارد دارای یک برنامه مدیریت انرژی با بودجه کافی است که بطور مناسبی توسط کارکنان آموزش تسهیلات زایمانی .00 )26.77(. شودتنظیم میدار شود و توسط یک مقام صلاحیتدیده نگهداری می دادبرون در تسهیلات زایمانی بوده و از آب، نظافت و خدمات انرژی ابراز رضایت حاضر های آنها کهنسبت زنان و خانواده .0 )17.27(شان توصیه کرده بودند. خانوادهاعضای کرده و تسهیلات زایمانی را به دوستان و اندانرژی ابراز رضایت کرده خدماتیلات زایمانی که از آب، نظافت و نسبت تمام کارکنان مراقبت سلامتی در تسه .6 )16.27(کند. که این خدمات بطور مثبت به ایجاد مراقبت با کیفیت بالا کمک می در تسهیلات زایمانی بوده و از منبع انرژی و نور ابراز رضایت کرده بودند و حاضر هایشان کهنسبت زنان و خانواده .1 )16.17(پیشنهاد داده بودند. شانخانوادهاعضای انی را به دوستان و تسهیلات زایم دهی و نگهداری های لیبر، زایمان و پس از زایمان طوری طراحی، سازمان: بخش1.8کیفیت یهبیان -در محیط خلوت می در مراقبت مداوم، بر اساس نیازهایشاند که هر زن و نوزادی، برای تسهیل شده قبت قرار گیرد.تواند مورد مرا ای، تهویه خوب، منبع انرژی و بهداشت خوب اداره تسهیلات زایمانی باید کافی بوده و با خدمات پایه زیرساختهایمنطق: شود. -های لیبر و زایمان یا اتاقکه نزدیک به بخشاند دهی شدهسازمان اختصاصیهای خدمات عمومی به بخش هایزیرساخت ، ر و نوزادهم اتاقی مادهای یا اتاق هاپس از زایمان ، بخشویژه های های ارزیابی، بخشبخش پذیرش، تریاژ،مانند (ها د و نباشمی )سزارین عمل، بخش نوزادان بیمار، بخش مراقبت کانگرویی، واحد مراقبت ویژه نوزادان، اتاق های نوزادانبخش . واحدهای خدمت تمیز، با تهویه خوب و روشن بویژه در شب دانبهینه، موثر و سازگار تجهیز شدهمراقبت بطور مناسبی برای تخت مانند (شده خوبی حفظبهبوده و خدمات اساسی کافی، ایمن، تمیز، )پرده، دیوارداشتن مانند (با محیط خصوصی در محل موجود هستند. )توالت ها، ملافه تخت، خدمات شستشو، حمام وها، ملافهخواب تهای کیفیگیریاندازه داددرون که بطور کامل با یک میز یا تسهیلات زایمانی یک بخش اختصاصی در واحد لیبر و زایمان برای احیا نوزادان دارد .0 )72.11(. *و ذخایر احیا مناسب مجهز شده استکننده، بخاری تابشی، نور و تجهیزات وسیله احیا ا واحدهایی برای تعداد تخمینی از تولدها در واحد تسهیلات زایمانی یک بخش لیبر و تعداد کافی اتاق زایمان ی .6 )60.11(. *خدمت دارد های وابسته دارد که تمیز، بطور مناسب روشن، با تهویه تسهیلات زایمانی واحدهای لیبر، زایمان و نوزادان و بخش .1 . *شودمی ایجاد محیط خصوصی شده و بطور کافی مجهز شده و بطور منظم تمیز و نگهداری باعث خوب بوده و )61.18( ساعت 16تا مادران و نوزادان در کند ایجاد میاتاقی مادر و نوزاد برای همه زنان امکان همتسهیلات زایمانی .1 )71.28(شبانه روز کنار هم بمانند. الت ، تمیز و قابل دستیابی و توقابل استفادهتسهیلات زایمانی واحد لیبر و زایمان یا اتاقی با یک حمام یا دوش .1 )11.88(برای استفاده صرف توسط زنان در لیبر دارد. از به آسانی و بوده در نزدیکی لیبر و زایمان دارد کهمجهز اتاق عملدهد تسهیلاتی که خدمات جراحی ارائه می .2 )18.88(. قابل دستیابی استواحدهای لیبر و زایمان )11.28(دارد. (بیماری) زنان با مشکلاتتسهیلات زایمانی اتاق اختصاصی ریکاوری یا واحدی برای .7 تسهیلات زایمانی یک بخش اختصاصی برای پذیرش کودکان کوچک و ناپایدار از نظر علائم و بیمار دارد. .8 )71.28( داد/فرایندبرون اند که یک محیط فیزیکی تمیز و آماده برای در تسهیلات زایمانی که گزارش کرده حاضر نسبت همه زنان حامله .0 )12.68(. داشتندزایمان پیامد با به توالت، که تمیز، نزدیکنسبت همه زنان زایمان کرده در تسهیلات زایمانی که از بخش لیبر و زایمان .0 )08.08(ابراز رضایت کرده بودند. بود، محیط خصوصیو کم سطح شلوغیروشنایی عمومی، تجهیزات برای مراقبت روتین و اداره مشکلات کافی از داروها، منابع و هیر: ذخ1.8کیفیت یهبیان موجود هستند. هستند. ضروری ،مراقبت با کیفیت مطلوبارائه داروهای ضروری کافی و موجود، تجهیزات و سایر منابع برای منطق: ذخیره تمیز و بصورتآنها و دستورات، از و موارد استفاده )های آزمایشگاهیمعرف مانند( ذخایرضروری و لیستی از داروهای بندی وجود دارد. تمامی داروهای مناسب در واحدهای یستم کافی برای پیشگیری از سهمیهبرای این موارد با یک س ایمن های مناسب، در تمامی . تجهیزات ضروری در مکان)وم سولفات در واحد لیبر و زایمانیمانند منیز(بالینی موجود هستند . هستندتجهیزات موجود این برای استفاده مناسب از ییهاهداری منظم و دستورالعملها، با یک سیستمی برای نگزمان برای استفاده روتین و اداره مشکلات موجود هستند. )مانند هموگلوبین، گروه خونی، پروتئین ادرار(های آزمایشگاهی تست های لیبر و نوزادان وجود دارد.خون برای خدمات تزریق موجود بوده و یک ذخیره قطع نشدنی از اکسیژن در واحد های کیفیتگیریاندازه داددرون تسهیلات زایمانی به مقدار کافی ذخایری از داروهای کاهنده فشار خون و منیزیوم سولفات دارد که در هر زمانی .0 )08.61(. *در واحدهای لیبر، زایمان و پس از زایمان برای اداره زنان مبتلا به پره اکلامپسی دارد -، ستهاسرسوزنها، سرنگمانند (برای انفوزیون داخل وریدی امکاناتیتسهیلات زایمانی، داروی یوتروتونیک و .6 ها در واحدهای دارد که به مقدار کافی در همه زمان )های انفوزیون داخل وریدی و خونهای انفوزیون، محلول )01.61(. *پس از زایمان موجود است زایمان و مراقبت پس از زایمان برای اداره زنان با خونریزی قبل از زایمان مانند بتامتازون یا دگزامتازون، برای استفاده در تسهیلات زایمانی ذخایری از کورتیکواستروئیدهای .1 های زودرس موجود ها برای اداره زایمانها و منیزیوم سولفات دارد که به مقدار کافی در همه زمانیوتیکآنتی )10.61(. *است ج، گوشی دماسنج، فشارسن(مشکلات تشخیصضروری برای لات زایمانی تجهیزات و ذخایر عملکردیتسهی .1 ها در واحدهای لیبر و زایمان از بخش دارد که به تعداد کافی در همه زمان )اکسیمتریمامایی،کاغذ ادرای، پالس )12.01(مامایی موجود است. ها های خط اول و دوم و سایر داروهای ضروری دارد که در همه زمانکبیوتیتسهیلات زایمانی ذخایری از آنتی .1 برای اداره زنان و نوزادان در معرض خطر عفونت در طول لیبر، زایمان و دوره اولیه پس از زایمان موجود است. )81.01( گلبول قرمز، گروه خون، هموگلوبین یا حجممانند قند ( یتسهیلات زایمانی ذخایر آزمایشگاهی ضروری و آزمایشات .2 های عملکردی ها، تستروبین، پروتئین ادرار، شمارش کامل خون، کشت خون، الکترولیتخونی و کراس مچ، بیلی )60.01(برای حمایت از اداره زنان و نوزادان دارد. )های تشخیصی سریع مالاریاکلیه و کبد، سیفلیس، ایدز و تست های زایمانی، وکیوم، فورسپس، انکوباتور، شامل تخت(یزات عملکردی تسهیلات زایمانی ذخایر ضروری و تجه .7 )88.11( هستند.به تعداد کافی در واحدهای لیبر و زایمان موجود همیشهدارد که )های استریلترازو، دستکش تجهیز وب ترالی احیا خشامل (تسهیلات زایمانی ذخایر و تجهیزات عملکردی برای مراقبت اورژانسی و احیا زنان .8 های داخل تراشه، بگ و ماسک بزرگسالان، متری، راه هوایی، لارنگوسکوپ، لولهاکسیشده، وسایل ساکشن، پالس در واحدهای طراحی شده برای لیبر، همیشهکافی دارد که به تعداد )های انفوزیون، مایعات داخل وریدیست )17.18(. هستندزایمان و مراقبت پس از زایمان موجود -های بینی، کاتترها و ماسکلولهمانند (لات زایمانی منبع ایمن و قطع نشدنی از اکسیژن و تجهیزات زایمانی تسهی .1 نوزادان و اتاق همیشه در واحدهای لیبر، زایمان،باشد که دارد که شامل فشار مثبت مداوم راه هوایی بینی می )ها )71.18(عمل موجود است. مانند جدول احیا، ترالی (زات عملکردی برای مراقبت اورژانسی و احیا نوزادان تسهیلات زایمانی ذخایر و تجهی .10 دارد که )متری، لارنگوسکوپاکسی، وسایل ساکشن، پالستابشی خوب تجهیز شده احیا نوزادان، گرمادهنده )61.18(. هستنددر واحدهای طراحی شده برای لیبر، زایمان و مراقبت پس از زایمان موجود همیشه دیده یا داروساز دارد که توسط یک داروشناس آموزش سهیلات زایمانی داروخانه، دارو و سیستم اداره انبار ذخایرت .00 )11.88(شود. اداره می و ذخایر دارویی برای )و نگهداری از آنها(تسهیلات زایمانی بودجه اختصاصی برای داروهای ضروری، تجهیزات .60 )11.18(مراقبت از مادر و نوزاد دارد. توانند معاینه تسهیلات زایمانی دستگاه اولتراساند تشخیصی عملی و کارکنان سلامتی آموزش دیده دارد که می .10 های ها، تعیین سن حاملگی، تشخیص قبل از زایمان ناهنجاریاولتراساند مامایی پایه برای تعیین تعداد جنین )18.18(جنینی یا تشخیص زودرس عدم کفایت جفتی انجام دهند. داد/فرایندبرون -دگزامتازون، ویتامین کا، آموکسی منیزیوم ،سولفات اکسیژن، مانند (زندگی دهندهنجات وجود داروهای ضروری .0 سیلین ، سفتریاکسون، مترونیدازول، داروهای ضد مالاریا، داروهای ضد پنی بنزیلسیلین تزریقی و خوراکی، )18.88(در سه ماه گذشته. )بی و فلج اطفال ها و داروهای سل، هپاتیتویروسی، واکسن منیزیوم را سولفات اکلامپسی شدید یا اکلامپسی در تسهیلات زایمانی که دوز کامل نسبت همه زنان مبتلا به پره .6 )81.17(اند. بخاطر اتمام منبع دریافت نکرده اند. یل ضروری را خریداری کردهنسبت همه زنان زایمان کرده در تسهیلات زایمانی که دستکش یا سایر وسا .1 )62.17( پیامد خودبخود لیبر باکه هفته 71زا با حاملگی تک قلویی سفالیک با حاملگی مساوی یا بالای نسبت تمام زنان اول .0 )11.68(. )nosboR 0گروه (اند تحت سزارین قرار گرفته )08.17(کارکنان آموزش دیده برای انجام سزارین. یا منابعسزارین در نتیجه کمبود برای نسبت نیاز برآورده نشده .6 درادناتسا تمسق رد هدافتسا دروم عبانم8  Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Safe management of wastes from health-care activities. Geneva: World Health Organization; 2014 (http://www.who.int/water_sanitation_health/publications/wastemanag/en/).  Water Supply and Sanitation Collaborative Council. WASH targets and indicators post- 2015: recommendations from international consultations. Geneva; 2014 (http://www.wssinfo.org/fileadmin/user_upload/resources/post-2015-WASH-targets- factsheet-12pp.pdf).  World Health Organization. Essential elements of obstetric care at first referral level. Geneva; 1991 (http://apps.who.int/iris/bitstream/10665/41740/1/9241544244.pdf).  World Health Organization. Essential environmental health standards in health care. Geneva; 2008 (http://www.who.int/water_sanitation_health/hygiene/settings/ehs_health_care.pdf.pdf).  World Health Organization. Systems thinking for health systems strengthening. Geneva; 2009 (http://www.who.int/alliance-hpsr/resources/9789241563895/en/).  World Health Organization. Evaluating household water treatment options: health based targets and microbiological performance specifications. Geneva; 2011 (http://www.who.int/water_sanitation_health/publications/household_water/en/).  World Health Organization. Service availability and readiness assessment. Geneva; 2014 (http://apps.who.int/iris/bitstream/10665/149025/1/WHO_HIS_HSI_2014.5_eng.pdf).  World Health Organization, UNICEF. Progress on drinking-water and sanitation: Joint Monitoring Programme update 2014. Geneva; 2014 (http://www.who.int/water_sanitation_health/publications/jmp-report-2014/en/).  World Health Organization, UNICEF. Water, sanitation and hygiene in health care facilities. Status in low- and middle-income countries and way forward. Geneva; 2015 (http://apps.who.int/iris/bitstream/10665/154588/1/9789241508476_eng.pdf). یات. عمل6 زنان و نوزادان حمایت ازهای سلامتی که از مراقبت مطلوب اقبت بر پایه شواهد، موثر، با کیفیت بالا و عناصر سیستممر بکار بردن استانداردهای مراقبت و از طریق اند،تعریف شده ارچوب مراقبت با کیفیت سازمان جهانی بهداشتدر چ کنند ومی از جزئیات فرایندهای باشند تا هر کشوری متناسب با ظرفیتاستانداردها باید .باشندمی عملقابل کیفیت، های بیانیه ، )1-2(، تجربه مراقبت )1(های ارجاعی ، سیستم)6(های اطلاعاتی ، سیستم)0استاندارد (مراقبت بالینی بر پایه شواهد های کیفیت بر پایه شواهد بیانیه همراه با . استانداردهااطمینان حاصل شود )8(و منابع کافی )7(نیروی کاری توانا و مشتاق و مراقبت با بخشیدهباشند. این موارد کیفیت را بهبود دادها و پیامدها می، بروندادهادرون گیریکه شامل اندازه باشندمی به هر کشور و استانداردها باید بر اساس تجراستقرار برای نظراتخواهد کرد. تضمین را مادران و نوزادان ازکیفیت بالا .یا بین کشورها باشد کشوری مطابق با آموزش درون انتشار: 1.6 توانند در اسناد که می شوندمیمرجع تکنیکی منتشر سندهای کیفیت در یک گیریب، استانداردهای مراقبت و اندازهارچوچ عمول برای حمایت از بهبود کیفیت قسمتی از یک بسته از ابزارهای م این اسناد. گنجانده شوداستراتژیک در سطح کشور به تر ای سازمان جهانی بهداشت برای گردش گستردهبا همکاری ادارات منطقهمراقبت از مادران و نوزادان هستند. آنها های اداره سازمان جهانی سایتهای عربی، فرانسوی، روسی، اسپانیایی ترجمه خواهند شد. انتشارات موجود از وبزبان های سازمان جهانی بهداشت و ادارات همراه که در کشورها، مرکز همکاریادارات موجود در ای و رات منطقهبهداشت، ادا دفاتر یتمام نشریه بهاین کپی هاینسخه، قابل دانلود خواهند بود. کنندکار میزمینه مراقبت با کیفیت از مادر و نوزاد فروش از کتابفروشی سازمان جهانی بهداشت و شبکه توزیع آن برای و شودمنتشر میکشوری سازمان جهانی بهداشت خواهند بود. های اشخاص در دسترسهای پزشکی و کتابخانهتمامی کتابخانهبرای : تهیه رویکرد1.6 در سازیهای آموزشی و ظرفیتکارگاههای کیفیت، گیریاز استانداردهای مراقبت و اندازهو استفاده دسترسیافزایش برای بعمل کشورها از مندخواهد شد. حمایت هدف ایجادای سازمان جهانی بهداشت در همراهی با ادارات منطقه مناطقامی تم میان داخل یا در در هاشیوهبهترین به اشتراک گذاشتن یادگیری برای یک فرمت توسط یک رویکرد نوآورانه، و آمدخواهد شواهد پایهبوده و بر )66(» tcA ydutS oD nalP«با مدل سازگاریکه در )1شکل (ایجاد خواهد شد کشورها با تنظیم اهداف و ایجاد ،ای جهت بهبود مستمر کیفیتمورد، برنامه. این باشدو تجربه می عملکرد، بهترین استخراج شده یا پیچیده منظورهدی، چندانفرامداخلات (های تغییر برنامه استفاده از بسته از طریقهایی برای دستیابی به نتایج مطلوب تیم کند. فراهم میسازی جهت پیاده هابه حداکثر رساندن فرصتها برای و سایر استراتژی سازی، ظرفیت)و نیازها زمینهبسته به : رویکرد تهیه شده1شکل جاد ساختارهای مدیریتی و عملیای .0 موقعیت/ارزیابی تجزیه و تحلیل .1 با استانداردهای مراقبت سازگاری .6 های ضروری برای شروعاطمینان از زیرساخت .1 توانایی ایجاد .5 انجامو مداخلات اصلاح .7 ها استراتژی طبقه جهت بندی طرح انجام مطالعه عمل و پیامدها هاکیفیت مراقبت گیری مداوماندازه .2 کیفیت ازکیفیت سلامت مادر و نوزاد در استراتژی مراقبت ایجاد سیستمی جهت بهبود برای، گام به گام راهنماییعلاوه، به همراه کشوری قوی برای مدیریت سازی ظرفیتبا هدف ابزارهای ضروری و هدایت با خواهد کرد. عملیاتی ارائهملی و خواهد بود. ارزیابی . بررسی و1 همراه بهد بود. بررسی درونی و ارزیابی بررسی درونی و بیرونی و ارزیابی طرح خواه به همراهایجاد این استانداردها دقیق اجرا. بررسی بیرونی و ارزیابی برای ارزیابی خواهد شدیادگیری وصل فرمپلت خروجی و به بودراهنمایی خواهد ، فرایند )های عملی و نیمه تجربیطرح(اطمینان از موثر بودن جهتهای مطالعه های گوناگون، منابع و طرحبوسیله روش ها برای بهبود خواهد شد. نتایج هر دو بررسی درونی و بیرونی و ارزیابی انجامو کفایت مالی )های کمی و کیفیطرح( یادگیری مورد استفاده قرار خواهد گرفت. فرمپلتدستورالعمل و رسانی استانداردها روز. به8 ی استادنداردهای مراقبت و روزرسانبرای بازبینی و بهرزیابی ایجاد، یادگیری و ا فرمپلتبهترین عملکرد گزارش شده در مورد مورد استفاده قرار خواهد گرفت. )در صورت مناسب بودن(های کیفیت گیریاندازه عبانم 1. Raven JH, Tolhurst RJ, Tang S, van den Broek N. What is quality in maternal and neonatal health care? Midwifery 2012;28:e676–e683. 2. Tuncalp Ö, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al, Quality of care for pregnant women and newborns – the WHO vision. Br J Obstet Gynaecol 2015;122:1045–1049. 3. World Health Organization. Strategies toward ending preventable maternal mortality. Geneva; 2015 (http://who.int/reproductivehealth/topics/maternal_perinatal/epmm/en/,accessed 22 March 2015). 4. World Health Organization. Every newborn: an action plan to end preventable deaths. Geneva; 2014 (www.who.int/maternal_child_adolescent/topics/newborn/enap_consultation/en/, accessed 19 January 2015). 5. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health 2014;2: e323–e333. 6. WHO Global Health Observatory. 2014 (http://apps.who.int/gho/data/?theme=main,accessed 12 January 2015). 7. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347–370. 8. United Nations. Global strategy for women’s and children’s health. New York; 2010. 9. Campbell OM, Graham WJ. Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284–1299. 10. Global Health Group. Where women go to deliver: overview of the project and review of preliminary findings. San Francisco, California: University of California at San Francisco, Global Health Sciences; 2014. 11. World Health Organization. WHO multicountry survey on maternal and newborn health 2010–2012. Geneva; 2011 (http://www.who.int/reproductivehealth/topics/maternal_perinatal/nearmiss/en/). 12. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gulmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health 2014;11:71. 13. World Health Organization. The second report of the independent expert review group (iERG) in information and accountability for women’s and children’s health. Geneva; 2013. 14. Wilson L, Goldsmith P. Quality and its measurements. In: Wilson L, Goldsmith P, Editors. Quality management in health care. Sydney: McGraw-Hill; 1995;229–258. 15. Roemer MI, Montoya-Aguilar C. Quality assessment and assurance in primary health-care. Geneva: World Health Organization; 1988. 16. Institute of Medicine. A strategy for quality assurance. Washington DC: National Academy Press; 1990. 17. World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva; 2006. 18. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260:1743–1748. 19. Maxwell RJ. Dimensions of quality revisited: from thought to action. Qual Health Care1992; 1:171–177. 20. Ovretveit J, Bate P, Cleary P, Cretin S, Gustafson D, McInnes K, et al. Health service quality. An introduction to quality methods for health services. Oxford: Blackwell Scientific Publications; 1992. 21. Hulton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Southampton: University of Southampton; 2000. 22. International Organization for Standardization. Geneva (http://www.iso.org/iso/home/standards.htm accessed 24 June 2016) 23. The Joint Commission. Oakbrook Terrace, Illinois http://www.jointcommission.org/standards_information/jcfaq.aspx accessed 24 June 2016. 24. The Council for Health Service Accreditation of Southern Africa (COHSASA) accreditation standards. Pretoria (http://www.cohsasa.co.za/ accessed 24 June 2016). 25. National Institute for Health and Care Excellence. London (https://www.nice.org.uk/standards-and-indicators accessed 24 June 2016). 26. Pharmaccess group. Safe care basic healthcare standards. The Hague (http://www.safecare.org/index.php?page=safecare-standards accessed 24 June 2016). 27. World Health Organization. Standards for maternal and neonatal care. Group 1: General standards of care for healthy pregnancy and childbirth. Geneva; 2007 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/a9 1272/en/) همیمض1سوت هورگ هسلج رد ناگدننک تکرش : ،ونژ ،لمعلاروتسد هع1-1 نئوژ1115  Dr Pierre Barker, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA  Mrs Sheena Currie, Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA  Dr Kim Dickson, UNICEF, New York City (NY), USA  Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden  Dr Kathleen Hill, JHPIEGO, Washington DC, USA  Dr Asia Kassim Hussein, UNICEF, Dar-es-Salaam, United Republic of Tanzania  Dr Theopista John, WHO Country Office, Dar-es-Salaam, United Republic of Tanzania  Dr Lily Kak, Global Partnerships and Newborn Health, Washington DC, USA  Dr Senait Kebede, Emory University, Atlanta, Georgia, USA  Professor Joy Lawn, London School of Hygiene and Tropical Medicine, London, United Kingdom  Dr Tess Lawrie, Evidence-based Medicine Consultancy Ltd, Bath, United Kingdom  Mr Norman Lufesi, Ministry of Health, Lilongwe, Malawi  Dr Carolyn Maclennan, Alice Springs Hospital, Alice Springs, NT, Australia  Dr Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany  Dr Md. Ziaul Matin, UNICEF, Dakka, Bangladesh  Dr Goldy Mazia, Maternal and Child Survival Program, PATH, Seattle, Washington, USA  Dr Georgina Msemo, Ministry of Health and Social Welfare, Dar-es-Salaam, United Republic of Tanzania  Dr Jim Neilson, Professor of Obstetrics & Gynaecology, University of Liverpool,  United Kingdom  Mr Lee Pyne-Mercier, Bill & Melinda Gates Foundation, Seattle, Washington, USA  Dr Isabella Sagoe-Moses, Ministry of Health, Accra, Ghana  Dr Memuna Tanko, Acting Director, Quality Assurance, National Health Insurance Authority, Accra, Ghana  Professor Nynke van den Broek, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, United Kingdom  Ms Donna Vivio, Senior Newborn Health Advisor, United States Agency for International Development, Washington DC, USA  Dr Nabila Zaka, Senior Advisor Health, UNICEF, Geneva, Switzerland همیمض1 هعلاطم رد ناگدننک تکرش زا یتسیل :Delphi  Joel Adze, Kaduna State University, Kaduna, Nigeria  Anna Afugglas, United Nations Population Fund, Phnom Penh, Cambodia  Dr Elnahas Amir, Sidra Medical and Research Center, Doha, Qatar  Professor Surasak Angsuwathana, Faculty of Medicine, Mahidol University, Bangkok, Thailand  Sir Sabaratnam Arulkumaran, FIGO, London, United Kingdom  Dr Deorari Ashok, All-India Institute of Medical Sciences, New Delhi, India  Ms Joanne Ashton, Joint Commission International, Oakbrook Terrace, Illinois, USA  Professor Nabhan Ashraf, Ain Shams University, Cairo, Egypt  Dr Alberta Bacci, Independent consultant, Lisbon, Portugal  Dr Solange Balaga, , Independent Consultant, Kinshasa, Democratic Republic of the Congo  Dr Cyprien Baribwira, Maryland Global Initiative Corporation (MGIC), Kigali, Rwanda  Dr Suppawat Boonkasidecha, Queen Sirikit National Institute of Child Health, Bangkok Thailand  Dr Betzabe Butron, WHO Regional Office for the Americas, Washington DC, USA  Dr Romano Byaruhanga, Kampala Medical Chambers Hospital, Kampala, Uganda  Ms Anna Coates, WHO Regional Office for the Americas, Washington DC, USA  Dr Jeanine Umutesi Condo, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda  Dr Dilberth Cordero, WHO Country Office, Tegucigalpa, Honduras  Ms Sheena Currie, JHIEGO and Maternal and Child Health Integrated Program, United States Agency for International Development, Washington DC, USA  Dr Louise Day, LAMB Integrated Rural Health and Development, Dakka, Bangladesh  Professor Soo Downe, Research in Childbirth and Health Group, London, United Kingdom  Atf Gherissi, El Manar University, Tunis, Tunisia  Professor Michael English, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya  Professor Jan Jaap Erwich, University of Groningen, Groningen, Netherlands  Professor Vicki Flenady, University of Queensland, Herston, Australia  Mr Fabrice Fotso, UNICEF West and Central Africa Regional Office, Dakar, Senegal  Dr Sabine Gabrysch, Heidelberg University, Heidelberg, Germany  Dr Karima Gholzbhouri, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt  Dr Gathari Gichuhi, Ministry of Health, Nairobi, Kenya  Dr Aparajita Gogoi, Whiteribbon Alliance, New Delhi, India  Dr Rogelio Gonzalez, Centre for Perinatal Diagnosis, Catholic University of Chile, Santiago, Chile  Professor Malik Goone wardene, Faculty of Medicine, University of Ruhuna, Sri Lanka  Ms Ana Guerreiro, independent consultant, Lisbon, Portugal  Privat Guie, Polyclinic Internationale sainte Anne Marie, Abidjan, Cote d’Ivoire  Ms Gill Gyte, University of Liverpool, Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom  Ms Fransisca Handy, Apotek Puri Satu Kembangan, Jakarta, Indonesia  Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden  Dr Jim Heiby, United States Agency for International Development, Washington DC, USA  Dr Jorge Hermida, Assist/University Research Co., Quito, Ecuador  Dr Kathleen Hill, United States Agency for International Development, ASSIST Project, Washington, DC, USA  Dr Stephen Hodgins, Save the Children, Washington DC, USA  Dr Caroline Homer, University of Technology, Sydney, Australia  Ms Petra Hoope-Bender, Instituto de Cooperaciَn Social – Integrare, Barcelona, Spain  Dr Grace Irimu, Kenyatta University, Nairobi, Kenya  Ms Rima Jolivet, White Ribbon Alliance for Safe Motherhood, Washington, DC, USA  Dr Theopista Kabuteni-John, WHO Country Office, Dar-es-Salaam, United Republic of Tanzania  Dr Lily Kak, United States Agency for International Development, Washington DC, USA  Dr Ariel Karolinski, WHO Country Office, Buenos Aires, Argentina  Professor Holly Kennedy, Yale University, Boston (MA), USA  Dr Neena Khadka, Maternal and Child Survival Program, Washington DC, USA  Prof Zulfiya Khodjaeva, Federal Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation  Dr Tamar Khomasuridze, United Nations Population Fund, European Regional Office, Ankara, Turkey  Dr Andre Lalonde, The Society of Obstetricians and Gynaecologists of Canada (SOGC), Ottawa, Canada  Dr Marzia Lazzerin, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Italy  Dr Li Wenying, Aviation General Hospital of China Medical University, Beijing, China  Dr Jerker Liljestrand, Bill and Melinda Gates Foundation, Seattle, USA  Dr Liu Cheng, Beijing Armed Police Corps Hospital, Beijing, China  Dr Nigel Livesley, University Research Co., Bethesda, USA  Mr Norman Lufesi, ARI/Community Health Service, Ministry of Health, Lilongwe, Malawi  Ms Silke Mader, European Foundation for the Care of Newborn Infants, Munich, Germany  Dr Kuhu Maitra, Abt Associates, Cambridge (MA), USA  Prof Zoe Matthews, University of Southampton, Southampton, United Kingdom  Dr Goldy Mazia, PATH, Seattle (WA), USA  Dr Alison McFadden, University of Liverpool, Liverpool, United Kingdom  Ms Alison Mcintyre, WaterAid, East Melbourne, Australia  Prof Tarek Meguid, Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania  Dr Tanko Memuna, National Health Insurance Authority, Accra, Ghana  Dr Abraham Mengistu, Ministry of Health, Addis Ababa, Ethiopia  Dr Raul Mercer, Universidad Nacional de La Plata, Buenos Aires, Argentina  Dr Allisyn Moran, United States Agency for International Development, Washington DC, USA  Dr Rintaro Mori, National Centre for Child Health and Development, Tokyo, Japan  Dr Georgina Msemo, Ministry of Health, Dar-es-Salaam, United Republic of Tanzania  Dr Bremen de Mucio, WHO Country Office, Montevideo, Uruguay  Dr Christine Muzel, Philips Healthcare, Amsterdam, Netherlands  Dr Victoria Nakibuka, Nsambya Hospital, Kampala, Uganda  Dr James Neilson, University of Liverpool, Liverpool, United Kingdom  Dr Hiromi Obara, Bureau of International Medical Cooperation, Tokyo, Japan  Dr Dwiana Ocviyanti, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia  Dr Jeanne Odette, Université du Burundi, Bujumbura, Burundi  Prof Pius Okong, Health Service Commission, Kampala, Uganda  Dr Eduardo Ortiz-Panozo, Centro de Investigaciones Regionales, Mérida, Mexico  Prof Ouadraogo Charlemagne, Centre Hospitalier Universitaire Yalgado, Ouagdougou, Burkina Faso  Dr Duran Pablo, WHO Country Office, Montevideo, Uruguay  Dr Imran Pambudi, Ministry of Health Indonesia, Jakarta, Indonesia  Dr Robert Pattinson, Maternal and Infant Health Care, South Africa Medical Research Council, Kalafong Hospital, Pretoria, South Africa  Dr Loveday Penn-Kekana, University of the Witwatersrand, Johannesburg, South Africa  Dr Emily Peterson, Centers for Disease Control and Prevention, Atlanta (GA), USA  Dr Cynthia Pileggi, Ribeiro Preto Medical School, University of Sمo Paulo, Sمo Paulo, Brazil  Dr Neil Prose, Duke University, Durham (NC), USA  Ms Pamela Putney, Options Consultancy Services Limited, London, United Kingdom  Dr Neena Raina, WHO Regional Office for South- East Asia, New Delhi, India  Prof Kathryn Ramsey, Columbia University Medical Center, New York, USA  Prof Mary Renfrew, Scottish Improvement Science Collaborating Centre, Dundee, United Kingdom  Dr Alexander Rowe, Centers for Disease Control and Prevention, Atlanta (GA), USA  Prof Irina Ryumina, Research Centre for Obstetrics, Gynaecology and Perinatology, Moscow, Russian Federation  Dr Harshad Sanghvi, JHPIEGO, Baltimore, MD, USA  Prof Ola Saugstad, University of Oslo, Oslo, Norway  Dr Kerri Schuiling, International Confederation of Midwives, Rochester (MI), USA  Ms Gloria Seguranyes, University of Barcelona, Barcelona, Spain  Ms Priti Dave Sen, Children’s Investment Foundation, London, United Kingdom  Dr Hemantha Senanayake, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka  Prof Shi Qi, North Sichuan Medical College, Obstetrics and Gynaecology, Nanchong, China  Dr Miannes Silvestre, University of the Philippines College of Medicine, Manila, Philippines  Dr Jeffrey Smith, JHPIEGO, Baltimore, MD, USA  Dr Howard Sobel, WHO Regional Office for the Western Pacific, Manila, Philippines  Prof Williams Stones, FIGO, London, United Kingdom  Dr Tang Zengjun, Hebei Provincial People’s Hospital, Shijiazhuang, China  Ms Nicole Thiele, European Foundation for the Care of Newborn Infants, Munich, Germany  Dr Paul Vinod, All-India Institute for Medical Sciences, New Delhi, India  Ms Donna Vivio, United States Agency for International Development, Washington DC, USA  Dr Gijs Walraven, Aga Khan Development Network, Paris, France  Dr Wang Yeping, Wenzhou City People’s Hospital, Wenzhou, China  Dr Martin Weber, WHO Regional Office for Europe, Copenhagen, Denmark  Prof Zhang Hongyu, Hainan Medical, Haikou, China  Dr Zhang Jim, Shanghai Jiao Tong University School of Medicine, Shanghai, China  Dr Zhou Wei, Chongqing medical university, Chongqing, China  Dr Nabila Zaka, UNICEF Headquarters, New York, USA  Professor Zhang Huixin, Fourth Hospital of Hebei Medical University, Shijiazhuang, China STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES

Standardi za poboljšanje kvalitete njege za majku i novorođenče u zdravstvenim ustanovama Udruženje Prirodan Porod Sarajevo, 2018. Objavila Svjetska zdravstvena organizacija (2016) pod naslovom “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities” © World Health Organization (2016) Svjetska zdravstvena organizacija je ustupila pravo na prevod i publikaciju izdanja “Standardi za poboljšanje kvalitete njege za majku i novorođenče u zdravstvenim ustanovama” udruženju Prirodan Porod, koji je jedini odgovoran za kvalitetu i vjerodostojnost tumačenja “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities”. U slučaju bilo kakvih diskrepanci između engleske verzije i bosanske verzije, originalna engleska verzija je jedina obavezujuća i autentična verzija. “Standardi za poboljšanje kvalitete njege za majku i novorođenče u zdravstvenim ustanovama” © Udruženje Prirodan Porod (2018) 1. Zdravstvene usluge majke. 2. Majčino blagostanje. 3. Novorođenče i beba. 4. Zdravstvene usluge djeteta. 5. Standardi pružanja zdravstvene njege. 6. Perinatalna njega. I. Svjetska zdravstvena organizacija. Izdavač: Udruženje Prirodan Porod, Sarajevo Uredila: Amira Ćerimagić Prevele: Lejla Hasandedić - Đapo Dolores Radonić Amira Ćerimagić Lektorisala: prof. Dženana Bajraktarević Recenzenti: Amela dr Hodža, spec.ginekologije i akušerstva Amira dr Ćerimagić Tehnički urednik: Adnan Tatarević Grafički Dizajn: 'Belma Art' Publikacija dostupna kao e-knjiga na web stranici Udruženja Prirodan Porod na linku: http://www.prirodanporod.com/wp-content/uploads/2016/01/Standardi-za-poboljsanje- kvalitete-njege-za-majku-i-novorodjence-u-zdravstvenim-ustanovama.pdf CIP - Katalogizacija u publikaciji Nacionalna i univerzitetska biblioteka Bosne i Hercegovine, Sarajevo 006.32:618.2] WORLD Health Organization Standardi za poboljšanje kvalitete njege za majku i novorođenče u zdravstvenim ustanovama [Elektronski izvor] / World Health Organization ; [prevele Lejla Hasandedić-Đapo, Dolores Radonić, Amira Ćerimagić]. - El. knjiga. - Sarajevo : Udruženje Prirodan porod Način dostupa (URL): http://www.prirodanporod.com/wp-content/uploads/2016/01/Standardi-za- poboljsanje-kvalitete-njege-za-majku-i-novorodjence-u-zdravstvenim-ustanovama.pdf . - Prijevod djela: Standards for improving quality of maternal and newborn care in health facilities. - Nasl. sa nasl. ekrana. - Opis izvora dana 20. 9. 2018. ISBN 978-9926-8297-0-4 COBISS.BH-ID 26286086 Publikaciju podržala Agencija za kvalitetu i akreditaciju u zdravstvu u Federaciji Bosne i Hercegovine (AKAZ) i Federalno ministarstvo zdravstva Sarajevo, 2018 SADRŽAJ Akronimi i skraćenice ................................................................................................................................ 4 Rezime ............................................................................................................................................................ 5 1. Osnove ....................................................................................................................................................... 9 1.1. Uvod ................................................................................................................................................... 9 1.2 Prioriteti za smanjenje majčinske i perinatalne smrtnosti .............................................. 9 1.3 Obrazloženje ................................................................................................................................... 10 1.4 Ciljna publika .................................................................................................................................. 11 2. Metoda i postupak ............................................................................................................................... 12 2.1. Pregled ................................................................................................................................................. 12 2.2 Obim .................................................................................................................................................. 12 2.3 Razvoj okvira i standarda njege ............................................................................................. 13 2.3.1 Prikupljanje i sinteza dokaza ............................................................................................ 13 2.3.2 Pregled stručnjaka i izgradnja konsenzusa ................................................................. 14 2.4 Razvoj mjera kvalitete ................................................................................................................ 14 2.4.1 Upoređivanje i izrada nacrta mjera kvalitete ............................................................. 15 2.4.2 Izgradnja konsenzusa o mjerama kvalitete ............................................................... 15 3. Definicija i okvir kvalitete njege .................................................................................................... 18 3.1 Dokazi i rezime zaključaka ........................................................................................................ 18 3.2 Definisanje kvaliteta njege ........................................................................................................ 18 3.3 Kvalitet okvira njege .................................................................................................................... 19 3.4 Strateška područja djelovanja ................................................................................................. 20 4. Standardi njege .................................................................................................................................... 21 4.1 Dokazi i rezime pronalazaka ..................................................................................................... 21 4.2 Definicija i struktura standarda ............................................................................................... 21 4.3 Obim i upotreba standarda i izjava o kvaliteti................................................................... 22 4.4 Lista standarda i izjava o kvaliteti .......................................................................................... 23 5. Izjave o kvaliteti i mjere ................................................................................................................... 28 5.1. Ishod Delfi procesa ..................................................................................................................... 28 5.2 Korištenje mjera kvalitete ......................................................................................................... 28 5.3 Mjere za izjave o kvaliteti .......................................................................................................... 29 6. Operacionalizacija ............................................................................................................................... 69 6.1 Diseminacija .................................................................................................................................... 69 6.2 Pristup implementacije ............................................................................................................... 69 7. Monitoring i evaluacija ...................................................................................................................... 71 8. Ažuriranje standarda .......................................................................................................................... 72 Reference ..................................................................................................................................................... 73 Aneks 1. ........................................................................................................................................................ 75 Aneks 2. ........................................................................................................................................................ 76 4 Akronimi i skraćenice ICD - Međunarodna klasifikacija bolesti NICE - Nacionalni institut za zdravlje i izvrnost njege, Velika Britanija UNICEF - Ujedinjeni narodi, dječji hitni fond 5 Rezime Tokom posljednje dvije decenije postignut je velik napredak u izvještavanju o rađanju u zdravstvenim ustanovama, međutim malo je pažnje posvećeno smanjenju smrtnosti majki i neonatalne smrtnosti. Uz povećanje broja poroda u zdravstvenim ustanovama, pažnja je preusmjerena na kvalitet njege, jer loš kvalitet njege pridonosi morbiditetu i smrtnosti općenito. Razdoblje oko porođaja je najkritičnije za spašavanje života majki i novorođenčadi te sprječavanje stope smrtnosti beba pri porodu. SZO (Svjetska zdravstvena organizacija) vidi budućnost u kojoj "Svaka trudnica i novorođenče prima visoko kvalitetnu njegu tokom trudnoće, porođaja i postnatalnog razdoblja ". Da bi se ostvarila ova vizija, SZO je definirala "kvalitet njege" i pripremila okvir za poboljšanje kvalitete njege za majke i novorođenčad u periodu prije, tokom i poslije poroda. Okvir sadrži osam područja kvalitete njege koja se trebaju procijeniti, poboljšati i pratiti u cjelokupnom zdravstvenom sistemu. Zdravstveni sistem pruža strukturu pristupa kvalitetnoj njezi u dvije važne, međusobno povezane, dimenzije pružanja i iskustva njege. U sklopu ovog okvira i u skladu sa mandatom Organizacije, SZO će raditi na realizaciji svoje vizije u šest strateških područja, koja će biti osnova za sistemski pristup zasnovan na dokazima. Ovaj okvir će služiti kao osnova za pružanje smjernica za poboljšanje kvalitete njege majki i novorođenčadi. Šest strateških područja su: 1. kliničke smjernice, 2. standardi njege, 3. efikasne/djelotvorne intervencije, 4. mjere kvalitete njege, 5. relevantno istraživanje i 6. izgradnja kapaciteta. Obzirom na to da trenutno nema jasnog uputstva, standardi brige i mjere kvaliteta su prioritet, jer je to ključ za osiguranje kvaliteta njege uopće. Standardi eksplicitno definiraju šta je sve potrebno uraditi da bi se postigla visokokvalitetna njega prije, tokom i nakon porođaja. U prvoj fazi korišten je strožiji pristup radi identifikacije postojećih resursa, provođenja obimnog pretraživanja literature i mapiranja standarda brige različitih organizacija. Ovakav strogi pristup je korišten kako bi se definisala i odredila struktura standarda. Predloženo je da se postave široki standardi, podržani specifičnim izjavama o kvaliteti i nizom ulaznih informacija (inputa) o djelotvornosti odnosno mjerama procesa i ishoda. Formulirano je osam standarda, po jedan za svaki od osam domena kvaliteta zaštite njege. Kako bi se osiguralo da su standardi specifični i fokusirani, formulirane su izjave o kvalitetu (od 2 do 13 izjava) za svaki standard koji se odnosi na mjerljiva poboljšanja u kvaliteti njege prije, tokom i poslije porođaja. Kako bi se pregledali i spojili dokazi osnovana je Međuresorska radna grupa SZO-a. Tokom januara 2015. i februara 2016. spomenuta grupa je pregledala objavljene studije kako bi definirala „kvalitet njege" i formulisala okvir za osiguravanje kvalitete njege majke i novorođenčeta. Okvir je predstavljen Grupi za razvoj smjernica na konsultacijama održanim u Ženevi od 3. do 4. juna 2015. godine, gdje je razmotrena 6 sama definicija "kvalitete njege", predložen okvir, standardi njege, izjave o kvaliteti i kriteriji za definiranje mjera kvalitete. Sporazum o definiciji, domeni okvira, standardima njege i izjave o kvaliteti su postignute konsenzusom. Grupa za razvoj smjernica je raspravljala i o kriterijima za definisanje mjera koje će se koristiti za procjenu, mjerenje i praćenje kvalitete njege. U drugoj fazi, Međuresorska grupa za smjernice je upoređivala, pregledala i formulirala ulazne informacije (inpute), djelotvornost i mjere ishoda za svaku izjavu o kvaliteti. Ove mjere su izvedene iz pokazatelja kojeg koriste SZO i druge međunarodno priznate organizacije u javnoj sferi. Mjere su, potom, sastavljene od strane relevantnog tehničkog odjela i precizirane u toku konsultacija u radnim grupama. Konačna lista je pregledana u dva kruga Delphi procesa kako bi se osigurao širi geografski (46 država) i stručni (116 stručnjaka) konsenzus. Ove mjere mogu koristiti timovi zdravstvenih ustanova za prepoznavanje nedostataka u kvaliteti njege i na taj način poboljšati iskustvo u pružanju njege prema standardima i izjavama o kvaliteti. One su namijenjene rukovodiocima zdravstvenih ustanova, planerima, menadžerima i onima koji pružaju usluge u procesu procjene i nadzora resursa, djelotvornosti, kao i područja za poboljšanje intervencija, što samim tim dovodi do bolje kvalitete. Osam standarda njege i 31 izjava o kvaliteti su navedeni ispod. Standardi njege i izjave o kvaliteti Standard 1: Svaka žena i novorođenče primaju rutinsku zaštitu i njegu zasnovane na dokazima, kao i upravljanje mogućim komplikacijama tokom porođaja, rođenja djeteta i ranog postnatalnog perioda, ovo sve navedeno prema smjernicama SZO. Izjave o kvaliteti 1.1a: Žene se rutinski procjenjuju prilikom prijema, tokom porođaja i rođenja djeteta, te im se pruža blagovremena i odgovarajuća njega. 1.1b: Novorođenčad dobijaju rutinski tretman odmah nakon rođenja. 1.1c: Majke i novorođenčad dobijaju rutinsku postnatalnu njegu. 1.2: Žene sa pre-eklampsijom ili eklampsijom odmah primaju odgovarajuće intervencije prema smjernicama SZO. 1.3: Žene sa postpartalnom hemoragijom odmah primaju odgovarajuće intervencije prema smjernicama SZO. 1.4: Žene s odgodom poroda ili čiji je porod ometan primaju odgovarajuće intervencije prema SZO smjernicama. 1.5: Novorođenčad koja ne dišu samostalno, primaju odgovarajuću stimulaciju i oživljavanje vrećicom i maskom unutar 1 minute od rođenja, a prema SZO smjernicama. 1.6a: Žene koje se prijevremeno porode primaju odgovarajuće intervencije kako za sebe tako i za svoje bebe prema SZO smjernicama. 1.6b: Bebe rođene prije termina i male bebe primaju odgovarajuću njegu prema smjernicama SZO. 1.7a: Žene sa ili pod rizikom od infekcije prije porođaja, u toku porođaja ili u ranom postnatalnom periodu odmah dobijaju odgovarajuće intervencije prema smjernicama SZO. 1.7b: Novorođenčad sa faktorima rizika za infekciju odmah primaju antibiotik prema uputstvima SZO. 7 1.8: Sve žene i novorođenčad dobivaju njegu prema standardnim mjerama opreza za sprečavanje infekcije u toku hospitalizacije. 1.9: Niti jedna žena ili novorođenče nije podvrgnuto nepotrebnim ili štetnim postupcima prije porođaja, u toku porođaja i ranog postnatalnog razdoblja. Standard 2: Sistem informisanja u zdravstvu omogućava korištenje podataka kako bi se osiguralo rano, odgovarajuće djelovanje u smjeru poboljšanja njege i brige o svakoj ženi i novorođenčetu. Izjave o kvaliteti 2.1: Svaka žena i novorođenče imaju potpun, tačan, standardiziran medicinski zapis/karton prije, tokom porođaja i ranog postnatalnog perioda. 2.2: Svaka zdravstvena ustanova ima mehanizam za prikupljanje podataka, analizu i povratne informacije u okviru aktivnosti za praćenje i poboljšanje porođaja. Standard 3: Svaka žena i novorođenče se upućuje na dalje promatranje i tretman na odgovarajući način, sa stanjem ili stanjima koji se ne mogu efikasno tretirati raspoloživim resursima. Izjave o kvaliteti 3.1: Svaka žena i novorođenče se na odgovarajući način procjenjuje prilikom prijema, tokom porođaja i tokom ranog postnatalnog perioda sa ciljem utvrđivanja opravdanosti upućivanja, a odluka o upućivanju se donosi bez odlaganja. 3.2: Svaka žena i novorođenče koji traže dodatno upućivanje, se prate prema unaprijed utvrđenom planu koji se može implementirati bez odlaganja i u bilo koje vrijeme. 3.3: Za svaku ženu i novorođenče koji se upućuju unutar ili između zdravstvenih ustanova, postoji odgovarajuća razmjena informacija i povratne informacije koje se dostavljaju relevantnom zdravstvenom osoblju. Standard 4: Komunikacija sa ženama i njihovim porodicama je efikasna i odgovara njihovim potrebama i željama. Izjave o kvaliteti 4.1: Sve žene i njihove porodice dobijaju informacije o njezi i imaju efektivnu interakciju sa osobljem. 4.2: Sve žene i njihove porodice imaju koordiniranu njegu, sa jasnim, tačnim informacijama koje se razmjenjuju između relevantnih stručnjaka iz oblasti zdravstva i socijalne zaštite. Standard 5: Žene i novorođenčad imaju brigu sa poštovanjem i očuvanjem njihovog dostojanstva. Izjave o kvaliteti 5.1: Sve žene i novorođenčad imaju privatnost za vrijeme porođaja i njihova povjerljivost se poštuje. 5.2: Niti jedna žena ili novorođenče ne podliježe bilo kojem vidu zlostavljanja, kao što su fizičko, seksualno ili verbalno zlostavljanje, diskriminacija, zanemarivanje, pritvaranje, iznuđivanje ili odbijanja pružanja usluga. 5.3: Sve žene su obaviještene o odabiru usluga koje primaju, jasno su objašnjeni razlozi za eventualne intervencije kao i ishodi istih. 8 Standard 6: Svaka žena i njena porodica dobijaju emocionalnu podršku koja je prilagođena njihovim potrebama i koja jača sposobnost žene. Izjave o kvaliteti 6.1: Svakoj ženi se nudi opcija da doživi porod sa pratiocem po njenom izboru. 6.2: Svaka žena dobija podršku sa ciljem jačanja svoje sposobnosti tokom porođaja. Standard 7: Za svaku ženu i novorođenče je uvijek dostupno, kompetentno i motivisano osoblje sposobno pružiti rutinsku njegu i brigu o mogućim komplikacijama. Izjave o kvaliteti 7.1: Svaka žena i dijete u svakom trenutku imaju pristup najmanje jednom stručnjaku koji nadzire porod te pomoćnom osoblju za rutinsku njegu i brigu u slučaju komplikacija. 7.2: Stručnjaci za porod kao i pomoćno osoblje imaju odgovarajuće kompetencije i vještine koje zadovoljavaju zahtjeve porođaja i ranog postnatalnog perioda. 7.3: Svaka zdravstvena ustanova ima menadžersko i kliničko rukovodstvo koje je kolektivno odgovorno razvijati i primjenjivati odgovarajuće politike te njegu okruženja koje podstiče osoblje na kontinuirano poboljšanje kvalitete. Standard 8: Zdravstvena ustanova ima odgovarajuće fizičko okruženje za majku i novorođenče, kao i odgovarajuću vodu, sanitarije, snabdjevanje energijom, lijekovima, zalihama te opremu za rutinsku brigu i upravljanje komplikacijama. Izjave o kvaliteti 8.1: Voda, energija, sanitarije, higijena ruku i sredstva za odlaganje otpada su funkcionalni, pouzdani, sigurni i dovoljni da zadovolje potrebe osoblja, žena i njihovih porodica. 8.2: Prostorije za porod i postnatalnu njegu su projektovane, organizovane i održavane na način da se svakoj ženi i novorođenčetu može pružiti individulana i kontinuirana njega prema njihovim potrebama. 8.3: Dostupna je odgovarajuća zaliha lijekova, potrošnog materijala i opreme za rutinsku njegu i upravljanje komplikacijama. 9 1. Osnove 1.1. Uvod Tokom protekle dvije decenije učinjeni su znatni napori kako bi se osiguralo prisustvo stručnog osoblja pri porodu, s ciljem smanjenja morbiditeta kod majki i novorođenčadi. Ovim naporima značajno se povećao broj poroda u zdravstvenim ustanovama, a procenat porođaja kojima su prisustvovali kvalifikovani zdravstveni radnici u zemljama u razvoju povećao se sa 56% u 1990. godini na 68% u 2012. godini. Uprkos ovim nastojanjima, 800 žena i 7700 novorođenih beba i dalje umire od komplikacija tokom trudnoće, porođaja i u postnatalnom periodu; a dodatnih 7300 žena rodi mrtvorođenče. Sa sve većim brojem porođaja u zdravstvenim ustanovama, smanjio se broj smrtnosti majki i perinatalnih smrtnosti i morbiditeta koji se javljaju u tim ustanovama. Rezultat brige o ženama i novorođenčadi za vrijeme porođaja u zdravstvenim ustanovama oslikava se kroz praksu zasnovanu na dokazima i ukupnom kvalitetu pruženih usluga. Kvalitet njege zavisi od fizičke infrastrukture, ljudskih resursa, znanja i sposobnosti da se bave podjednako normalnim trudnoćama kao i komplikacijama koje zahtijevaju hitne intervencije. Na taj način poboljšanje kvaliteta njege u zdravstvenim ustanovama je sve više prepoznato kao važan faktor u sprječavanju smrtnosti i morbiditeta kod majki i novorođenčadi na koje bi se moglo preventivno djelovati. Istraživanja su pokazala da maksimiziranje pokrivenosti bitnim intervencijama nije dovoljno za smanjenje smrtnost majki i beba. Osim toga, postoji kompleksna međusobna veza između iskustva njege i ishoda trudnoće. Da biste zaustavili i prevenirali smrtnost majki i novorođenčadi, svaka trudnica i novorođenče trebaju imati stručnu njegu pri porodu zasnovanu na praksi, temeljenu na dokazima, uz podržavajuće okruženje s principima ljudskosti i poštovanja. Dobra kvalitetna njega zahtijeva odgovarajuću upotrebu djelotvornih kliničkih i nekliničkih intervencija, jačanje zdravstvene infrastrukture, optimalnih vještina i pozitivan stav davaoca zdravstvenih usluga. To će poboljšati zdravstvene ishode i dati ženama pozitivno iskustvo, kao i njihovim porodicama i davateljima zdravstvene njege. Kvalitetna njega dio je prava na zdravlje i to je put do pravednosti i očuvanja dostojanstva kako za žene tako i za djecu. Obezbijediti pristup kvalifikovano vođenom porodu te neophodnoj, kvalitetnoj i djelotvornoj akušerskoj njezi, pomoći će smanjenju smrtnost majki i novorođenčadi (1). SZO standardi za kvalitet njege majki i novorođenčadi se zasnivaju na prioritetnim dokazima i intervencijama tokom kritičnih perioda njege. SZO predviđa svijet u kojem "svaka trudnica i novorođenče dobijaju kvalitetnu njegu tokom trudnoće, porođaja i neposrednog postnatalnog perioda "(2) Ova izjava je usklađena sa dvije komplementarne globalne akcione agende: "Strategije za okončanje smrti majki koje se mogu prevenirati " (3) i "Svako novorođenče: akcioni plan za završetak smrtnih slučajeva koji se mogu spriječiti "(4). 1.2 Prioriteti za smanjenje majčinske i perinatalne smrtnosti Na globalnom planu komplikacije u trudnoći i tokom porođaja poput hemoragija/krvarenja, hipertenzivnih poremećaja, sepse te pobačaja imaju za posljedicu smrt majke i to više od 70%(5). Komplikacije poput preranog rođenja, 10 asfiksija, intra-partum perinatalne smrti i neonatalne infekcije uzrokuju i čine više od 85% smrti novorođenčadi (6). Istraživanja pokazuju vjerovatnoću da efikasna, kvalitetna njega usmjerena na sprječavanje i upravljanje komplikacijama tokom ovog kritičnog razdoblja značajno smanjuje smrtnost majki, mrtvorođenih beba i ranih neonatalnih smrti (7). Dakle, vrijeme porođaja i razdoblje neposredno nakon toga su posebno kritični za majčino, fetalno i neonatalno preživljavanje i zbog toga predstavljaju priliku za uvid u to kako se vraćaju i u konačnici isplate ulaganja u poboljšanja njege istih. Djelotvorna prevencija i upravljanje uslovima u kasnoj trudnoći, porođaju i ranom periodu novorođenčeta vjerovatno će značajno smanjiti broj umrlih majki, mrtvorođenčadi čija je smrt povezana sa antepartumom i intrapartumom te ranih neonatalnih smrti. Zbog toga, poboljšanje kvalitete preventivne njege tokom ovog kritičnog perioda moglo bi imati najveći utjecaj na preživljavanje majke, fetusa i samog novorođenčeta. Na temelju postojećih dokaza o utjecaju istih na ovaj osjetljiv period, sljedeća tematska područja smatraju se visokim prioritetima kao temeljni dokazi za razvijanje prakse u rutinskoj i hitnoj njezi (2). • rutinska njega tokom porođaja, uključujući praćenje poroda i novorođenčadi pri rođenju i tokom prve sedmice; • upravljanje preeklampsijom, eklampsijom i njenim komplikacijama; • upravljanje teškim porodom sa sigurnim, odgovarajućim medicinskim tehnikama; • upravljanje postpartalnom hemoragijom; • reanimacija ili oživljavanje novorođenčeta; • upravljanje ranim porodom, rađanjem i pružanjem odgovarajuće njege za prijevremeno rođene i male bebe; i • upravljanje infekcijama majki i novorođenčadi. 1.3 Obrazloženje Kvalitet njege se na međunarodnoj razini sve više priznaje kao kritični aspekt nedovršenog plana za zdravlje majki i novorođenčadi, najviše poštujući njegu prije, za vrijeme poroda i u neposrednom postnatalnom periodu (8). Prepoznata je i činjenica da visoka pokrivenost uslugama sama po sebi nije dovoljna za smanjenje smrtnosti kako majki tako i beba. Da bi se smrtnost majke i novorođenčadi znatno smanjila i pomaknula prema uklanjanju preventivnih uzroka smrti majke i novorođenčadi, povećana pokrivenost treba pratiti poboljšana kvaliteta tokom njege (9, 10). Višestruko istraživanje SZO-a o zdravlju majki i novorođenčadi (11) kojim su prikljupljeni podaci na više od 300 000 žena koje posjećuju 359 zdravstvenih ustanova u 29 zemalja, pokazalo je lošu korelaciju između pokrivenosti "esencijalnih intervencija" (npr. procenat populacije koji je dobio induciranu intervenciju, kao što su žene sa eklampsijom koje su primile magnezijum sulfat) i smrtnosti majki u zdravstvenim ustanovama. Studije također pokazuju da visokokvalitetna njega zahtijeva odgovarajuće korištenje raspoloživih infrastrukturnih resursa, kao i osoblja i proizvoda sa ciljem osiguranja efikasnog upravljanja slučajevima (12). Visokokvalitetna njega zahtijeva adekvatnu upotrebu klinički dokazanih praksi i nekliničkih intervencija, ojačanu zdravstvenu infrastrukturu, optimalne vještine i pozitivan stav davatelja zdravstvenih usluga. Davanje visokokvalitetne antenatalne, intrapartalne i postnatalne njege mora biti integrirano u bilo koju strategiju koja ima za cilj poboljšanje kvalitete. Norme ljudskih 11 prava, medicinska etika i tehnički standardi podstiču integraciju ovih usluga, direktno ili putem efikasnog upućivanja, stoga one trebaju biti osnovni element kvaliteta njege.1 Pravo na zdravlje je osnovno ljudsko pravo koje je ključno za smanjenje smrtnosti majki, neonatalnih i smrti djece, i kao takvo je jedini put ka ravnopravnosti i očuvanju dostojanstva žena i djece (13). 1.4 Ciljna publika Kvalitet i standardi njege kao i mjere kvaliteta mogu se koristiti kao okvir za vođenje i pripremu nacionalnih standarda njege i mjera za poboljšanje, procjenu i praćenje kvaliteta njege koje su pružene majkama i novorođenčadi u zdravstvenim ustanovama. Ovaj okvir se, također, može koristiti kao osnova za poboljšanje kvalitete strategija i aktivnosti za uključivanje kvaliteta u postojeće nacionalne programe. Okvir, standardi njege i mjere kvaliteta su namjenjene prvenstveno za upotrebu od strane odgovornih lica koji kreiraju politike, programskih menadžera, onih koji se bave planiranjem zdravstvenih politika na nacionalnom, subnacionalnom, lokalnom i na nivou ustanova; profesionalaca za zdravstvenu zaštitu majki i novorođenčadi, i profesionalnih tijela ili tehničkih partnera uključenih u kvalitetu njege ili koji savjetuju državna ministarstva zdravlja. Istovremeno, ovi okviri mogu se koristiti i kao resursi u ustanovama za medicinsku obuku. Uvažavajući razlike između država u pogledu same organizacione strukture zdravstvenih ustanova i zdravstvenih radnika koji pružaju njegu majkama i neonatalnu njegu, ovaj dokument se fokusira na standarde njege, kompetencije, usluge i fizičke resurse koji su potrebni da bi se osigurali odgovarajući uslovi za majku i neonatalni zdravstveni uslovi sa ciljem odgovarajućeg načina upravljanja i izvršenja procjene, te sa ciljem upućivanja istih u funkcionalni zdravstveni sistem kako bi se na taj način obezbijedila optimalna njega. Standarde mjera zaštite i kvaliteta treba prilagoditi lokalnom kontekstu kako bi se osigurala njihova primjenjivost i kako bi se postigli željeni rezultati za majke i novorođenčad. 1 Germain A. Postizanje normi ljudskih prava na kvalitetu informacija i usluga seksualnog i reproduktivnog zdravlja. Zapisnik o raspravi predstavljen na Međunarodnoj konferenciji o stanovništvu i razvoju nakon Međunarodne konferencije o ljudskim pravima 2014, Noordwijk, 7-10. juli 2013. 12 2. Metoda i postupak 2.1. Pregled Vizija kvaliteta njege, okvira, standarda njege i mjere kvaliteta su definirane u tri faze. U prvoj fazi postignut je konsenzus o viziji SZO-a i definiran je kvalitet njege majke i novorođenčadi. U drugoj fazi, postignut je dogovor o koncepciji kvaliteta njege, strateškom pristupu implementaciji i strateškim oblastima za poboljšanje kvalitete njege. U trećoj fazi, grupa je identifikovala praznine/rupe u strateškim oblastima rada i definisala je standarde i mjere za praćenje poboljšanja kvalitete njege u zdravstvenim ustanovama. Ove faze su uključivale pregled literature, stručne konsultacije i izgradnju konsenzusa u sklopu Delfijevog procesa. 2.2 Obim Obim rada je bio takav da pruža sveobuhvatna uputstva i smjernice međunarodnim i nacionalnim organizacijama koje će ispuniti globalnu viziju SZO-a o poboljšanju kvaliteta njege majke i novorođenčadi. Ovo je zahtijevalo okvir za definiranje domena mjerenja, odnosno od kojih intervencija se može očekivati da postignu željene zdravstvene rezultate i koje su mjere potrebne za procjenu istih. U 2015. godini pokrenute su konsultacije pod vođstvom pomoćnika Generalnog direktora za grupu: Porodica, žene i djeca. Postavljena je Grupa za vođenje međusektorskih smjernica i ona se inicijalno sastojala od članova iz dva odjeljenja koja su direktno odgovorna za zdravlje majki i novorođenčadi i to: Odjeljenje za zdravlje majki, novorođenčadi, djeteta i adolescenata i Odjeljenje za reproduktivno zdravlje i istraživanje. Kada je vizija definisana, Upravljačka grupa je proširena tako da uključuje Odjeljenja za Javno zdravstvo, životnu sredinu i socijalne odrednice zdravlja, Pružanje usluga i sigurnost, Zdravstvena radna snaga i Nutricionizam za zdravlje i razvoj. Glavna radna grupa sa članovima iz Odjeljenja za zdravlje majki, novorođenčadi, djeteta i adolescenata i odjeljenja za reproduktivno zdravlje i istraživanje vodila je proces pronalaženje i sinteze dokaza, kao i obezbjeđivanje koordinacije. Upravljačka grupa za izradu smjernica sastajala se svake dvije sedmice kako bi postigla konsenzus o viziji SZO-a o kvaliteti njege majki i novorođenčadi, kao i da bi definisali obim njihovog rada. Oni su identificirali tri kategorije: • definisanje kvalitete njege u kontekstu zdravlja majki i novorođenčadi; • definisanje postojećih modela kvalitete njege i dizajna sistemskog okvira područja za kvalitetu njege majke i novorođenčeta; i • definisanje literature i efikasne strategije za intervencije kliničkih i zdravstvenih službi koje su usmjerene na poboljšanje kvalitete njege na nivou države. Ovim oblastima se bavilo tokom prve i druge faze i oni su poslužili kao osnova za definisanje kvaliteta njege, okvira kvalitete njege i za identifikaciju strateških područja rada. Definicija standarda njege je identifikovana kao glavni jaz ili rupa. 13 2.3 Razvoj okvira i standarda njege Osnovna radna grupa je pregledala objavljenu i neobjavljenu literaturu u kojoj se navode definicije kvalitete njege, modeli njege, okvir kvalitete njege i strateški pristupi korišteni za poboljšanje kvalitete njege uopće a posebno za zdravlje majke i novorođenčeta. Zaključci su predstavljeni grupi za izradu međusektorskih smjernica, na pregled i diskusiju, i postignut je konsenzus o definiciji kvalitete njege, konceptualnog okvira i pristupa strateškoj implementaciji (2). Standardi predstavljaju mjerila uz pomoć kojih se mogu mjeriti poboljšanja i zbog toga je neophodno da mogu biti mjerljivi. Definisanje standarda brige identifikovan je kao prioritet, jer je bilo dostupno malo uputstava, osim smjernica za kliničku praksu zasnovanu na dokazima. U prvom koraku osmišljena je definicija, taksonomija i struktura, a zatim su formulisani standardi njege. Postignut je konsenzus o definiciji, nacrtu okvira i standardima njege, koji su zatim u junu 2015. godine predstavljeni na sastanku grupe za razvoj smjernica. (Prilog 1). 2.3.1 Prikupljanje i sinteza dokaza MEDLINE, SZO publikacije i druge baze podataka su pretražene sa ciljem pronalaska relevantnih publikacija koje bi ponudile definicije i modele kvalitete njege, a pojmovi koji su korišteni za pretraživanje su: "standard [definicija], [kriteriji], [pružanje usluga], [kliničke ili smjernice], [standardne operativne procedure] ". Dodatno, pretraga je urađena dodavanjem ključnih riječi "majka i novorođenče". Publikacije su pretražene na internet stranicama organizacija koristeći polja za pretraživanje internet stranica ili određenih dijelova stranica posvećenih publikacijama. Identificirane su organizacije koje su vjerovatno razvile opće standarde i posebno strandarde za majke i novorođenčad uključujući organizacije koje promovišu međunarodni kvalitet i sigurnost, vladine agencije, nevladine i profesionalne organizacije. U Okviru 1 su navedene organizacije čije su publikacije korištene kao glavni izvori za definicije, taksonomiju i strukturu standarda njege. Također, urađeno je i opće "internet-pretraživanje" koristeći Google pretraživač i iste ključne riječi. Dokumenti su, potom, pregledani i analizirani kako bi se identificirao standard u smislu definicije, opisa, formata, mjerenja i taksonomije. Grupa je pregledala i iskustva u poboljšanju kvalitete njege u različitim projektima provedeni u odjeljenjima SZO-a. Okvir 1. Pregledani resursi korišteni za definisanje standarda • International Organization for Standardization – Međunarodna organizacija za standardizaciju • International Society for Quality in Health Care – Međunarodno društvo za kvalitet njege u zdravstvu • The Joint Commission (USA) - Zajednička komisija (SAD) • National Institute for Health and Care Excellence (NICE), United Kingdom - Nacionalni institut za zdravlje i izvrsnost njege (NICE), Ujedinjeno Kraljevstvo • Council for Health Service Accreditation of Southern Africa - Vijeće za akreditaciju zdravstvene službe Južne Afrike 14 • National Department of Health: National Core Standards for Health Establishment in South Africa (2011) - Nacionalni odjel za zdravstvo: Nacionalni osnovni standardi za uspostavljane zdravlja u Južnoj Africi (2011) • Safecare Basic Health Care Standards (PharmAccess Foundation of the Netherlands, the Joint Commission International of the USA and the Council for Health Service Accreditation of Southern Africa) - Osigurani osnovni zdravstveni standardi (PharmAccess Fondacija iz Holandije, Zajednička međunarodna komisija SAD-a i Vijeće za akreditaciju zdravstvene službe Južne Afrike) • Australian Commission on Safety and Quality in Health Care: National safety and quality health service standards (2012) - Australska komisija za sigurnost i kvalitetu u zdravstvu: Nacionalni standardi za sigurnost i kvalitetu zdravstvene zaštite (2012) • WHO standards for maternal and newborn health. Group 1: General standards of care for healthy pregnancy and childbirth (2007) - SZO standardi za zdravlje majki i novorođenčadi. Grupa 1: Opšti standardi brige o zdravoj trudnoći i porođaju (2007) • WHO Regional Office for South-East Asia: Standards of Midwifery Care (1999) - Regionalna kancelarija SZO za jugoistočnu Aziju: Standardi njege za primalje/babice (1999) 2.3.2 Pregled stručnjaka i izgradnja konsenzusa Kako bi se na odgovarajući način odrazila raznolikost stručnog mišljenja i tehničkih perspektiva, okvir kvalitete njege i standardi njege su definisani u participativnom procesu. Nacrt su pregledali relevantni odjeli SZO-a kako bi se osigurala tehnička tačnost i konzistentnost, kako bi regionalne kancelarije SZO-a i predstavnici zemalja procijenili njihovu primjenljivost u različitim kontekstima. Savjetovanje je provedeno elektronskim putem i sastancima licem u lice, koje je praćeno jednodnevnim sastancima članova Razvojne grupe za međusektorske smjernice koja je trebala razmotriti, finalizirati i izraditi okvir i standarde njege za prezentaciju i diskusiju od strane Grupe za razvoj smjernica. U junu 2015. održan je sastanak eksperata (Prilog 1) koji su pregledali viziju i okvir SZO-a kako bi se postigao konsenzus o pristupu SZO-a i nacrtima standarda njege. Stručnjaci su pregledali osnovne informacije i nacrte kako bi utvrdili sveobuhvatnost pregleda i da li predložena definicija kvalitete njege, okvira i standarda njege odražava sadašnje znanje i razumijevanje kvaliteta njege, kao i njihovu primjenljivost na vrijednosti u okruženjima sa malo resursa te samu izvodljivost implementacije. Konzenzus je postignut za većinu stavki i samo u izuzetnim slučajevima podizanjem ruku. Nacrti su finalizirani na osnovu ishoda sastanka. 2.4 Razvoj mjera kvalitete Mjere kvalitete su temeljna komponenta standarda njege. Od njih se traži da mjere inpute/ulazne informacije, postupak njege ili pružanje usluga, a ako je primjereno i ishod njege, te na taj način prate napredak ka postizanju određenog standarda njege. Međutim, definiranje mjera kvalitete je izazovno imajući u vidu varijacije u definicijama, složene interakcije između faktora odgovornih za ishode i konteksta njihove upotrebe i primjene. 15 Grupa je tražila realne parametre i uravnotežen pristup mjerenju intervencija u zdravstvenim ustanovama. Oni su istovremeno tražili i odgovarajuće direktne mjere te opće mjere koje odražavaju kombinovani efekat intervencija. Prvi korak je bio da se identifikuju elementi intervencija koji definišu standarde njege, na osnovu smjernica SZO-a i drugih relevantnih izvora. Nakon toga, lista mjera kvalitete bila je sređena, a relevantna tehnička jedinica SZO-a je formulisala Izjavu o kvaliteti. Ovo je razmotreno od strane rukovodeće Grupe za međusektorske smjernice prije Delfi procesa izgradnje konsenzusa. 2.4.1 Upoređivanje i izrada nacrta mjera kvalitete Tehnički odjeli SZO su izradili nacrt mjera kvalitete za svaku izjavu u saradnji sa osnovnom radnom grupom. Grupa je mapirala i uporedila postojeće mjere iz SZO smjernica, nekoliko SZO alata za procjenu zdravstvenih ustanova i prikupljanje podataka od nacionalnih i međunarodnih partnera. Nakon što u ovim izvorima nisu pronađene mjere, nove mjere su bile formulirane na osnovu trenutnih smjernica i o njima se raspravljalo unutar relevantnih jedinica SZO-a. Mjere su sakupljene, a koordinaciona Grupa za međusektorske odnose napravila je nacrt liste od 318 mjera za 31 izjavu o kvalitetu, koje su zatim pregledane u sklopu širih konsultacija. 2.4.2 Izgradnja konsenzusa o mjerama kvalitete Da bi se izgradio i u konačnici postigao konsenzus o mjerama kvalitete, provedena je šira konsultacija, u početku u okviru tehničkih jedinica SZO-a i regionalnih i državnih kancelarija, a potom globalno u Delfijevom procesu. Identificirani su potencijalni učesnici u globalnim konsultacijama i to oni koji su imali širok spektar stručnosti, od pružanja njege do iskustva njege. Oni su uključivali stručnjake za kvalitet njege i to profesionalce (npr. akušeri, neonatolozi, pedijatri, babice, medicinske sestre, stručnjaci za komunikaciju, advokati), istraživače, akademike, korisnike i implementatore na različitim nivoima, predstavnike organizacija potrošača, profesionalnih društava, međunarodnih organizacija i bilateralnih agencija. Poziv je upućen prema 215 potencijalnih učesnika u 60 država sa ciljem procjene interesa i saglasnosti za učešće. Cilj je bio da se regrutuje približno jednak broj učesnika u različitim sektorima zdravstvene i socijalne zaštite, koji bi osigurali globalno predstavljanje. Od 215 pozvanih, 130 (60%) osoba iz 48 zemalja sa niskim, srednjim i visokim prihodima pristalo je da učestvuju. Mjere kvalitete poslane su onima koji su pristali da učestvuju u konsultacijama, koje su provedene u dva kruga tokom više od 14 sedmica. Online softver (SurveyMonkey®) je omogućio učesnicima da dostave svoje komentare i rangiranje mjera i to u dva kruga. U prvom krugu učesnici su pregledali listu od 318 mjera kvalitete za validaciju i potpunost tj. cjelovitost, te su dali komentare i predložili dodatne mjere. U drugom krugu, od učesnika je zatraženo da daju prioritet mjerama na osnovu kriterija koji su dogovoreni na stručnom sastanaku Grupe za razvoj smjernica. Prvi krug "Delfi istraživanja" U prvom krugu, za 130 učesnika sačinjen je spisak mjera kvalitete te je isti podijeljen na tri dijela. 16 Prvi dio se odnosio na pružanje njege (standardi 1-3), drugi dio je bio u vezi iskustva njege (standardi 4-6), a treći o unakrsnim područjima (standardi 7 i 8). Učesnici su mogli odabrati da se bave ili pružanjem njege ili iskustvom njege i uz to unakrsnim područjima ili da se fokusiraju na sva tri dijela u zavisnosti od njihove ekspertize. Od njih je zatraženo da daju opće komentare o valjanosti i potpunosti mjera za svaku izjavu o kvalitetu i ako je potrebno da predlože dodatne mjere. Istraživanje je bilo otvoreno dvije sedmice tokom kojih su tri puta poslane podsjetnice putem e-pošte (e- mail-a). Učesnici su podstaknuti da završe istraživanje njihovim ličnim tempom i preispitaju svoje odgovore prije nego što ih pošalju. Osnovna radna grupa je analizirala tekstove i mjere za kvalitet koje su predložili ispitanici i grupisala ih za svaku izjavu o kvalitetu. Tekstualni komentari su analizirani i organizovani u kategorije, koje su prečišćene i grupisane po aspektima njege obuhvaćenim u izjavama o kvalitetu. U kategorije su se uvrstili komentari koji su omogućili uvid u oblasti koje nisu bile pokrivene, a smatraju se važnim, zatim, oni koji su predložili preformulisanje mjera i oni koji su na neki način proširili izjavu. Predložene dodatne mjere kvalitete su, također, grupisane u teme. Nakon toga, relevantne tehničke jedinice su razmotrile grupisane komentare, dodatne mjere i sastavile listu za 2. krug Delfijevog procesa. Drugi krug "Delfi istraživanja" Drugi krug je proveden šest sedmica nakon prvog i tada je lista poslana na adrese 116 ispitanika koji su izrazili preferencije u prvom krugu. Dizajnirana su tri istraživanja: prvo se odnosilo na pružanje njege i unakrsna područja (standardi 1-3, 7 i 8), drugo se fokusiralo na iskustvo njege i unakrsna područja (standardi 4-6, 7 i 8), a treći na sve izjave o kvaliteti. Online/elektronsko istraživanje je bilo otvoreno četiri sedmice tokom kojih su četiri puta poslane podsjetnice putem e-pošte (e-mail-a). U ovom krugu od ispitanika je traženo da ocijene mjere kvaliteta na osnovu sljedećih pet kriterija, dogovorenih od strane Grupe za razvoj smjernica: • Značaj/važnost: Tema mjera je značajna i strateški važna za zainteresovane strane (npr. pacijente, kliničare, kupce, zdravstvene radnike, kreatore politika). Zdravstveni značaj: Aspekt zdravlja na koji se mjere odnose je važan, što pokazuje visoka prevalencija ili učestalost i/ili značajan uticaj na težinu bolesti (tj. uticaj na smrtnost i morbiditet kod populacije). • Mjerljivost: Zahtjevi za prikupljanje podataka za mjeru su razumljivi i izvodljivi. Izvor podataka potreban za sprovođenje mjere je dostupan i moguće mu je pristupiti u vremenskom okviru za mjerenje. • Pouzdanost: Rezultati mjerenja se reprodukuju za fiksni skup uslova, bez obzira ko vrši mjerenje ili kada se ono vrši. • Validnost: Mjera zaista mjeri ono što se podrazumijeva mjerenjem. • Korisnost: Mjera pruža uvid u značajnu promjenu mjere tokom vremena, što je potrebno za proces odlučivanja. Za svaki od gore navedenih kriterija, učesnici su imali šest opcija za ocjenjivanje, od kojih su mogli izabrati jedan: • Ne: Ova mjera kvalitete ne ispunjava ovaj kriterij; 17 • Vjerovatno ne: Ova mjera kvalitete vjerovatno ne ispunjava ovaj kriterij; • Nisam siguran: Nisam siguran da li ova mjera kvalitete ispunjava ovaj kriterij; • Vjerovatno da: Ova mjera kvalitete vjerovatno ispunjava ovaj kriterij; • Da: Ova mjera kvalitete ispunjava ovaj kriteriji; • Bez ekspertize: Ja nisam stručnjak/ekspert u ovoj oblasti. Rangiranje mjera kvalitete Ocjene koje su ispitanici dali u drugom krugu korištene su za procjenu prosječne ocjene svake mjere kvaliteta i to kako slijedi: • Ne: Ova mjera kvalitete ne ispunjava ovaj kriterij. = 0 bodova • Vjerovatno ne: Ova mjera kvalitete verovatno ne ispunjava ovaj kriterij. = 0,25 bodova • Nisam siguran: Nisam siguran da li ova mjera kvalitete ispunjavaju ovaj kriterij. = 0,5 bodova • Verovatno da: Ova mjera kvaliteta vjerovatno ispunjava ovaj kriterij. = 0,75 bodova • Da: Ova mjera kvalitete ispunjava ovaj kriterij. = 1 bod • Bez ekspertize: Ja nisam stručnjak/ekspert u ovoj oblasti. = Blank/Prazno "Blank/Prazno" odgovori nisu uključeni u proračun prosječnih ocjena. Izračunavanje srednjih vrijednosti/aritmetičke sredine rezultata Srednji rezultat ili aritmetička sredina izračunata je za svaku mjeru kvaliteta na svakom kriteriju i nazvan je "Srednji" rezultat, koji je jednak zbiru svih bodova za određeni kriteriji podijeljeno sa brojem ispitanika. Srednji rezultat za mjeru kvalitete za jedan kriterij = srednji rezultat (C) za tu mjeru kvalitete po broju ispitanika. "C" je jednako zbiru rezultata za taj kriteriji podijeljeno sa ukupnim brojem ispitanika (bez blank ili praznih polja). Pošto je bilo pet kriterija, izračunata je srednja vrijednost od pet srednjih ocjena da bi se dobio konačni prioritetni rezultat za svaku mjeru kvalitete. Konačan prioritetni rezultat za svaku mjeru kvalitete bio je izračunat dodavanjem srednjih rezultata za tu mjeru na pet kriterija podijeljenih sa 5. Konačni rezultat za mjeru kvalitete = Srednja vrijednost/aritmetička sredina srednjih rezultata za pet kriterija= (C1 + C2 + C3 + C4 + C5) / 5. Ulazne, izlazne i mjere kvalitete ishoda su, potom, rangirane za svaku izjavu o kvalitetu, prema konačnom rezultatu prioriteta. 18 3. Definicija i okvir kvalitete njege 3.1 Dokazi i rezime zaključaka Niti jedna, univerzalno prihvaćena, definicija kvalitete njege nije pronađena u literaturi (14-18). Utvrđeno je da je kvalitet njege višeslojan i opisan iz različitih perspektiva i dimenzija, uključujući pružaoce zdravstvenih usluga, menadžere, pacijente i sistem zdravstvene zaštite i to na osnovu kvalitativnih karakteristika kao što su sigurnost, djelotvornost, pravovremenost, efikasnost, pravičnost i fokusiranost na pacijenta; i kao pružanje i iskustvo njege (Okvir 2). Od Donabediana 1988. godine (18) predloženo je nekoliko modela kvaliteta njege: Maxwell (19), Ovretveit i sar. (20), Hulton i sar. (21), Institut za medicinu (16) i SZO (17). Tri modela koja su najčešće korištena i najjasnije definisana su perspektiva, karakteristike i sistemski modeli, koji su korišteni za operacionalizaciju karakteristika kvalitete njege na osnovu različitih elemenata. Najupečatljiviji je bio model SZO-a (17), koji je unaprijedio zdravstvene sisteme identifikovanjem šest glavnih blokova – isporuka usluge; zdravstvena radna snaga; informacije, medicinski proizvodi, vakcine i tehnologija; finansiranje, liderstvo i upravljanje; i struktura za uspostavljanje analize zdravstvenih sistema i tačaka intervencije. Zdravstveni sistem stvara strukturu koja omogućava pristup visokokvalitetnoj njezi. Ovi modeli su korišteni za dizajniranje konceptualnog okvira za definiranje, procjenu i praćenje kvaliteta njege majki i novorođenčadi. Definicija i okvir kvaliteta njege majki i novorođenčadi opisani su u nastavku, a doneseni su na osnovu gore navedene analize i konsenzusa postignutog na stručnom sastanku Grupe za razvoj smjernica. 3.2 Definisanje kvaliteta njege Na osnovu nekoliko definicija iz literature, definicija SZO kvalitete njege je "u kojoj mjeri zdravstvene usluge pružene pojedincima i populaciji pacijenata poboljšavaju željeni zdravstveni ishod. Da bi se to postiglo, zdravstvena zaštita mora biti sigurna, efektivna tj. djelotvorna, blagovremena, efikasna, pravedna tj. ravnopravna i usmjerena na ljude "(2). Okvir 2. Operativne definicije karakteristika kvalitete njege • Sigurno - pružanje zdravstvene zaštite koja minimizira rizike i štetu korisnicima usluga, uključujući izbjegavajnje ozljeda koje se mogu spriječiti te smanjivanje medicinskih grešaka. • Efektivno tj. djelotvorno - pružanje usluga zasnovanih na naučnim spoznajama i smjernicama zasnovanim na dokazima. • Pravovremeno - smanjivanje kašnjenja u pružanju i primanju zdravstvene zaštite. • Efikasno - pružanje zdravstvene zaštite na način koji maksimizira upotrebu resursa i izbjegava rasipanje. • Ravnopravno - pružanje zdravstvene zaštite koja se ne razlikuje po kvaliteti prema ličnim karakteristike kao što su rod, rasa, etnička pripadnost, geografska lokacija ili socioekonomski status. • Usmjereno na ljude – pružanje njege koja uzima u obzir preferencije i aspiracije pojedinačnih korisnika usluga i kulturu njihove zajednice. 19 Kvalitet njege za žene i novorođenčad je stoga stepen do kojeg zdravstvene usluge (za pojedince i populaciju) za majke i novorođenčad povećavaju verovatnoću blagovremene, odgovarajuće njege u svrhu postizanja željenih rezultata koji su u skladu sa trenutnim stručnim spoznajama i uzimajući u obzir preferencije i aspiracije pojedinačnih žena i njihovih porodica. Ova definicija uzima u obzir karakteristike kvalitete njege i dvije važne komponente njege: kvalitet pružanja njege i kvalitet njege kako je doživljavaju žene, novorođenčad i njihove porodice. 3.3 Kvalitet okvira njege Pošto je kvalitet njege multidimenzionalan, različiti modeli su korišteni za pripremu konceptualnog okvira koji bi trebao poslužiti kao smjernica za davaoce zdravstvene njege, menadžere i donosioce odluka u poboljšanju kvalitete zdravstvenih usluga za majke i novorođenčad. Na osnovu ovih modela i SZO sistemskog pristupa zdravlju, dizajniran je kvalitet okvira njege (slika 1) identifikacijom domena koje bi trebale biti usmjerene na procjenu, poboljšanje i nadgledanje njege u zdravstvenim ustanovama u kontekstu zdravstvenog sistema (2). Okvir ima osam domena kvalitete njege u okviru cjelokupnog zdravstvenog sistema. Iako se on fokusira na njegu koja se pruža u ustanovama, on predstavlja ujedno i ključnu ulogu u zajednici za korisnike usluga u identifikaciji njihovih potreba, preferenci i upravljanju sopstvenim zdravljem. Pogledi žena, njihovih porodica i njihovih zajednica na kvalitet usluga njege koja se pruža majkama utiču na njihovu odluku da traže njegu i osnovne su komponente u potražnji i pristupu visokokvalitetnim uslugama za majke i novorođenčad (12). Zato je angažovanje zajednice važan aspekt koji treba razmotriti, izvan zdravstvenih ustanova, i treba da bude integralna komponenta poboljšanja kvalitete brige za žene i novorođenčad. Slika 1. SZO okvir za kvalitet zdravstvene zaštite majki i novorođenčadi 20 Okvir osam domena kvalitete njege za trudnice i novorođenčad u institucijama povećava vjerovatnoću da će biti postignuti željeni ishodi pojedinca i institucije. Pristup zdravstvenog sistema pruža strukturu za poboljšanje kvalitete u dvije povezane dimenzije pružanja i iskustva njege. Pružanje njege uključuje upotrebu prakse zasnovane na dokazima za rutinsku i hitnu njegu, informacione sisteme u kojima se vodi evidencija i koji omogućavaju reviziju i pregled i funkcionalne sisteme za upućivanje između različitih nivoa njege. Iskustvo njege se sastoji od efikasne komunikacije sa ženama i njihovim porodicama o pruženoj njezi, o njihovim očekivanjima i njihovim pravima; njega sa poštovanjem i očuvanjem dostojanstva; te pristup socijalnoj i emocionalnoj podršci po njihovom izboru. Presjek oblasti okvira uključuje dostupnost kompetentnom i motivisanom upravljanju ljudskim resursima i fizičkim resursima koji su preduslovi za dobar kvalitet njege u zdravstvenim ustanovama. Ovaj okvir se može koristiti za procjenu karakteristika ili dimenzija kvaliteta njege u različitim sektorima zdravstvenog sistema, iz perspektive korisnika usluga, pružalaca usluga i menadžera. Na osnovu ovog okvira i u skladu sa organizacijskim mandatom, identificirano je šest strateških oblasti rada za poboljšanje kvalitete njege majki i novorođenčadi. Ovih šest oblasti su korištene kao osnova za sistematski pristup zasnovan na dokazima u pripremi smjernica, standarda njege, efikasnih tj. djelotvornih intervencija, indikatora kvalitete njege, istraživanja i izgradnje kapaciteta za poboljšanje kvaliteta njege majki i novorođenčadi. 3.4 Strateška područja djelovanja Šest strateških oblasti/područja za poboljšanje kvalitete njege i prevenciju smrtnosti majki i novorođenčadi su: 1. istraživanja, 2. smjernice, 3. standardi njege, 4. djelotvorne strategije intervencije, 5. indikatori za monitoring na globalnom, nacionalnom i nivou ustanove i 6. jačanje kapaciteta za poboljšanje kvaliteta, mjera i programa (2). Vođeni okvirom, rad na ovim strateškim oblastima će podržati poboljšanje kvalitete njege majki i novorođenčadi, sa ciljanim jačanjem nacionalnih kapaciteta i tehničke podrške. Međutim, pregled je ukazao na to da su smjernice kliničke prakse zasnovane na dokazima generalno dostupne, ali nije bilo smjernica o očekivanim standardima njege i odgovarajućim mjerama kvalitete. Zbog toga, standardi njege i mjere kvaliteta su bili prioritet kao prvi proizvodi normativa. 21 4. Standardi njege 4.1 Dokazi i rezime pronalazaka Potraga za definicijama, taksonomijom i strukturom standarda njege rezultirala je nekonzistentnom "definicijom" ili specifičnom, standardiziranom "strukturom". Većina identificiranih izvora bili su iz oblasti koje nisu vezane za zdravlje i koje su definirale standard kao izjavu koja pruža smjernice sa ciljem osiguranja konzistentnosti u procesima i proizvodima (22). Standardi vezani za zdravlje su bili pretežno iz okruženja sa visokim standardima tj. visokim primanjima (23, 24). Nacionalni Institut za zdravlje i izvrsnost njege (NICE) je pružio primjere standarda za majke i novorođenčad, uključujući i standarde za antibiotike za neonatalnu infekciju, hipertenziju u trudnoći, indukciju poroda, carski rez, postnatalnu njegu i antenatalnu njegu (25). PharmAccess Fondacija iz Holandije (26), Zajednička međunarodna komisija SAD-a (23) i Vijeće za akreditaciju zdravstvene službe Južne Afrike (24) izdali su standarde za zemlje sa niskim i srednjim prihodima. U 2007. godini, SZO je objavila ograničen broj standarda za njegu majki i novorođenčadi (27), od kojih se niti jedan nije specifično odnosio na period oko porođaja. Ovi zdravstveni izvori definisali su standarde prije svega za "akreditaciju", mada ih je nekoliko bilo za "poboljšanje kvaliteta", dajući "kriterije" za ispunjavanje standarda u "prioritetnim područjima ", prepoznavajući praznine u kvalitetu i sigurnosti. Iako je većina preporučila potrebu za "mjerenjem kriterija", mali broj njih je obezbijedio takva mjerenja. 4.2 Definicija i struktura standarda Na osnovu ovih saznanja vezanih za njegu majki i novorođenčadi, "standard" se definiše kao "opis onoga što se očekuje da se obezbijedi kako bi se postigla visokokvalitetna njega oko samog perioda porođaja". Standard njege ima dvije glavne komponente: izjavu o kvaliteti i mjeru kvalitete (slika 2). Izjava o kvaliteti postavlja zahtjeve za postizanje usaglašenosti sa standardima i mjerama kvalitete koje pružaju objektivne dokaze za utvrđivanje da li su ili nisu ispunjeni uslovi. Izjave o kvaliteti su koncizne izjave o prioritetima za mjerljivo poboljšanje kvalitete njege oko porođaja (prilagođene na osnovu NICE standarda kvalitete (25)). One definišu markere kvalitete koji se dobijaju iz dokaza o tematskoj oblasti i potrebnim resursima. Mjere kvalitete su kriteriji za procjenu, mjerenje i praćenje kvalitete njege kao što je navedeno u izjavi o kvaliteti. Postoje tri vrste mjera kvalitete: • unos: šta mora biti na mjestu za željenu njegu (npr. fizički resursi, ljudski resursi, politike, smjernice), • izlaz/izlazne informacije: da li je željeni proces njege bio obezbijeđen kao što se očekivalo i • ishod/rezultat: efekat pružanja i iskustva njege na zdravlje i ishodi usmjereni na ljude. 22 Slika 2: Struktura standarda U skladu sa osam domena SZO okvira za kvalitet njege, formulisano je osam standarda za definisanje prioriteta za poboljšanje kvalitete: 1. prakse zasnovane na dokazima za rutinsku njegu i upravljanje komplikacijama; 2. dostupni informacioni sistemi; 3. funkcionalni sistemi upućivanja; 4. efikasna komunikacija; 5. poštovanje i očuvanje dostojanstva; 6. emocionalna podrška; 7. kompetentno, motivisano osoblje; i 8. dostupnost osnovnih fizičkih resursa. Standarde prate dvije ili tri izjave o kvaliteti; izuzetak je standard 1 o praksama zasnovanim na dokazima za rutinsku njegu i upravljanje komplikacijama, za koje postoji 13 izjava o kvaliteti koje odražavaju specifične prioritete za intervenciju. Postoje ukupno 31 izjave o kvaliteti. Za standard 1, neke su označene sa 'a' ako se odnose samo na ženu, 'b' ako se odnose samo na bebu i 'c' ako se odnose na majku i bebu. Svaka od 31 izjave o kvaliteti imaju 6-18 mjera ulaznih, izlaznih informacija i ishoda tj. rezultata. 4.3 Obim i upotreba standarda i izjava o kvaliteti Standardi njege obuhvataju rutinsku njegu i upravljanje komplikacijama koje se javljaju kod žena i njihovih beba prije i tokom porođaja te ranog postnatalnog perioda, uključujući i one kod malih beba tokom prve sedmice života. Oni su usredsređeni na ženu, novorođenčad i porodice i primenjuju se na sve zdravstvene ustanove koje nude porodiljske usluge. Oni su usklađeni sa smjernicama SZO-a i osmišljeni su za rješavanje specifičnih prioriteta identifikovanih u odjeljku 1.2. Standardi njege pružaju osnovu za ono što se očekuje i traži, podržavaju monitoring odnosno praćenje i mjerenje performansi u odnosu prema mjerama najbolje prakse sa ciljem identifikacije prioriteta za poboljšanje i pružanje informacija o tome kako se najbolje prakse mogu koristiti za podršku visokog kvaliteta njege ili pružanje usluga. Oni definišu prioritete za poboljšanje kvaliteta materinstva i brige o novorođenčadi koje planeri, menadžeri i zdravstveni radnici tj. davaoci zdravstvene njege koriste za: 23 • pripremu nacionalnih i podnacionalnih standarda njege zasnovanih na dokazima kako bi osigurali visoko kvalitetne i efikasne zdravstvene usluge za majke i neonatalnu njegu u vrijeme porođaja; • uvođenje očekivanih standarda i pružanja njege u cilju identifikacije komponenti njege koje traže poboljšanje kako bi se osigurala visokokvalitetna usluga; • korištenje dostupnih resursa kako bi se postigli optimalni zdravstveni rezultati i poboljšala upotreba i zadovoljstvo pojedinaca, porodica i zajednica uslugama usmjerenim na zdravlje majki i neonatalne usluge; • praćenje poboljšanja u pružanju usluga, pokazivanjem da je pružena visokokvalitetna njega i usluge za majke i novorođenčad, naglašavajući oblasti za poboljšanje; i • pružanjem mjerila za reviziju nacionalnih zdravstvenih ustanova, akreditaciju i nagrade za performance pružaoca usluga. Oni bi se trebali usvojiti i usavršiti u okviru nacionalnih strategija za kvalitet njege i okvira za pružanje zdravstvenih usluga majkama i novorođenčadi kako bi se osiguralo da su pružene usluge visoke kvalitete. 4.4 Lista standarda i izjava o kvaliteti Prakse zasnovane na dokazima za rutinsku njegu i upravljanje komplikacija Standard 1: Svaka žena i novorođenče primaju rutinsku zaštitu i njegu zasnovane na dokazima, kao i upravljanje mogućim komplikacijama tokom porođaja, rođenja djeteta i ranog postnatalnog perioda, a sve prema smjernicama SZO. Cilj: Cilj ovog standarda je da osigura očekivano i zasnovano na dokazima upravljanje tokom poroda, porođajem i neposrednim postnatalnim periodom u prvih nekoliko dana nakon poroda majki i života novorođenčadi. To uključuje rutinsku njegu, ranu dijagnozu komplikacija i njihovo odgovarajuće upravljanje. Mnogi uslovi tj. stanja zahtijevaju pažnju tokom ovog perioda, zbog toga je standard ograničen na one povezane sa visokim mortalitetom. Upravljanje ovim uslovima/stanjima na odgovarajući način će drastično smanjiti broj smrtnih slučajeva i poboljšati rezultate žena i novorođenčadi u ovom periodu. Izjave o kvaliteti Izjava o kvaliteti 1.1a: Žene se rutinski procjenjuju prilikom prijema, tokom porođaja i rođenja djeteta, te im se pruža blagovremena i odgovarajuća njega. Izjava o kvaliteti 1.1b: Novorođenčad dobijaju rutinski tretman odmah nakon rođenja. Izjava o kvaliteti 1.1c: Majke i novorođenčad dobijaju rutinsku postnatalnu njegu. Izjava o kvaliteti 1.2: Žene sa pre-eklampsijom ili eklampsijom odmah dobijaju odgovarajuće intervencije, prema smjernicama SZO. Izjava o kvaliteti 1.3: Žene sa postpartalnom hemoragijom odmah dobijaju odgovarajuće intervencije, prema smjernicama SZO. 24 Izjava o kvaliteti 1.4: Žene s odgodom poroda ili čiji je porod ometan primaju odgovarajuće intervencije, prema SZO smjernicama. Izjava o kvaliteti 1.5: Novorođenčad koja ne dišu spontano primaju odgovarajuću stimulaciju i oživljavanje vrećicom i maskom unutar 1 minute od rođenja, prema SZO smjernicama. Izjava o kvaliteti 1.6a: Žene koje se prijevremeno porode dobivaju odgovarajuće intervencije za sebe i svoje bebe, prema SZO smjernicama. Izjava o kvaliteti 1.6b: Prijevremeno rođene i male bebe dobivaju odgovarajuću njegu, prema smjernicama SZO-a. Izjava o kvaliteti 1.7a: Žene sa ili pod rizikom od infekcije prije, tokom porođaja ili u ranom postnatalnom periodu odmah dobijaju odgovarajuće intervencije, prema smjernicama SZO. Izjava o kvaliteti 1.7b: Novorođenim bebama sa sumnjom na infekcije ili sa faktorima rizika za infekciju odmah se daje antibiotik prema uputstvima SZO. Izjava o kvaliteti 1.8: Sve žene i novorođenčad primaju njegu prema standardnim mjerama opreza za sprečavanje infekcije u toku hospitalizacije. Izjava o kvaliteti 1.9: Niti jedna žena ili novorođenče nije podvrgnuta nepotrebnim ili štetnim postupcima prije, tokom porođaja i ranog postnatalnog razdoblja. Djelotvorni informacijski sistemi Standard 2: Sistem informisanja u zdravstvu omogućava korištenje podataka kako bi se osiguralo rano, odgovarajuće djelovanje u smjeru poboljšanja njege i brige o svakoj ženi i novorođenčetu. Cilj: Cilj ovog standarda je precizno evidentiranje svih informacija u zdravstvenoj ustanovi, kako bi na odgovarajući način iskoristile prikupljene informacije i tako poboljšale brigu o ženama i novorođenčadi. Ovo zahtijeva dostupnost standardnih obrazaca za prikupljanje informacija o svim pacijentima tokom njihovog boravka u ustanovi i obučeno, stručno osoblje za prikupljanje podataka, analizu i korištenje rezultata koji trebaju pružiti povratne informacije za praćenje i poboljšanje performansi na svim nivoima zdravstvenog sistema, uključujući i rad osoblja koje se brine za pružanje zdravstvene njege. Izjave o kvaliteti Izjava o kvaliteti 2.1: Svaka žena i novorođenče imaju potpun, tačan, standardiziran medicinski zapis/karton tokom porođaja, poroda i ranog postnatalnog perioda. Izjava o kvaliteti 2.2: Svaka zdravstvena ustanova ima mehanizam za prikupljanje podataka, analizu i povratne informacije u okviru aktivnosti za praćenje i poboljšanje djelotvornosti prije, tokom porođaja kao i ranog postnatalnog perioda. 25 Funkcionalni sistemi upućivanja Standard 3: Svaka žena i novorođenče se upućuje na dalje promatranje i tretman na odgovarajući način, sa stanjem ili stanjima koji se ne mogu efikasno tretirati raspoloživim resursima. Cilj: Cilj ovog standarda je osigurati pravovremeno i adekvatno upućivanje svih pacijenata kojima je potrebna njega koja im se ne može pružiti u zdravstvenoj ustanovi. Odluka o upućivanju pacijenta treba da bude čim se dijagnosticira stanje koje se ne može liječiti u zdravstvenoj ustanovi, a nakon što im je pružen obavezni tretman prije upućivanja. Komunikacija se mora obavljati sa centrom u koji se vrši upućivanje a prije prebacivanja pacijenta, kako bi se mogao napraviti odgovarajući aranžman za prijem pacijenta. Potpunu brigu o pacijentu treba prepustiti prijemnoj zdravstvenoj instituciji, a povratne informacije o stanju pacijenta treba periodično tražiti kako bi se poboljšala njega u zdravstvenoj instituciji koja je izvršila upućivanje i u onoj u koju je upućivanje izvršeno. Izjave o kvaliteti Izjava o kvaliteti 3.1: Svaka žena i novorođenče se na odgovarajući način procjenjuju prilikom prijema, tokom porođaja i tokom ranog postnatalnog perioda da bi se utvrdilo da li je dalje upućivanje potrebno, a odluka o upućivanju se donosi bez odlaganja. Izjava o kvaliteti 3.2: Za svaku ženu i novorođenče koji traže dodatno upućivanje, upućivanje se prati prema unaprijed utvrđenom planu koji se može implementirati bez odlaganja i u bilo koje vrijeme. Izjava o kvaliteti 3.3: Za svaku ženu i novorođenče koji se upućuju unutar ili između zdravstvenih ustanova, postoji odgovarajuća razmjena informacija i povratne informacije koje se dostavljaju relevantnom zdravstvenom osoblju. Efikasna komunikacija Standard 4: Komunikacija sa ženama i njihovim porodicama je efikasna i odgovara njihovim potrebama i željama. Cilj: Cilj ovog standarda je efikasna tj. djelotvorna komunikacija, koja je osnovna komponenta iskustva njege koju prima pacijentica i njena porodica. Pacijentica treba biti upoznata sa svim informacijama vezanim za njenu njegu i treba biti involvirana tj. uključena u sve odluke koje se donose vezano za njen tretman. Efikasna komunikacija između davaoca zdravstvene njege i pacijenta može smanjiti nepotrebnu anksioznost i učiniti rođenje djeteta pozitivnim iskustvom za ženu. Izjave o kvaliteti Izjava o kvaliteti 4.1: Sve žene i njihove porodice dobijaju informacije o njezi i imaju efektivnu interakciju sa osobljem. Izjava o kvaliteti 4.2: Sve žene i njihove porodice imaju koordiniranu njegu, sa jasnim, tačnim informacijama koje se razmjenjuju između relevantnih stručnjaka iz oblasti zdravstva i socijalne zaštite. 26 Poštovanje i očuvanje dostojanstva Standard 5: Žene i novorođenčad dobijaju brigu sa poštovanjem i očuvanjem njihovog dostojanstva. Cilj: Cilj ovog standarda je dati potpuno poštovanje i očuvati dostojanstvo svih žena tokom njihovog boravka u zdravstvenoj ustanovi. Treba poštovati njihovu privatnost i povjerljivost u svakom trenutku, a treba izbjegavati bilo kakvo maltretiranje, kao što su fizičko, seksualno ili verbalno zlostavljanje, diskriminaciju, zanemarivanje, pritvaranje, iznuđivanje ili uskraćivanje usluga. Izjave o kvaliteti Izjava o kvaliteti 5.1: Sve žene i novorođenčad imaju privatnost za vrijeme porođaja i njihova povjerljivost se poštuje. Izjava o kvaliteti 5.2: Niti jedna žena ili novorođenče ne podliježe bilo kakvom obliku ili vidu zlostavljanja, kao što su fizičko, seksualno ili verbalno zlostavljanje, diskriminacija, zanemarivanje, pritvaranje, iznuđivanje ili odbijanja pružanja usluga. Izjava o kvaliteti 5.3: Sve žene su obaviještene o odabiru usluga koje primaju i jasno su objašnjeni razlozi za te intervencije ili ishodi istih. Emocionalna podrška Standard 6: Svaka žena i njena porodica dobijaju emocionalnu podršku koja je prilagođena njihovim potrebama i koja jača sposobnost žene. Cilj: Emocionalna podrška je bitna komponenta iskustva njege. Po rođenju pratioc po njenom izboru pomaže ženi da samouvjereno prođe kroz porod. Svaka žena dobija podršku koja jača njenu sposobnost tokom porođaja. Izjave o kvaliteti Izjava o kvaliteti 6.1: Svakoj ženi se nudi opcija da doživi porod sa pratiocem po njenom izboru. Izjava o kvaliteti 6.2: Svaka žena dobija podršku kako bi ojačala svoju sposobnost tokom porođaja. Kompetentno, motivisano osoblje Standard 7: Za svaku ženu i novorođenče, kompetentno, motivisano osoblje je uvijek dostupno da pruži rutinsku njegu i brine se o mogućim komplikacijama. Cilj: Sva područja zdravstvenog objekta u kojima se rađa i porođa treba da imaju kompetentno, dobro obučeno osoblje koje će biti prisutno 24 sata dnevno u dovoljnom broju za očekivano radno opterećenje. Dobro liderstvo i upravljanje u zdravstvenom objektu su od suštinskog značaja za pružanje podrške i osiguravanje kontinuiranog poboljšanja kvalitete. 27 Izjave o kvaliteti Izjava o kvaliteti 7.1: Svaka žena i dijete u svakom trenutku imaju pristup najmanje jednom stručnjaku koji nadzire porod i pomoćnom osoblju za rutinsku njegu i brigu u slučaju komplikacija. Izjava o kvaliteti 7.2: Stručnjaci za porod i pomoćno osoblje imaju odgovarajuće kompetencije i vještine koje zadovoljavaju zahtjeve porođaja i ranog postnatalnog perioda. Izjava o kvaliteti 7.3: Svaka zdravstvena ustanova ima menadžersko i kliničko rukovodstvo koje je kolektivno odgovorno da razvija i primjenjuje odgovarajuće politike i njeguje okruženje koje podstiče osoblje na kontinuirano poboljšanje kvalitete. Dostupnost osnovnih fizičkih resursa Standard 8: Zdravstvena ustanova ima odgovarajuće fizičko okruženje, uz odgovarajuću vodu, sanitarije i snabdjevanja energijom, lijekovima, zalihama i opremu za rutinsku brigu o majci i novorođenčadi, kao i upravljanje komplikacijama. Cilj: Svaki zdravstveni objekat treba da ima osnovnu infrastrukturu i sadržaje, uključujući vodu, sanitarije, higijenu i električnu energiju, odlaganje otpada, zalihe osnovnih tj. esencijalnih lijekova, pribor i opremu koja zadovoljava potrebe zdravstvene zaštite žena i novorođenčadi u objektu. Oblasti za rađanje, porođaj i postnatalnu njegu treba da budu higijenski, udobni, logički dizajnirani i organizovani za održavanje kontinuiteta njege. Izjave o kvaliteti Izjava o kvaliteti 8.1: Voda, energija, sanitarije, higijena ruku i sredstva za odlaganje otpada su funkcionalni, pouzdani, sigurni i dovoljni da zadovolje potrebe osoblja, žena i njihovih porodica. Izjava o kvaliteti 8.2: Prostorije za porod, porođaj i postnatalnu njegu su projektovane, organizovane i održavane na način da se svakoj ženi i novorođenčetu može pružiti individulana i kontinuirana njega prema njihovim potrebama. Izjava o kvaliteti 8.3: Dostupna je odgovarajuća zaliha lijekova, potrošnog materijala i opreme za rutinsku njegu i upravljanje komplikacijama. 28 5. Izjave o kvaliteti i mjere 5.1. Ishod Delfi procesa Većina od 318 mjera izrađenih za online/elektronske Delfi konsultacije bile su ulazne i izlazne mjere, budući da mjere ishoda nisu nužno pokrivene jedinstvenom izjavom o kvaliteti. Mjere ishoda su uglavnom one koje bi se mogle koristiti na lokalnoj razini kako bi pouzdano procijenile kvalitet njege i omogućile usporedbu ustanova ili promjene tokom vremena. U prvom krugu od 130 učesnika koji su dobili anketu, 116 (89%) je odgovorilo. Uglavnom složili su se da su razmatrane mjere kvalitete koje su se odnosile na ulazne informacije, proces i rezultate kvalitete njege koju žene i novorođenčad primaju tokom vremena porođaja. Od dobivenih komentara neki su predložili važne oblasti koje nisu obuhvaćene, također predložili su preoblikovanje nekih mjera ili proširenje razmišljanja izvan izjava o kvaliteti. Neki nisu bili direktno povezani sa izjavama o kvaliteti, nego su odražavali opće poglede učesnika na kvalitet njege. Na osnovu komentara razjašnjeno je nekoliko izjava o kvaliteti, 10 je izbrisano, a dodana je 41 nova mjera, što je rezultiralo sa ukupno 350 mjera kvalitete koje su razmatrane u drugom krugu. U drugom krugu ukupno 81 učesnik iz 46 zemalja s visokim, srednjim i niskim prihodima je završio jedno od tri istraživanja sa stopom odgovora od 70% (81/116). 61 od 83 ispitanika je komentarisao pružanje njege, a 48 od 74 iskustvo njege. Većina mjera kvalitete rangirana je visoko, najviše od 94,8 do najniže od 64,3; samo tri mjere su rangirane ispod 70. Za pružanje njege, srednja ocjena bila je > 90 za 35 mjere, 80-90 za 116 mjera i < 80 za 45 mjera. Za iskustvo njege, srednji/prosječni rezultat je bio > 90 za devet mjera, 80-90 za 47 mjera i < 80 za 16 mjera. Za mjera ukrštanja, srednja ocjena bila je ≥ 90 za 12 mjera, 80-90 za 50 mjera i ≤ 80 za 16 mjera. Dakle, 56 mjera kvalitete dobilo je rang od > 90. Najviše rangirane izjave o kvaliteti bile su ulazne mjere. 5.2 Korištenje mjera kvalitete Timovi zdravstvenih ustanova mogu koristiti mjere kvalitete kako bi se utvrdili nedostaci u kvaliteti njege i poboljšalo pružanje i iskustvo njege prema standardu i relevantnim izjavama o kvaliteti. Vođe zdravstvenih ustanova, planeri, menadžeri i pružaoci usluga mogu ih koristiti za procjenu i praćenje dostupnosti resursa, izvedbe procesa, područja koja zahtijevaju poboljšanje i utjecaj intervencija, a time i poboljšanje kvalitete. Mjere treba prilagoditi svakom kontekstu, ali se standardi moraju dosljedno provoditi kako bi se osiguralo poboljšanje kvalitete. Mjere kvalitete uključuju ulazne, izlazne/procesne i mjere ishoda. Ulazne mjere uključuju fizičke resurse, ljudske resurse, politike, protokole i smjernice. Izlazne mjere obuhvataju pokrivanje ključnih praksi, a većina se izražava kao proporcije, kao što je "Procenat svih žena koje su rodile u zdravstvenoj ustanovi čiji je rezultat analize urina bio odgovarajuće zabilježen tokom procesa poroda, samog porođaja i ranog postpartum perioda. " Mjere ishoda uključuju ishode usmjerene na ljude i na zdravlje. 29 Većina izjava o kvaliteti je praćena mjerama koje su vrlo specifične za tu izjavu; međutim, neke mjere mogu biti relevantne za više od jedne izjave, pogotovo u odnosu na fizičke resurse (standard 8). Brojevi mjera kvalitete odražavaju redosljed kojim su bile navedene u anketi. Rezultat koji je dobila svaka mjera je dat u zagradama, a tri najviše rangirane mjere kvalitete za svaku izjavu označene su sa zvjezdicama. 5.3 Mjere za izjave o kvaliteti Standard 1: Svaka žena i novorođenče primaju rutinsku zaštitu i njegu zasnovane na dokazima, kao i upravljanje mogućim komplikacijama tokom porođaja, rođenja djeteta i ranog postnatalnog perioda, a sve prema smjernicama SZO. Izjava o kvaliteti 1.1a: Žene se rutinski procjenjuju prilikom prijema, tokom porođaja i rođenja djeteta, te im se pruža blagovremena i odgovarajuća njega. Obrazloženje: Procjena žena i redovno praćenje tokom prijema, porođaja i rođenja je od presudnog značaja da bi se osigurala osnovna briga koja odgovara inividualnom slučaju svake žene i kako bi se spriječio početak komplikacija i identifikovao rizik ili komplikacije koje zahtijevaju hitno djelovanje ili upućivanje kako bi se osigurali bolji rezultati trudnoće i poroda i za majku i za novorođenčad. Na prijemu, žene se podvrgavaju cjelovitom pregledu sa evidencijom o antenatalnoj njezi, trudnoći i istoriji rađanja, vaginalnom pregledu i potvrdi rađanja. Fetalni otkucaji srca, fetalni položaj ležanja i izgled, krvni pritisak, impuls i temperatura se određuju i bilježe. Krvna grupa i R tip, hemoglobin, protein u urinu i glukoza, i po potrebi HIV status, se testiraju i bilježe. Napredak procesa rađanja se prati partografom; krvni pritisak, puls, temperatura i otkucaji srca fetusa se redovno ocjenjuju svaka 4 sata. Ponuđeno je olakšanje bola i izbor majke se poštuje. Spontano vaginalno rođenje se podržava i vodi se sa majčinom potrebom na potisak/guranje. Aktivno se upravlja trećom fazom poroda i intravenski ili intramuskularni oksitocin se daje odmah nakon rođenja. Bilo koje komplikacije pri prijemu i tokom procesa rađanja i porođaja se brzo identifikuju i njima se adekvatno upravlja (pogledajte izjave o kvaliteti 1.2, 1.3, 1.4, 1.5, 1.6a i b, 1.7a i b). Mjere kvalitete Ulazne mjere 1. Zdravstveni objekat ima osnovnu, neophodnu opremu i zalihe za rutinsku njegu i otkrivanje komplikacija (termometri, sfigmomanometri, fetalni stetoskopi, šipke za urin) koje su uvijek dostupne u dovoljnim količinama u područjima porodilišta za rađanje i porođaj*. (93.38) 2. Zdravstveni objekat ima pisane, ažurirane kliničke protokole za procjenu intrapartumske njege i djelovanja u područjima porodilišta za rađanje i porođaj, a koji su u skladu sa smjernicama SZO*. (89.37) 3. Zdravstveno osoblje u područjima porodilišta za rađanje i porođaj dobija stručno usavršavanje i redovne sesije obnavljanja naučenog, najmanje jednom svakih 12 30 mjeseci, a o identifikaciji i upravljanju akušerskim vanrednim situacijama tokom procesa rađanja i porođaja. (83.42) 4. Zdravstveno osoblje u područjima za rađanje i porođaj dobija najmanje mjesečni trening ili simulacijske vježbe o podržavanju nadzora u rutinskoj njezi i otkrivanju akušersikih komplikacija tokom procesa rađanja i porođaja. (78.65) Izlazne mjere/mjere procesa 1. Procenat svih žena koje su rodile u zdravstvenoj ustanovi čiji je krvni pritisak, puls i temperatura prikladno zabilježena tokom rađanja, porođaja i ranog perioda nakon poroda (postpartuma) (i dalje postupak po potrebi). (87.25) 2. Procenat svih žena koje su rodile u zdravstvenoj ustanovi, a koje su primile oksitocin u roku od 1 minute od rođenja svoje bebe. (86.18) 3. Procenat svih žena koje su rodile u zdravstvenoj ustanovi i čiji je napredak u procesu rađanja ispravno praćen i dokumentovan sa partografom i četverosatnom akcijom. (84.56) 4. Procenat svih žena koje su rodile u zdravstvenoj ustanovi i čiji je rezultat analize urina odgovarajuće zabilježen tokom perioda rađanja, porođaja i ranog perioda nakon porođaja (i dalje postupak po potrebi). (78.45) 5. Procenat svih žena koje su rodile u zdravstvenoj ustanovi i koje su dobile bilo kakvu opciju za olakšanje bola tokom procesa rađanja i porođaja. (73.04) Mjere ishoda 1. Stopa perinatalne smrtnosti u zdravstvenoj ustanovi [broj smrtnih slučajeva fetusa (mrtvorođenčadi) ili ranih neonatalnih smrtnih slučajeva / ukupnog broja rođenih beba težine od najmanje 1000 g ili trudnoće od 28 sedmica (mrtvorođeni + živo rođeni) x 1000] *. (91.39) 2. Stopa mrtvorođenih u intrapartumu (broj mrtvorođenih tokom perioda intrapartuma na 1000 rođenja). (88.42) 3. Procenat svih žena primljenih u zdravstvenu ustanovu u periodu aktivnog rađanja i koje su rodile unutar 12 sati od prijema. (72.83) Izjava o kvaliteti 1.1b: Novorođenčad dobijaju rutinski tretman odmah nakon rođenja. Obrazloženje: Rutinska njega novorođenčeta odmah nakon rođenja olakšava adaptaciju novorođenčeta na novo okruženje, zadovoljava njene ili njegove neposredne potrebe na najbolji mogući način i izbjegava komplikacije koje se mogu prevenirati. Odmah poslije porođaja, novorođenčad se temeljno osuše i stavljaju u kontakt sa kožom na kožu sa majkom i to najmanje jedan sat. Stezanje pupčane vrpce je odloženo od 1 do 3 minute nakon rođenja, i dojenje je podržano u prvom satu nakon rođenja. Identifikuju se sve komplikacije i njima se adekvatno upravlja. Mjere kvalitete Ulazne mjere 1. Zdravstveni objekat ima pisane, ažurirane, kliničke protokole za esencijalnu njegu novorođenčeta koji su u skladu sa smjernicama SZO i dostupne su u područjima porodilišta za rađanje i porođaj*. (91,09) 31 2. Zdravstveni objekat ima zalihe sterilnih vezica (ili stezaljki) i makaza (ili oštrica), koje su u svakom trenutku dostupne u dovoljnim količinama za očekivani broj rođenja *. (89.86) 3. Zdravstveni objekat ima zalihe čistih peškira u područjima porodilišta za rađanje i porođaj zbog neposrednog sušenja novorođenčadi, a koji su u svakom trenutku dostupni u dovoljnim količinama za očekivani broj rođenja. (84.83) 4. Zdravstveno osoblje u područjima porodilišta za rađanje i porođaj dobija stručno usavršavanje ili redovne sesije obnavljanja naučenog o osnovnoj brizi za novorođenčad i podršci za dojenje, najmanje jednom u 12 mjeseci. (83.94) 5. Zdravstveni objekat ima lokalne aranžmane i mehanizam za održavanje temperatura sobe u područjima porodilišta za rađanje i porođaj na ili iznad 25 °C i bez naglih oscilacija. (77,9) 6. Zdravstveno osoblje u područjima porodilišta za rađanje i porođaj dobija najmanje mjesečni trening ili simulacijske vježbe i podržavajuću superviziju o osnovama brige o novorođenčadi i podršci dojenju. (77.82) Izlazne mjere/mjere procesa 1. Procenat sve novorođenčadi koji su dojili u roku od jednog sata po rođenju *. (86.42) 2. Procenat sve novorođenčadi koji su držani u kontaktu kože na kožu (sa pokrivenom tijelom i glavom) sa majkama najmanje jedan sat nakon rođenja. (83.34) 3. Procenat sve novorođenčadi koji su primili sva četiri elementa neophodna za brigu o novorođenčadi: neposredno i temeljito sušenje, neposredni kontakt kože na kožu, odgođeno stezanje pupčane vrpce i iniciranje dojenja u prvom satu. (78.93) 4. Procenat sve novorođenčadi čija je pupčana vrpca stegnuta jednu do tri minute nakon rođenja. (76.56) 5. Procenat sve novorođenčadi koji su se odmah i temeljito osušili po rođenju. (76.53) Mjere ishoda 1. Procenat svih novorođenih koji su imali normalnu tjelesnu temperaturu (36,5-37,5 °C) na prvom kompletnom pregledu (60-120 minuta nakon rođenja). (85.37) Izjava o kvaliteti 1.1c: Majke i novorođenčad dobijaju rutinsku postnatalnu njegu. Obrazloženje: Rutinska postnatalna njega predstavlja primjenu najboljih praksi za prevenciju, rano otkrivanje i liječenje komplikacija kod majke i bebe i savjetovanje majki o tome kako najbolje brinuti o sebi i novorođenčadi. Postnatalna njega, individualizirana njega pružena majci i njenoj bebi nakon porođaja trebalo bi da se odnosi na svaku varijaciju od očekivanog normalnog oporavka nakon rođenja. Krvni pritisak, temperatura, krvarenje i pražnjenje urina često se prate tokom prvih 48 sati poslije porođaja. Komplikacije se identifikuju i njima se upravlja, a dojenje je posebno podržano. Majke se savjetuju o znacima opasnosti u njima samima i na njihovim bebama, o razmaku rođenja i metodama planiranja porodice. Novorođenčad dobijaju potpunu fizičku procjenu, čuvaju se u kontaktu koža na kožu sa majkom i vodi se njega oko pupčane vrpce. Kupanje se odlaže za 24 sata, vitamin K i vakcine se daju prema nacionalnim smjernicama, prati se temperatura i komplikacije se identifikuju i njima se upravlja. Bebama koje su rođene sa niskom kilažom i malim bebama se po potrebi pruža dodatna njega (vidjeti Izjavu o kvaliteti 1.6b). 32 Mjere kvalitete Ulazne mjere 1. Zdravstveni objekat ima pisane, ažurirane kliničke protokole za majčinsku postnatalnu njegu i / ili postnatalnu njegu u porodilištu, a koji su u skladu sa smjernicama SZO*. (90.10) 2. Zdravstvene ustanove praktikuju i omogućavaju prostor u sobama kako bi majke i bebe mogle ostati zajedno 24 sata dnevno*. (86.57) 3. Zdravstveni objekat ima pisanu politiku o dojenju koja se rutinski prenosi svom zdravstvenom osoblju za njegu i pomoćnom osoblju. (83.18) 4. Zdravstveno osoblje u porodilištu dobija stručno usavršavanje i redovne sesije obnavljanja naučenog o osnovnoj brizi za novorođenčad i podršci za dojenje, najmanje jednom svakih 12 mjeseci. (83.04) 5. Zdravstveni objekat ima lokalne aranžmane kako bi obezbijedili da svaka majka zna kada i gdje će joj biti pružena postnatalna njega za nju i njeno novorođenče nakon otpusta iz bolnice. (79.98) 6. Zdravstveni objekat ima lokalne aranžmane za metode alternativnog hranjenja, uključujući čašice ili hranjenje čašicom i kašikom i izbjegavanje hranjenja bočicom. (78.97) 7. Zdravstveni objekat ima lokalni aranžman za informisanje trudnica i njihovih porodica o koristima i upravljanju dojenjem. (74.49) 8. Zdravstvena ustanova osigurava da se ishrana beba sa formulama za hranjenje pokazuje majkama i članovima porodice novorođenčadi samo kada je to potrebno, uz potpuno objašnjenje opasnosti nepravilne upotrebe. (71.85) Izlazne mjere/mjere procesa 1. Procenat sve novorođenčadi u odjeljenjima ili područjima zdravstvenog objekta za postnatalnu njegu koji su primili vitamin K i potpunu vakcinaciju po nacionalnim smjernicama*. (91.23) 2. Procenat sve stabilne novorođenčadi u zdravstvenom objektu koja se hrani isključivo majčinim mlijekom od rođenja do otpuštanja. (84.37) 3. Procenat svih žena u odjeljenjima ili područjima zdravstvenog objekta za postnatalnu njegu koje imaju dokumentovani problem krvnog pritiska, pulsa, vaginalnog krvarenja, lohije (krvarenje nakon poroda) ili dojenja. (84.02) 4. Procenat sve novorođenčadi u zdravstvenom objektu koji su dobili puni klinički pregled prije otpusta. (83.13) 5. Procenat svih zdravih majki i novorođenčadi koji su u zdravstvenoj ustanovi primali njegu najmanje 24 sata nakon nekompliciranog vaginalnog poroda. (82.50) 6. Procenat sve novorođenčadi u odjeljenjima ili područjima zdravstvenog objekta za postnatalnu njegu za koje postoje dokumentovane informacije o temperaturi novorođenčeta, brzini disanja, ponašanju prilikom hranjenja i odsustvu ili prisustvu znakova opasnosti. (82.41) 7. Procenat svih zdravih majki na odjeljenjima ili područjima zdravstvenog objekta za postnatalnu njegu koje su primile savjetovanje vezano za dojenje i podršku od strane kvalifikovanog zdravstvenog osoblja. (82.14) 8. Procenat svih žena koje su rodile u zdravstvenoj ustanovi i kojima je dozvoljeno da budu u sobi sa svojim novorođenčetom 24 sata dnevno. (78.90) 9. Procenat svih žena u zdravstvenoj ustanovi kojima je nakon poroda ponuđeno savjetovanje o razmaku između rađanja i planiranju porodice, a prije otpusta. 33 Mjere ishoda 1. Procenat sve novorođenčadi u zdravstvenom objektu koji su samo i isključivo dojili u vrijeme otpusta iz bolnice. (85.55) 2. Procenat svih žena u zdravstvenoj ustanovi koja su nakon poroda, a prije otpusta, primile savjet o kontracepciji, razmaku između poroda i planiranju porodice. (84.03) Izjava o kvaliteti 1.2: Žene sa pre-eklampsijom ili eklampsijom odmah primaju odgovarajuće intervencije prema smjernicama SZO. Obrazloženje: Hipertenzija izazvana trudnoćom, pre-eklampsija i eklampsija glavni su uzroci smrtnosti majki, mrtvorođenju i neonatalnoj smrtnosti. Prevencija, rana dijagnoza i pravovremeno, odgovarajuće liječenje može drastično smanjiti povezanu smrtnost i morbiditet. Ženama s ozbiljnom pre-eklampsijom odmah se daje, intravenozno ili intramuskularno, magnezijev sulfat i antihipertenziv, prema potrebi. Magnezijev sulfat je potrebno dati u odgovarajućoj dozi, ako je ženu potrebno prebaciti u drugi odjel. Znakovi disfunkcije organa i drugi znakovi opasnosti (krvni tlak, respiratorna brzina, tekućine, izlučivanje urina, refleks tetive i fetalni otkucaji srca) su praćeni. Laboratorijsko ispitivanje uree i elektrolita određuje napredovanje bolesti. Ako je žena u terminu ili je fetus neodrživ, porođaj je induciran instrumentalnom intervencijom ili carskim rezom, prema potrebi. Za trudnoće koje nisu u terminu, proaktivno se tretira s kortikosteroidima, ako je stanje stabilno. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima zalihe oralnih i intravenoznih antihipertenzivnih sredstava i magnezija sulfata, dostupne u dovoljnim količinama, uvijek, na odjelima antenatalne, akušerske i postnatalne njege *. (91.8) 2. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole o upravljanju preeklampsijom koji su dostupni u antenatalnom, akušerskom i postnatalnom odjelu njege i sukladni su sa smjernicama SZO. (90,59) 3. Osoba za zdravstvenu njegu u porodničkoj jedinici dobiva stručnu obuku i redovite sesije podsjećanja o upotrebi antihipertenzivnih sredstava, intravenozne infuzije i magnezijevog sulfata za liječenje preeklampsije i eklampsije, najmanje jednom u 12 mjeseci. (84,54) Izlazne mjere/mjere procesa 1. Razmjer svih žena s ozbiljnom pre-eklampsijom ili eklampsijom koje su u zdravstvenoj ustanovi dobile punu dozu magnezijevog sulfata *. (91,37) 2. Razmjer svih žena s ozbiljnom hipertenzijom izazvanom trudnoćom, koje su u zdravstvenoj ustanovi primile preporučene antihipertenzive. (88,02) 3. Razmjer svih žena s preeklampsijom u zdravstvenoj ustanovi čije stanje je napredovalo u eklampsiju. (81,9) Mjere ishoda 1. Razmjer svih žena s preeklampsijom ili eklampsijom u zdravstvenoj ustanovi koje su preminule kao rezultat pre-eklampsije ili eklampsije *. (91,22) 34 2. Razmjer svih žena s preeklampsijom ili eklampsijom koje su stigle u zdravstvenu ustanovu s živim fetusom, a čija je beba umrla u perinatalnom razdoblju (mrtvorođenče ili rana neonatalna smrt). (86.55) 3. Razmjer svih žena s preeklampsijom ili eklampsijom u zdravstvenoj ustanovi koje su mogla umrijeti zbog pre-eklampsije ili eklampsije. (76,88) Izjava o kvaliteti 1.3: Žene sa postpartalnom hemoragijom odmah primaju odgovarajuće intervencije prema smjernicama SZO. Obrazloženje: Krvarenje nakon poroda je vodeći uzrok majčinske smrtnosti koja se može prevenirati, a većina smrti nastupi u prvih 24-48 sati, po porođaju. Rana dijagnoza i pravovremeno, adekvatno tretiranje su osnova za učinkovito smanjenje smrtnosti. Rutinski se prati postpartalno krvarenje. Ako dođe do krvarenja, potrebno je odmah uvesti intravenski oksitocin, masažu maternice, ručno uklanjanje zaostale posteljice kao i odgovarajuće mjere koje će smanjiti štetu ili kirurške intervencije kada je to naznačeno. Daljnji gubitak krvi, puls i krvni tlak pažljivo se nadziru, a šok se tretira s reanimacijom pomoću intravenskih tekućina i transfuzijom krvi, ako je indicirano. Mjere kvalitete Ulazne mjere 4. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole za krvarenje nakon poroda koji su dostupni na odjelima akušerske i postnatalne njege i koji su u skladu sa smjernicama SZO *. (90.76)) 5. Zdravstvena ustanova ima uterotonične lijekove i pomagala za intravensku primjenu tekućine i krvi (šprice, iglice, intravenozne kanile, intravenske otopine tekućina, krv) dostupno u odgovarajućim količinama, uvijek, u odjelima akušerske i postnatalne njege.(89,55) 6. Funkcionalna transfuzija krvi dostupna je u zdravstvenoj ustanovi u svakom trenutku.(86,82) 7. Osoblje zdravstvene njege na odjelima akušerske i postnatalne njege prima kontinuiranu obuku i redovite obnove znanja o tretiranju krvarenja nakon porođaja, najmanje jednom u 12 mjeseci. (84,25) Izlazne mjere/mjere procesa 1. Razmjer svih žena s postpartalnim krvarenjem nakon poroda u zdravstvenoj ustanovi, koje su primile terapeutske uterotonične lijekove *. (89,75) 2. Razmjer svih žena koje su u zdravstvenoj ustanovi krvarile nakon poroda zbog zaostale posteljice, a za koje je ručno uklanjanje posteljice obavljao stručni zdravstveni djelatnik.(80,48) Mjere ishoda 1. Razmjer svih žena koje su u zdravstvenoj ustanovi preminule kao rezultat postporođajnog krvarenja. *. (92,98) 2. Razmjer svih žena koje su nakon poroda carskim rezom u zdravstvenoj ustanovi, a koje su primile transfuziju krvi. (85,80) 35 3. Razmjer svih žena koje su rodile vaginalno u zdravstvenoj ustanovi, a koje su primile transfuziju krvi. (85.58) 4. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, s teškim postpartalnim krvarenjem (abnormalno krvarenje> 1000 mL ili bilo koji krvarenje s hipotenzijom ili transfuzijom krvi). (83,69) 5. Razmjer svih žena koje su poslije porođaja u zdravstvenoj ustanovi imale krvarenje, radi kojeg je majka mogla umrijeti. (77.97) Izjava o kvaliteti 1.4: Žene s odgodom poroda ili čiji je porod ometan primaju odgovarajuće intervencije prema SZO smjernicama. Obrazloženje: Opstruirani porođaj glavni je uzrok i majčinskog i novorođenačkog morbiditeta i smrtnosti. Nedijagnosticirani opstruirani porod može dovesti do rupture uterusa, veziko-vaginalne fistule ili rekto-vaginalne fistule kod majke i većeg rizika za mrtvorođenče, neonatalnu asfiksiju, aspiracijskog sindroma uzrokovanog mekonijem i drugih stanja. Pravilno praćenje poroda radi izbjegavanja prolongiranosti i komplikacija i rano otkrivanje i pravovremeno tretiranje opstruiranog poroda može smanjiti učestalost ovih komplikacija. Intervencije za nenapredovanje poroda uključuju digitalni vaginalni pregled u intervalima od 4 h i brzu potvrdu nenapredovanja poroda s partografom s akcijskom linijom od 4 h, provjera za cefalopelvični nesrazmjer i procjenu hidratacije žene. Ubrzanje porođaja pomoću intravenskog oksitocina (i s amniotomijom, ako membrana ne pukne) se koristi ako postoji nenapredovanje u prvoj fazi bez cefalopelvičnog nesrazmjera. Nenapredovanje u drugoj fazi poroda tretira se odgovarajućom upotrebom instrumenata (vakuum ili forceps) ili pomoću carskog reza, ako postoje dokazi o opasnosti po fetus ili znakovi opstruiranosti. Napomena: Ubrzanje poroda se treba koristiti samo u potvrđenom nenapredovanju poroda, nakon isključenja cefalopelvičnog nesrazmjera i u ustanovama koje su sposobne za čestu, redovitu kontrolu brzine otkucaja srca fetusa i obrazac kontrakcije maternice i može tretirati bilo kakve štetne učinke. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pisane, ažurirane kliničke protokole za sprečavanje i tretiranje prolongiranih poroda, koji su dostupni na odjelima akušerske i postnatalne njege, a koji su skladni smjernicama SZO*. (90,88) 2. Zdravstvena ustanova ima osnovne zalihe i opremu za porođaj pomoću vakuuma ili forcepsa, uključujući opremu za reanimaciju novorođenčeta, dostupnu u dovoljnim količinama u svakom trenutku, na odjelu akušerske i postnatalne njege *. (90,33) 3. Zdravstvena ustanova ima adekvatno opremljenu operacijsku salu u blizini akušerskog i prenatalnog odjela *. (90,13) 4. Zdravstvena ustanova ima odgovarajući broj osoblja vještog u obavljanju carskog reza, 24 sata na dan. (87.93) 5. Osoblje koje pruža zdravstvenu njegu na području akušerskog i postnatalnog odjela zdravstvene ustanove dobiva stručnu obuku i redovitu obnovu znanja (svakih 6 mjeseci) o tretiranju produženog i opstruiranog porođaja.(82.19) 36 Izlazne mjere/mjere procesa 1. Razmjer svih prvorotki u u zdravstvenoj ustanovi, koje su imale jedan fetus, glavom okrenutom prema dolje, na ≥37 sedmica trudnoće, koje su podvrgnute carskom rezu za trajanja spontanog porođaja (Robson grupa 1).(87,27) 2. Razmjer svih žena u zdravstvenoj ustanovi s produženim i/ili opstruiranim porodom koji je završio carskim rezom. (86,03) 3. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, a koje su podvrgnute porodu pomoću korištenja instrumenata, radi prolongirane druge faze poroda. (83,21) 4. Razmjer žena s produženim ili opstruiranim porodom koje su podvrgnute hitnom carskom rezu unutar 30 minuta od odluke o carskom rezu. (79,9) 5. Razmjer svih žena u zdravstvenoj ustanovi s potvrđenim nenapredovanjem prve faze poroda, koje su primile oksitocin za ubrzanje. (79,06) 6. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, čija je aktivna faza u prvoj fazi poroda prekoračila trajanje od 12 sati. (76,79) 7. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi s produženom drugom fazom poroda. (74,82) Mjere ishoda 1. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi koje su imale rupturu maternice tokom poroda.(89,35) 2. Razmjer svih perinatalnih smrti koje su se dogodile u zdravstvenoj ustanovi nakon prolongiranog poroda ili opstrukcije poroda.(85,23) 3. Razmjer sve novorođenčadi rođene u zdravstvenoj ustanovi, koja je imala ozljede prilikom rađanja (brahijalna paraliza, frakture, hematom na glavi). (83,75) 4. Razmjer žena u zdravstvenoj ustanovi s prolongiranim ili opstruiranim porodom, a koje su umalo umrle iz tog razloga. (78.0) Izjava o kvaliteti 1.5: Novorođenčad koja ne dišu samostalno, primaju odgovarajuću stimulaciju i oživljavanje vrećicom i maskom unutar 1 minute od rođenja, a prema SZO smjernicama. Obrazloženje: Asfiksija jedan je od vodećih uzroka neonatalne smrti u prvom tjednu života i također je odgovorna za dugoročno neurološko oštećenje i invaliditet. Može biti spriječena uz odgovarajuće, učinkovito oživljavanje novorođenčadi koja ne diše pri rođenju. Novorođenčad koja ne diše spontano se nakon temeljitog sušenja trlja dva do tri puta po leđima za dodatnu stimulaciju. Usisavanje se koristi samo kad je novorođenčad ispustila mekonij ili ako je prisutan sekret u ustima ili nosu. Ventilacija s pozitivnim tlakom sa samopušućom vrećicom-i-maskom primjenjuje se 1 minutu po rođenju, sa zrakom za novorođenče > 32 tjedna trudnoće i 30% kisika za prijevremenu bebu kod gestacije <32 tjedna. Adekvatnost ventilacije prati se mjerenjem brzine otkucaja srca, pokreta prsnog koša i pulsnom oksimetrijom (ako je dostupna). Veća koncentracija kisika se daje samo ako je brzina otkucaja srca <60 / min nakon 60 sekundi reanimacije. 37 Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova u akušerskom i neonatalnom odjelu ima usisni uređaj, najmanje dvije neonatalne maske i vreću koja se samonapuhava *. (93,83) 2. Zdravstvena ustanova u akušerskom i neonatalnom odjelu ima pisane i ažurirane kliničke protokole za njegu novorođenčadi koja nije spontano disala, a koji su u skladu sa smjernicama SZO *. (91.86) 3. Svi zdravstveni radnici koji pružaju njegu trudnicama, rodiljama i novorođenčadi u zdravstvenoj ustanovi, obučeni su za osnovnu reanimaciju novorođenčadi, a demonstrirano je simuliranjem pozitivnog tlaka ventilacije s vrećicom i maskom na lutki. (89,64) 4. Zdravstveno osoblje akušerskog i neonatalnog odjela u rodilištu dobiva stručno usavršavanje i redovite obnavljanu obuku u osnovnoj reanimaciji novorođenčadi barem jednom svakih 12 mjeseci. (87,06) 5. Zdravstveno osoblje akušerskog i neonatalnog odjela rodilišta radi mjesečne vježbe ili simulacijske vježbe i dobiva nadzor podrške u osnovnoj reanimaciji novorođenčeta.(83,91) Izlazne mjere/mjere procesa 1. Razmjer sve novorođenčadi u zdravstvenoj ustanovi koja nije spontano disala nakon dodatne stimulacije, koji je bio oživljavan s vrećicom i maskom. (81,10) 2. Razmjer sve novorođenčadi u zdravstvenoj ustanovi koja nije spontano disala nakon dodatne stimulacije i koja je reanimirana s vrećicom i maskom u roku od 1 min po rođenju.(75.56) Mjere ishoda 1. Razmjer svih živih beba rođenih u zdravstvenoj ustanovi u terminima (≥ 37 tjedana) bez većih kongenitalnih malformacija, koje su preminule u roku od 7 dana po rođenju (rani neonatalni mortalitet) *. (91,14) 2. Razmjer svih živih beba rođenih u terminima (≥ 37 tjedana) u zdravstvenoj ustanovi, koje nisu disale spontano, ali su disale spontano 5 minuta nakon oživljavanja. (77,92) Izjava o kvaliteti 1.6a: Žene koje se prijevremeno porode primaju odgovarajuće intervencije kako za sebe tako i za svoje bebe prema SZO smjernicama. Obrazloženje: Prijevremeni porod (prije 37 završenih tjedana trudnoće) može rezultirati brojnim zdravstvenim rizicima za bebu, koji se povećavaju, što je beba ranije rođena. Prevencija prijevremenog porođaja i odgovarajuće skrob pri prijevremenom porođaju su neophodni za smanjenje povezanih rizika za bebu, sprečavanje komplikacija koje se mogu izbjeći i poboljšanje ishoda i preživljavanja prijevremeno rođenih beba. Žene koje su u prijevremenom porođaju primaju se u ustanovu koja ima kapacitet njegovanja prijevremeno rođenih beba i njihovih komplikacija, prolaze temeljitu procjenu i pregled kako bi se ultrazvukom ili datumom prvog dana posljednje menstruacije utvrdila gestacijska starost, potražili znakovi i simptomi infekcije i procijenili da li je porođaj neizbježan ili se može odgoditi. 38 Antenatalni kortikosteroidi dani su, nakon isključivanja korioamnionita, za neposredan rizik od prijevremenog porođaja u 24-34 tjednu trudnoće, uz tokolizu, prema potrebi. Antenatalni magnezij sulfat se daje kod prijevremenog porođaja kod <32 tjedna trudnoće radi zaštite fetusa od neuroloških komplikacija. Ženama s potvrđenom prijevremenom pretporodnom rupturom membrana rutinski se daju antibiotici. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole za tretiranje prijevremenog poroda na akušerskom odjelu rodilišta, koje su u skladu sa smjernicama SZO *. (91,46) 2. Zdravstvena ustanova ima zalihe antenatalnih kortikosteroida (deksametazon ili betametazon), antibiotike i magnezijev sulfat dostupni u dovoljnim količinama, u svakom vremenu, kako bi se tretirao prijevremeni porod, u skladu sa smjernicama SZO *. (90,06) 3. Osoblje rodilišta dobiva stručno usavršavanje i redovite obnove znanja o tretiranju prijevremenog poroda, najmanje jednom svakih 12 mjeseci. (85,52) 4. Osoblje rodilišta ima mjesečne vježbe ili simulacijske vježbe i nadzor podrške kod tretiranja prijevremenog poroda. (79,18) Izlazne mjere/mjere procesa 1. Razmjer sve prijevremeno rođene novorođenčadi, rođene između 24. i 34. tjedna trudnoće u zdravstvenoj ustanovi, čije su majke primale najmanje jednu dozu antenatalnih kortikosteroida kada je to bilo naznačeno. (86,11) 2. Razmjer sve prijevremeno rođene novorođenčadi, rođene prije 32. tjedna trudnoće u zdravstvenoj ustanovi, čije majke su primile magnezijev sulfat kako bi zaštitile bebu od fetalnih neuroloških komplikacija.(78,52) 3. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi i imale rupturu membrane prije poroda, a koje su primile profilaktičke antibiotike. (87,60) Mjere ishoda 1. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi i imale prijevremenu rupturu membrane, koje su primile profilaktičke antibiotike *. (87,60) 2. Razmjer sve djece u zdravstvenoj ustanovi koja su, u opasnosti da se rode od 24 do <34 tjedana trudnoće, bila izložena antenatalnim kortikosteroidima. (73,61) 3. Razmjer sve djece u zdravstvenoj ustanovi koja su bila u opasnosti da se rode ≥ 34 tjedana trudnoće, a bili su izloženi antenatalnim kortikosteroidima. (72,43) Izjava o kvaliteti 1.6b: Bebe rođene prije termina i male bebe primaju odgovarajuću njegu prema smjernicama SZO. Obrazloženje: Prijevremeno rođene bebe i male bebe imaju mnogo veći rizik od smrti tokom neonatalnog perioda i rizik za dugoročne zdravstvene probleme i invaliditet tokom cijelog života. Njih treba njegovati u dobro opremljenim neonatalnim odjelima s dobro obučenim osobljem, prisutnim tokom cijelog dana. Prijevremeno rođene bebe i bebe male porođajne težine (<2500 g) su stalno dobro utopljene i pažljivo nadzirane radi mogućih komplikacija; njihove majke dobivaju 39 podršku u isključivom dojenju ili alternativno hranjenje (izdojeno majčino mlijeko, mlijeko iz mliječne banke ili adaptirano mlijeko). Klinički stabilna prijevremeno rođena novorođenčad težine ≤ 2000g dobivaju klokansku njegu. Oni koji su nestabilni drže se u čistom inkubatoru ili ispod izvora topline, a njihova se temperatura stalno prati. Rizici za uobičajene komplikacije (hipotermija, problemi s hranjenjem, apneja, sindrom respiratornog distresa i infekcije) se procjenjuju, prate, prepoznaju se rano i primjereno tretiraju. Antibiotici, sigurna terapija kisikom, kontinuirani pozitivni tlak zraka i zamjensko sredstvo za tenzid daje se prema potrebi. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole za njegu prijevremeno rođenih beba i beba male porođajne težine u akušerskom odjelu rodilišta, koji su u skladu sa smjernicama SZO*. (91,41) 2. Zdravstvena ustanova ima zalihe i materijale koji osiguravaju optimalnu toplinsku njegu stabilnim i nestabilnim prijevremeno rođenim bebama, uključujući klokansku njegu (umotavanje, kape za bebe, čarape), čiste inkubatore i grijače *. (89,14) 3. Zdravstvena ustanova ima zalihe i materijale koji osiguravaju optimalno hranjenje prijevremeno rođenim bebama i podršku za dojenje ili alternativno hranjenje (hranjenje šoljicom i kašikicom, adaptiranim mlijekom, izdajalicama, skladištima za mlijeko, pasterizatorima, bankama mlijeka, ako je moguće, nazogastričnim cijevima, intravenoznim tekućinama i cijevima). (86.56) 4. Zdravstveni djelatnici u zdravstvenoj ustanovi koji rade s trudnicama, rodiljama i novorođenčadi dobivaju redovite obnove znanja u odgovarajućoj njezi o prijevremeno rođenoj djeci i djeci male porođajne težine, najmanje jednom u 12 mjeseci. (85,82) Izlazne mjere/mjere procesa 1. Razmjer sve novorođenčadi rođene u zdravstvenoj ustanovi s porođajnom težinom ≤ 2000 g koji je u prvom tjednu života dobio kontinuiranu klokansku njegu. (83,35) 2. Razmjer sve nestabilne novorođenčadi u zdravstvenoj ustanovi, s porođajnom težinom ≤ 2000 g koja ne može primiti klokansku njegu, koja su zbrinuta u termo- neutralnom okruženju, ili pod lampom ili u inkubatorima, prema potrebi. (79,29) 3. Razmjer novorođenčadi u zdravstvenoj ustanovi s malom porođajnom težinom, čije su majke primile dodatnu podršku za uspostavljanje dojenja. (77,13) Mjere ishoda 1. Udio svih prijevremeno rođenih beba (<28 tjedana, 28-32 tjedana i 32-37 tjedana gestacijske dobi) rođenih u zdravstvenom objektu, koje su preminule u prvih 7 dana života*.(90.15) 2. Razmjer sve novorođenčadi u zdravstvenoj ustanovi s malom porođajnom težinom, koja je isključivo hranjena majčinim mlijekom tokom boravka u ustanovi. (84,57) 3. Razmjer svih živih prijevremeno rođenih beba, rođenih u zdravstvenoj ustanovi, s teškim neonatalnim morbiditetom (sindrom respiratornog distresa, intraventrikularno krvarenje, nekrotični enterokolitis). (81,20) 4. Razmjer smrtnih slučajeva djece s malom porođajnom težinom u zdravstvenoj ustanovi pripisanih mogućim ozbiljnim bakterijama ili sepsi (80.30) 40 Izjava o kvaliteti 1.7a: Žene sa ili pod rizikom od infekcije prije porođaja, u toku porođaja ili u ranom postnatalnom periodu odmah dobijaju odgovarajuće intervencije prema smjernicama SZO. Obrazloženje: Puerperalna sepsa je jedan od vodećih uzroka smrti majke i može također uzrokovati rani početak sepse kod novorođenčadi. Sprečavanje predisponirajućih čimbenika, aseptičke mjere opreza u svim intervencijama i postupcima, rana, točna dijagnoza i upotreba odgovarajućih antibiotika za liječenje infekcije majke smanjuje pojavu sepse i povezanog morbiditeta i smrtnosti i kod majki i kod novorođenčadi. Žene koje su izložene riziku od infekcije dobivaju profilaktičke antibiotike ako su podvrgnute elektivnom ili hitnom carskom rezu, u dugotrajnom porodu s rupturom membrana, u slučajevima zaostalih placentnih dijelova, s perinealnim puknućem trećeg ili četvrtog stepena ili prije manuelnog uklanjanje posteljice. Prije početka antibiotske terapije, uzimaju se uzorci, za kulturu i osjetljivost. Žene sa znakovima i simptomima infekcije (temperatura> 38 ° C prije porođaja ili tokom poroda, ruptura membrana ≥ 18 h prije rođenja, smrdljiva ili gnojna amnionska tekućina i bol u trbuhu i / ili neugodan vaginalni iscjedak u postnatalnom razdoblju) tretiraju se antibioticima i stalno prate, a njihovo tok redovito se procjenjuje. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima zalihe oralnih i injekcijskih antibiotika prve i druge linije (ampicilin ili penicilin i gentamicin, klindamicin, cefalosporin i metronidazol) dostupne u dovoljnoj količini, u svakom trenutku, za očekivani broj poroda*. (92,15) 2. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole za liječenje žena s rizikom od infekcije tokom poroda, porođaja i ranog postnatalnog razdoblja u akušerskom i postnatalnom odjelu rodilišta i u skladu su sa smjernicama SZO *. (91,75) 3. Zdravstveni djelatnici u zdravstvenoj ustanovi koji rade s trudnicama i rodiljama i dobivaju usavršavanje i redovite obnove znanja o prepoznavanju i tretiranju znakova peri-partum infekcije, najmanje jednom svakih 12 mjeseci. (85,20) Izlazne mjere/mjere procesa 1. Razmjer svih žena u zdravstvenoj ustanovi koje su podvrgnute carskom rezu u koje su primile profilaktičke antibiotike prije carskog reza *. (90.37) 2. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi s prijevremenom rupturom membrane, a koje su primale antibiotike.(87,44) 3. Razmjer svih žena u zdravstvenoj ustanovi s perinealnim puknućem trećeg ili četvrtog stupnja, a koje su primile antibiotike. (83,45) 4. Razmjer svih trudnica ili porodilja u zdravstvenoj ustanovi sa znakovima infekcije, koje su dobile injekcije antibiotika. (83,39) 5. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi s temperaturom> 38 ˚C ili drugim znakovima infekcije (smrdljive ili gnojne lohije) nakon porođaja. (82,87) Mjere ishoda 1. Razmjer svih žena koje su u zdravstvenoj ustanovi podvrgnute carskom rezu, a koje su imale tešku sistemsku infekciju ili sepsu nakon carskog reza. (86.56) 2. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi s teškom sistemskom infekcijom ili sepsom u postpartum periodu. (86,15) 41 Izjava o kvaliteti 1.7b: Novorođenčad sa faktorima rizika za infekciju odmah primaju antibiotik prema uputstvima SZO. Obrazloženje: Novorođenčad imaju veći rizik od infekcije zbog svog nezrelog imunološkog sistema. Infekcije u novorođenčadi mogu dovesti do smrti ili dugotrajnog invaliditeta kod preživjelih. Dobra higijena ruku, njega pupkovine i drugih odgovarajućih aseptičkih mjera opreza, screening za neonatalnu sepsu, prema prisutnosti jednog ili više faktora rizika, rana dijagnoza znakova i simptoma neonatalne sepse i odgovarajući tretman s antibioticima bitni su za sprječavanje sepse i povezanog morbiditeta i smrtnosti. Novorođenčadi s faktorima rizika za infekciju ili znakovima infekcije daje se antibiotski tretman, prema smjernicama SZO. Čimbenici rizika za infekciju su temperatura majke (> 38 ° C) prije porođaja ili tokom poroda, ruptura membrana ≥ 18 sati prije rođenja i smrdljiva ili gnojna amnionska tekućina. Novorođenčad sa znakovima ozbiljne bakterijske infekcije u nemogućnosti su da se hrane (ili su se prestala dobro hraniti), imaju konvulzije, brzo disanje (> 60 udisaja / min) uvlače prsa više, temperaturu (≥ 38 ° C) ili nisku tjelesnu temperaturu (<35 ° C), letargiju, kretanje samo kada su stimulirana ili nemaju nikakvih kretnji. Prije davanja antibiotika, uzima se krvna kultura, kod novorođenčadi u opasnosti ili sa znakovima infekcije. Tretiraju se empirijskim injektabilnim antibioticima za sepsu ili sumnju na sepsu i pažljivo se nadgledaju radi ponovnog tretmana. Nalazi kulture temelj su za odlučivanje o promjeni antibiotika i trajanje liječenja. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima zalihe injekcijskih antibiotika (najmanje antibiotici za prvu i drugu liniju za neonatalnu sepsu i meningitis) dostupne u dovoljnim količinama u svakom trenutku za očekivani broj poroda*. (92,14) 2. Zdravstvena ustanova ima pisane i ažurirane kliničke protokole za ranu dijagnozu i upravljanje neonatalnim infekcijama u rodilištu, koja je u skladu sa smjernicama SZO*. (90,47) 3. Zdravstveno osoblje u zdravstvenoj ustanovi koja brine za trudnice, porodilje i novorođenčad dobiva usavršavanje i redovite obnove znanja u prepoznavanju i tretiranju novorođenačkih infekcija, najmanje jednom u 12 mjeseci. (85,95) 4. Zdravstveni djelatnici u zdravstvenoj ustanovi prepoznaju znakove novorođačke sepse i kako je tretirati, prema smjernicama SZO. (84,29) Izlazne mjere/mjere procesa 1. Razmjer sve novorođenčadi sa znakovima infekcije u zdravstvenoj ustanovi, koja je primala injekcije antibiotika. (86,94) 2. Razmjer sve novorođenčadi čije su majke imale znakove infekcije u zdravstvenoj ustanovi, a primile su injekcije antibiotika. (77,53) Mjere ishoda 1. Razmjer novorođenčadi koja je u zdravstvenoj ustanovi preminula, a liječena je protiv sepse (stopa fatalnosti slučaja) *. (89,32) 2. Razmjer svih neonatalnih smrti u zdravstvenoj ustanovi, uzrokovanih sepsom. (86,96) 3. Razmjer svih teških neonatalnih bolesti u zdravstvenoj ustanovi, zbog sepse. (77,53) 42 Izjava o kvaliteti 1.8: Sve žene i novorođenčad dobivaju njegu prema standardnim mjerama opreza za sprečavanje infekcije u toku hospitalizacije. Obrazloženje: Infekcije nastale u bolnici povećavaju morbiditet i smrtnost, troškove njege i trajanje boravka u bolnici. Standardne mjere opreza su neophodne kako bi spriječilo nastajanje infekcija u bolnici. Uvijek se poštuju standardne mjere opreza, uključujući higijenu ruku sa sapunom i vodom ili korištenjem alkohola prije i nakon pregleda žene ili novorođenčeta i odgovarajuće upotrebe rukavica; sigurno skladištenje i uklanjanje infektivnog otpada i igli; sigurno rukovanje opremom za njegu bolesnika i prljavim rubljem; sterilizacija i dezinficiranje instrumenata i površina djeteta. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pouzdani izvor vode na licu mjesta i sapuna i peškire (po mogućnosti jednokratni) ili tekućinu za higijenu ruku na bazi alkohola *. (94,27) 2. Zdravstvena ustanova osigurava sigurno rukovanje, skladištenje i konačno zbrinjavanje infektivnog otpada *. (94,08) 3. Zdravstvena ustanova osigurava sigurno rukovanje, skladištenje (otporno na probijanje) i konačno zbrinjavanje oštrih predmeta*. (93,36) 4. Zdravstvena ustanova ima odgovarajuće sterilizacijske uređaje i dezinficijense za instrumente. (92,99) 5. Zdravstveni objekt ima funkcionalni spaljivač ili neku drugu prikladnu metodu za tretiranje infektivnog otpada i korištenih instrumenata. (92,56) 6. Zdravstvena ustanova ima pisane i ažurirane smjernice za standardnu kontrolu infekcije i mjere opreza protiv zaraze. (92,35) 7. Osoblje odjela za akušerstvo i neonatalne jedinice dobiva obuku u standardu kontrola infekcija i mjere predostrožnosti protiv zaraze najmanje jednom u 12 mjeseci. (87,27) Izlazne mjere/mjere procesa 1. Razmjer stručnog osoblja u zdravstvenoj ustanovi koji ispravno čisti svoje ruke, sukladno alatu za reviziju „5 Trenutaka za Higijenu Ruku“, kojeg je izdala SZO. (87,78) 2. Razmjer novorođenčadi kod kojih se sumnja na teške bakterijske infekcije, a koja je primila odgovarajuću antibiotsku terapiju (84,76) 3. Sigurno odlaganje otpada zdravstvene zaštite, od trenutka proizvodnje do točke zbrinjavanja. (82,73) 4. Razmjer djelatnika u zdravstvenoj ustanovi koji zadovoljavaju standarde biološke sigurnosti davanja parenteralnih lijekova. (81.85) Mjere ishoda 1. Razmjer svih žena koje su u zdravstvenoj ustanovi rodile s teškom sistemskom infekcijom ili sepsom u postnatalnom razdoblju, uključujući i ponovni povratak u ustanovu, nakon otpuštanja. (81,41) 2. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, koje su imale infekciju nastalu u bolnici. (78,43) 3. Razmjer svih novorođenčadi rođenih u zdravstvenoj ustanovi, koja je imala bolničke infekcije. (78,00) 43 Izjava o kvaliteti 1.9: Niti jedna žena ili novorođenče nije podvrgnuto nepotrebnim ili štetnim postupcima prije porođaja, u toku porođaja i ranog postnatalnog razdoblja. Obrazloženje: Nepotrebne i štetne prakse mogu dovesti do komplikacija i naštetiti majkama i njihovoj novorođenčadi. Mora ih se izbjeći i zamijeniti zdravstvenim praksama zasnovanim na dokazima. Nepotrebne ili štetne prakse se ne koriste ili prakticiraju. Te prakse uključuju: rutinski klistiri i brijanje stidnog ili perinealnog područja prije vaginalnog poroda; pritisak na kraju kako bi se olakšala druga faza porođaja; ubrzanje poroda s oksitocinom prije potvrđivanja prolongiranog poroda; epiziotomija (ukoliko nije indicirano); pritisak maternice za kontrolu krvarenja (ukoliko nije naznačeno); vaginalni porod uz korištenje instrumenata (ako nije indicirano); carski rez (ako nije indicirano) i porod vakuumom novorođenčeta (ukoliko nije naznačeno); neposredno kupanje djeteta po porodu, držanje zdravih beba odvojenim od majke, oglašavanje i promicanje nadomjestaka za majčino mlijeko i hranjenje bočicom i primjena pripravaka u pupkovinu. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pisane i ažurirane protokole o štetnim postupcima i nepotrebnim intervencijama tokom poroda, porođaja i ranog postnatalnog razdoblja *. (89,03) 2. Zdravstvena ustanova ne prikazuje mliječnu formulu ili boce i cucle, ni na posterima ili plakatima *. (88,98) 3. Zdravstvena ustanova ne daje novorođenčadi hranu ili piće osim majčinog mlijeka, osim kad je medicinski indicirano, i ne daju dojećim bebama cucle (također nazvane "dude" ili "dudice"). (85,13) 4. Zdravstveni djelatnici u ustanovi imaju stručnu obuku i redovite obnove znanja o štetnim praksama i nepotrebnim intervencijama, barem jednom svakih 12 mjeseci. (83.00) 5. Zdravstvena ustanova ne reklamira dojenačku formulu na odjelima, a uzorci se ne distribuiraju majkama ili osoblju. (82,93) 6. Zdravstveno osoblje u zdravstvenoj ustanovi prima mjesečnu pomoćnu superviziju i mentorstvo o štetnim postupcima i nepotrebnim intervencijama. (75,38) Izlazne mjere/mjere procesa 1. Razmjer svih nekompliciranih, spontanih vaginalnih porođaja u zdravstvenoj ustanovi, na kojima je urađena epiziotomija *. (86,01) 2. Razmjer žena koje su u zdravstvenoj ustanovi podvrgnute carskom rezu, prema Robsonovoj klasifikaciji. (83,2) 3. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, nad kojima je rađena intervencija, a bez indikacija nenapredovanja poroda. (80,01) 4. Razmjer svih beba rođenih u zdravstvenoj ustanovi, koje su imale kupanje po porodu i uklanjanje verniksa unutar 6 sati od rođenja. (79.30) 5. Razmjer svih žena koje su rodile u zdravstvenoj ustanovu koji su primali rutinsko brijanje stidnog ili perinealnog područja prije vaginalnog poroda. (77,59) 6. Razmjer svih beba rođenih u zdravstvenoj ustanovi, uz bistru amnionsku tekućinu, a koje su imale intervenciju rutinskog vakuuma. (77.35) 7. Razmjer svih žena koje su rodile u zdravstvenoj ustanovi, a koje su primale rutinski klistir u bilo kojem trenutku prije vaginalnog porođaja. (76.02) 44 Reference korištene u određivanju Standarda 1 Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Mogu li dostupne intervencije spriječiti smrt majki, novorođenčadi i mrtvorođenost, i po kojoj cijeni? Lancet 2014 .; 384: 347-370. Boulkedid R, Sibony O, Goffinet F, Fauconnier A, Branger B, Alberti C. Pokazatelji kvalitete za kontinuirano praćenje poboljšanja zdravlja majki i djeteta u porodilištima: izmijenjena Delphi anketa međunarodnog multidisciplinarnog panela. PLoS One 2013; 8: e60663. Gülmezoglu MA, Lawrie TA. Utjecaj vježbanja kod vještina hitnog oživljavanja: utjecaj na Milenijske ciljeve razvoja (MDG) 4 i 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10,1016 / j. bpobgyn.2015.03.018. Hussein J, Mavalankar DV, Sharma S, D'Ambruoso L. Pregled mjera kontrole infekcije zdravstvenih sistema u zemljama u razvoju: šta se može naučiti kako bi se smanjila smrtnost majki. Globalizacija zdravlje 2011; 7: 14. Khaskheli MN, Baloch S, Sheeba A. Faktori rizika i komplikacije puerperalne sepse u tercijarnom zdravstvenom centru. Pak J Med Sci 2013; 29: 972-976. Nacionalni institut za izvrsnost zdravstvene zaštite. NICE smjernice o rutinskoj intrapartum njezi (CG 190). London; 2014. (http://www.nice.org.uk/guidance/cg190/resources/ guidance- intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Polin RA, Odbor za fetus i novorođenče. Njega novorođenčadi sa sumnjom ili dokazanim ranim početkom bakterijske sepse. Pediatrics 2012; 129: 1006-1015. Raven J, Hofman J, Adegoke A, van den Broek N. Metodologija i alati za poboljšanje kvalitete u zdravstvenoj njezi majke i novorođenčadi. Int J Gynaecol Obstet 2011; 114: 4-9. Schuchat A, Zywicki SS, Dinsmoor MJ, Mercer B, Romaguera J, O'Sullivan MJ i sur. Faktori rizika i mogućnosti za prevenciju rane početne neonatalne sepse: multicentrična studija slučaja. Pedijatrija. 2000; 105: 21-26. Sibanda T, Fox R, Draycott TJ, Mahmood T, Richmond D, Simms RA. Pokazatelji kvalitete unutar porodice: sistemski pristup postizanja konsenzusa. Eur J Obstet Gynecol Reprod Biol 2013; 166: 23-29. Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, i sur. Poboljšanje kvalitete njege za zdravlje majke i novorođenčadi: buduća pilot studija SZO-ovog sigurnog programa za praćenje porođaja. PLoS One 2012; 7: e35151. Tietjen L, Bossemeyer D, McIntosh N. Smjernice za prevenciju infekcije za zdravstvene ustanove s ograničenim resursima. Baltimore, Maryland: JHPIEGO; 2003. 40 Svjetska zdravstvena organizacija. Međunarodni kodeks marketinga nadomjestaka za dojenče. Ženeva; 1981 (http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/). Svjetska zdravstvena organizacija. Standardne mjere opreza u zdravstvenoj zaštiti: dopis. Ženeva; 2007 (http:// www.who.int/csr/resources/publications/EPR_AM2_E7.pdf). Svjetska zdravstvena organizacija. SZO smjernice o higijeni ruku u zdravstvenoj zaštiti. Ženeva; 2009 (http:// www.who.int/gpsc/information_centre/hand-hygiene-2009/en/). Svjetska zdravstvena organizacija. Procjena kvalitete njege za teške komplikacije trudnoće. SZO near-miss pristup za zdravlje majki. Ženeva; 2011 (http://whqlibdoc.who.int/ publications/2011/9789241502221_eng.pdf). Svjetska zdravstvena organizacija. WHO preporuke za prevenciju i liječenje preeklampsije / eklampsije. Ženeva; 2011 (http://apps.who.int/iris/ bitstream/10665/44703/1/9789241548335_eng.pdf). 45 Svjetska zdravstvena organizacija. Preporuke Svjetske zdravstvene organizacije za prevenciju i liječenje krvarenja nakon poroda. Ženeva; 2012 (http://www.who.int/reproductivehealth/publications/ maternal_perinatal_health/9789241548502/en/). Svjetska zdravstvena organizacija. Smjernice o zdravlju majke, novorođenčadi, djeteta i adolescenata, koje je odobrilo Odbor za preispitivanje smjernica Svjetske zdravstvene organizacije. Preporuke o zdravlju novorođenčeta. Ženeva; 2013. (http://www.who.int/maternal_child_adolescent/documents/guidelines- recommendationsnewborn-health.pdf). Svjetska zdravstvena organizacija. Smjernice o zdravlju majke, novorođenčadi, djeteta i adolescenata, koje je odobrilo Odbor za preispitivanje smjernica Svjetske zdravstvene organizacije. Preporuke o majčinom i perinatalnom zdravlju. Ženeva; 2013. (http://www.who.int/maternal_child_adolescent/documents/guidelinesrecommendations- maternal-health.pdf?ua=1). Svjetska zdravstvena organizacija. SZO preporuke o postnatalnoj skrbi majke i novorođenčadi. Ženeva, 2013. (http://www.who.int/maternal_child_adolescent/documents/ postnatal-care- recommendations/en/). Svjetska zdravstvena organizacija. Sigurno upravljanje otpadom kod zdravstvene djelatnosti Ženeva; 2014 (http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1). Svjetska zdravstvena organizacija. SZO preporuke za augmentaciju poroda. Ženeva; 2014. (http:// ww.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation- labour/en/). Svjetska zdravstvena organizacija. Uloga SZO-a u javnom zdravlju. Ženeva; 2015. (http://www.who.int/ about/role/en/). Svjetska zdravstvena organizacija. SZO preporuke o intervencijama za poboljšanje ishoda prijevremenih poroda. Ženeva; 2015. (http://who.int/reproductivehealth/publications/ maternal_perinatal_health/preterm-birth-guideline/en/). Svjetska zdravstvena organizacija, partnerstvo za majku, novorođenče i dijete. Konsultacije o poboljšanju mjerenja kvalitete njege majke, novorođenčeta i djece u zdravstvenim ustanovama. Ženeva; 2014 (http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf). Svjetska zdravstvena organizacija, UNICEF. Inicijativa za bolnicu prijatelj beba: revidirana, ažurirana i proširena za integriranu njegu. Ženeva; 2009 (http://www.who.int/nutrition/publications/infantfeeding/ bfhi_trainingcourse/en/). Svjetska zdravstvena organizacija, UNICEF. Pokazatelji za procjenu prakse zdravstvenih ustanova koji utječu na dojenje. Ženeva; 1993 (http://apps.who.int/iris/handle/10665/62140). Regionalni ured za Evropu, Svjetska zdravstvena organizacija. Poboljšanje sigurnosti trudnoće: alat za procjenu kvalitete bolničke njege majke i novorođene bebe. Kopenhagen; 2009. (http://www. euro.who.int/__data/assets/pdf_file/0008/98792/E93128.pdf). Regionalni ured za Evropu, Svjetska zdravstvena organizacija. Bolnička njega majke i novorođene bebe: alat za procjenu i poboljšanje kvalitete. Kopenhagen; 2014. (http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn- health/publications/2014/hospital-care-formothers-and-newborn-babies-quality-assessment- andimprovement-tool.pdf?ua=1). 46 Standard 2: Sistem informisanja u zdravstvu omogućava korištenje podataka kako bi se osiguralo rano, odgovarajuće djelovanje u smjeru poboljšanja njege i brige o svakoj ženi i novorođenčetu. Izjava o kvaliteti 2.1: Svaka žena i novorođenče imaju potpun, tačan, standardiziran medicinski zapis/karton prije, tokom porođaja i ranog postnatalnog perioda. Obrazloženje: Potpuno i tačno medicinsko dokumentirano praćenje tokom poroda važno je za dokumentiranje njege, kliničko praćenje, precizno predavanje smjene, rano otkrivanje komplikacija i zdrave ishode i pruža informacije za prepoznavanje mjesta za poboljšanje. Na snazi su standardizirani registri o njezi za pacijente i kliničke evidencije majki i novorođenčadi od prijema do otpusta, i oni su tačni, potpuni i čitljivi. Dostupni su podaci o kontinuiranoj njezi (npr. uputnice, evidencije antenatalne i intrapartumske njege). Demografski podaci, vrijeme prijema, porođaji, napredak poroda, poduzete mjere i ishod porođaja, uključujući i mrtvorođenče, odgovarajuće su zabilježeni. Detalji o novorođenčadi, uključujući identifikaciju, gestacijsku dob, težinu rođenja i nalaz pregleda, zabilježeni su u sistemu koji omogućuje povezivanje žena i njihove novorođenčadi u svim kartonima. Međunarodna klasifikacija bolesti (ICD) koristi se za kodiranje dijagnoza. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima evidencije, obrasce za prikupljanje podataka, kliničke i tablice promatranja vremena za rutinsko snimanje i praćenje svih procesa njege žene i novorođenčadi *. (90,34) 2. Zdravstvena ustanova ima sistem za registraciju rođenja i smrti, koji je u svakom trenutku povezan s nacionalnim sistemom vitalne registracije *. (89,44) 3. Zdravstvena ustanova ima sistem za klasificiranje bolesti i porodnih ishoda, uključujući i smrt, koji je usklađen s ICD. (86,33) Izlazne mjere/mjere procesa 1. Razmjer sve novorođenčadi koja se trenutno nalazi u zdravstvenoj ustanovi s identifikatorom pacijenta i individualni klinički medicinski zapis *. (89,15) 2. Razmjer sve novorođenčadi koja je otpuštena iz zdravstvene ustanove u protekla 24 sata, koje je imala točno ispunjen zapis procesa njege, tretmana, ishoda i dijagnoze (s ICD kodiranjem). (83,28) 3. Razmjer svih žena otpuštenih u periodu postpartuma u protekla 24 sata, kojima je urađena precizna evidencija procesa njege, tretmana, ishoda i dijagnoze (s ICD kôdom). (82,88) Izjava o kvaliteti 2.2: Svaka zdravstvena ustanova ima mehanizam za prikupljanje podataka, analizu i povratne informacije u okviru aktivnosti za praćenje i poboljšanje porođaja. Obrazloženje: Svrha prikupljanja podataka je pružanje informacija koje se mogu analizirati i koristi se na odgovarajući način za pružanje povratnih informacija i poboljšanje zdravstvenih ishoda. 47 Podaci se prikupljaju, provjeravaju, analiziraju i koriste za rutinsko kliničko upravljanje i donošenje odluke za planiranje i poboljšanje kliničkih usluga. Dostupni su i upotrebljavani u objektu za kontinuirano poboljšanje procesa njege koje koriste doktori, babice, medicinske sestre, supervizori i mentori za planiranje i unaprjeđenje aktivnosti i kliničkih usluga. Podaci se na odgovarajuće nivoe podnose precizno i kompletno i pravovremeno i služe se periodičnim pregledima smrtnosti i morbiditeta kako bi se poboljšala kvaliteta Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova provela je pregled materinskih i perinatalnih smrti i perioda kad je majčin život bio u opasnosti barem jednom mjesečno u posljednjih šest mjeseci i ima mehanizam za provedbu preporuka revizije *. (88,20) 2. Zdravstvena ustanova ima u svakom trenutku standardne operativne postupke i protokole za provjeru, potvrđivanje i izvješćivanje o podacima. (86,35) 3. Zdravstvena ustanova ima sistem podataka za prikupljanje i analizu relevantnih pokazatelja i može proizvesti izlazne podatke u vizuelnom obliku i pravodobno izvještavati na papiru ili digitalno u svakom trenutku. (85,74) 4. Menadžeri i zdravstveni radnici u zdravstvenoj ustanovi sastaju se barem jednom mjesečno u proteklih šest mjeseci za pregled podataka o procesu i ishodu. (85.12) 5. Menadžeri i zdravstveni radnici u zdravstvenoj ustanovi koristili su preporuke pri pregledu podataka za donošenje odluka i za mentorstvo u svrhu poboljšanja performansa u proteklih šest mjeseci. (80,10) Izlazne mjere/mjere procesa 1. Udio svih perinatalnih smrti u zdravstvenom ustanovu koji su pregledani standardom alata za reviziju *. (90.26) 2. Udio svih smrtnih slučajeva i nedostataka kod majke u zdravstvenim ustanovama koje su bili pregledani standardnim alatima za reviziju *. (88,24) 3. Udio svih smrti i nedostataka kod majke koje su se dogodile u zdravstvenoj ustanovi i koji su obaviješteni. (86,84) Mjere ishoda 1. Podaci se u zdravstvenoj ustanovi rutinski prikupljaju tokom poroda, porođaja i postnatalnog razdoblja i redovno se koriste za donošenje odluka o poboljšanju kvalitete.(83,08) 2. Razmjer svih preporuka u pregledu perinatalnih smrti u zdravstvenoj ustanovi koji su bile u potpunosti provedene. (81,51) 3. Udio svih preporuka u pregledu smrti majke u zdravstvenoj ustanovi koji su bile u potpunosti provedene. (81,37) Reference korištene u određivanju Standarda 2 Brien ES, Lorenzetti LD, Lewis S, Kennedy J, Ghali AW. Prikaz formalnog pregleda izvješća zdravstvenih sistema. Implementacija Sci 2010; 5: 2. Graham WJ, Campbell OM. Majčino zdravlje i zamka mjerenja. Soc Sci Med 1992; 35: 967- 977. Lippeveld T, Sauerborn R, Bodart C. Izrada i implementacija zdravstvenih informacijskih sistema. Ženeva: Svjetska zdravstvena organizacija; 2000. 48 Murray SF, Davies S, Phiri RK, Ahmed Y. Alati za praćenje učinkovitosti sistema upućivanja na materinsku njegu. Plan zdravstvene politike 2001; 16: 353-361. UNICEF. Stanje svjetske djece 2009. Ženeva (http://www.unicef.org/sowc09/docs/SOWC09- FullReport-EN.pdf). Svjetska zdravstvena organizacija. Procjena dostupnosti i spremnosti (SARA). Godišnji sistem praćenja pružanja usluga. Referentni priručnik, verzija 2.2 Ženeva; 2015. (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). Svjetska zdravstvena organizacija, Fond za stanovništvo Ujedinjenih naroda, UNICEF, Svjetska banka. Trudnoća, porod, postpartum i novorođenčad: vodič za esencijalnu praksu, 3. izdanje. Ženeva: Svjetska zdravstvena organizacija; 2015. Standard 3: Svaka žena i novorođenče se upućuje na dalje promatranje i tretman na odgovarajući način, sa stanjem ili stanjima koji se ne mogu efikasno tretirati raspoloživim resursima. Izjava o kvaliteti 3.1: Svaka žena i novorođenče se na odgovarajući način procjenjuju prilikom prijema, tokom porođaja i tokom ranog postnatalnog perioda sa ciljem utvrđivanja opravdanosti upućivanja, a odluka o upućivanju se donosi bez odlaganja. Obrazloženje: Vrlo je bitno prepoznati slučajeve koji zahtijevaju brzo upućivanje kako bi se osiguralo da svaki pacijent prima pravodobnu, odgovarajuću njegu i izbjegava nepotrebne komplikacije. Na raspolaganju su aktuelni referentni protokoli i smjernice, dostupni su i odražavaju zdravlje i kapacitet pogona i resursa. Postoji sistem trijaža pri prijemu, i mehanizam da odmah procijene, identificiraju i reagiraju na hitne slučajeve. Sadržaji su dostupni pružiti njegu i liječenje prije stabilizacije. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima napisane, ažurirane kliničke protokole i smjernice za identifikaciju, menadžment (uključujući pre-referalnu njegu) i upućivanje žena s komplikacijama povezanim s trudnoćom i porodom te u novorođenčadi *. (89,94) 2. Zdravstveno postrojenje opremljeno je odgovarajućim lijekovima i medicinskim materijalima za stabilizaciju i pre-referalni tretman za referirane žene i novorođenčadi *. (89,20) 3. Osoba za zdravstvenu njegu u jedinici za majku dobiva stručnu obuku i redovite sesije referalnih protokola i smjernica najmanje jednom svakih 12 mjeseci *. (85,33) Izlazne mjere/mjere procesa 1. Udio žena i novorođenčadi u zdravstvenoj ustanovi u protekla tri mjeseca koji su bili upućeni su ispunili kriterije objekta za upućivanje. (81,79) 2. Udio svih trudnih ili postpartum žena kojima nije bilo u mogućnosti upravljati u zdravstvenoj ustanovi i koje su bez odlaganja prebačene u višu razinu za porod ili daljnje upravljanje, u pratnji zdravstvenog radnika i popunjenom standardiziranom uputnicom. (81,47) 3. Udio svih bolesnih, prijevremenih ili malih novorođenčadi kojima nije bilo moguće upravljati u zdravstvenoj ustanovi koji su bili preneseni na odgovarajuću razinu njege 49 u roku od 1 sata od odluke, u pratnji zdravstvenog radnika i popunjenom standardiziranom uputnicom. (79.90) Mjere ishoda 1. Udio svih žena primljenih u odjel rađaone koje su izjavile da su primile pozornost medicinskog osoblja odmah po dolasku u zdravstvenu ustanovu. (82,83) Izjava o kvaliteti 3.2: Svaka žena i novorođenče koji traže dodatno upućivanje, se prate prema unaprijed utvrđenom planu koji se može implementirati bez odlaganja i u bilo koje vrijeme. Obrazloženje: unaprijed utvrđeni plan preporuke ubrzava postupak, sprečava nepotrebno kašnjenje i rezultira boljom i pravodobnom njegom za pacijente. Dostupnost adekvatno opremljenih prijevoznih usluga koje rade 24 sata na dan, 7 dana u sedmici, da prevezu žene i novorođenčadi po potrebi. Popis poznatih mrežnih objekata i njihovih telefonski brojevi su na mjestu. Sistem upućivanja je nadziran i odgovoran, s pravilima koja štiti žene od financijskih prepreka do upućivanja, a postoji i postupak za praćenje i procjene sistema. Mjere kvalitete Ulazne mjere 1. Zdravstveno postrojenje ima spreman pristup funkcioniranoj hitnoj pomoći ili drugom vozilu za hitne slučajeve, za prijevoz žena i novorođenčadi na objekte za upućivanje *. (90,35) 2. Postoji ažurirani popis mrežnih postrojenja na istom zemljopisnom području koji osigurava upućivanje njege za žene i djecu *. (89,20) 3. Zdravstveni objekt ima lokalne aranžmane kako bi se osiguralo da žene i novorođenčad koji se ne mogu zbrinuti u zdravstvenoj ustanovi, bez odgađanja budu upućena na odgovarajuću razinu njege, 24 sata na dan, 7 dana u tjednu. (87,11) Izlazne mjere/mjere procesa 1. Udio svih novorođenčadi koji su umrli prije ili tokom transfera na više razine upravljanje*. (87,74) 2. Udio svih trudnih ili postpartumn žena koje su umrle prije ili tokom transfera na višu razinu upravljanja. (87,04) 3. Udio trudnica i porodica i novorođenčadi koji su bili upućeni bez odgovarajućeg hitnog transporta. (75,62) 4. Udio svih žena upućenih iz zdravstvenog ustanova koji su financijski pridonijeli komunikaciji ili transportu. (68,93) Mjere ishoda 1. Udio svih žena upućenih iz zdravstvenih ustanova koji su dovršili upućivanje. (80,97) 2. Udio svih novorođenčadi iz zdravstvenog ustanova koji su dovršili upućivanje. (80,95) 3. Udio novorođenčadi iz objekta koji su došli u objekt za upućivanje bez hipotermije. (76,34) 50 Izjava o kvaliteti 3.3: Za svaku ženu i novorođenče koji se upućuju unutar ili između zdravstvenih ustanova, postoji odgovarajuća razmjena informacija i povratne informacije koje se dostavljaju relevantnom zdravstvenom osoblju. Obrazloženje: odgovarajuća razmjena informacija i povratne informacije unutar i između zdravstvenih ustanova poboljšava njegu pacijenata, povećava motivaciju zdravstvenih radnika, pomaže u učenju iskustvom i vodi boljoj njezi pacijenata. Djeluje funkcionalni komunikacijski sistem (npr. radio, telefon) unutar referentne mreže u svakom trenutku, i formalni sporazumi i aranžmani za komunikaciju i konzultacije su na mjestu. Razmjena informacija i protokoli povratnih informacija o upućivanju i standardiziranom upućivanju i obrasci za preporuku su dostupni kada je to potrebno. Mjere kvalitete Ulazne mjere 1. Zdravstveno postrojenje ima standardizirani obrazac preporuke za dokumentiranje relevantnih demografskih i kliničkih podataka i informacija koje uključuju kliničke nalaze, dijagnozu, pred-preporuke ili liječenje i razlog za upućivanje *. (89,13) 2. Zdravstveni objekt ima pouzdane komunikacijske metode, uključujući mobilni telefon, zemaljsku liniju ili radio, koja funkcionira u svako doba, za preporuke i konzultacije o složenim slučajevima *. (87,14) 3. dokaz da zdravstveni objekt ima formalne sporazume, komunikacijske aranžmane i povratni sistem s referentnim centrima *. (85,55) Izlazne mjere/mjere procesa 1. Udio svih upućenih žena u referentnom objektu za koje su bile dovršene povratne informacije nakon upućivanju. (80,65) 2. Udio svih upućenih novorođenčadi u objektu za koje su bile dovršene povratne informacije nakon upućivanja. (80,12) 3. Udio svih upućenih žena i novorođenčadi u referentnom objektu koji su primili pravovremenu njegu u centru upućivanja. (79,57) Reference za standard 3 Lawn J, McCarthy BJ, Ross R. Zdravo novorođenče: referentni priručnik za voditelje programa. Atlanta, Georgia: Centri za kontrolu bolesti, CARE International; 2001. Maine D, Ward V, Eitahir AH. Sretanje potreba zajednice na pola puta: programiranje smjernica za smanjenje smrtnosti majke. New York, New York: UNICEF; 1993. Murray SF, Pearson S. Referentni sistemi za majčinstvo u zemljama u razvoju: tekuće znanje i buduće potrebe istraživanja. Soc. Sci. Med. 2006; 62: 2205-2215. Murray SF, Davies S, Phiri RK, Ahmed Y. Alati za praćenje učinkovitosti sistema upućivanja na materinsku njegu. Plan zdravstvene politike 2001; 16: 353-361. Svjetska zdravstvena organizacija. Osnovni elementi porodnične njege na razini prve preporuke. Ženeva: 1991. Svjetska zdravstvena organizacija. Procjena dostupnosti i procjene spremnosti (SARA). Godišnji sistem praćenja pružanja usluga. Referentni priručnik, verzija 2.2. Ženeva; 2015. (http://www.who.int/ healthinfo/systems/sara_indicators_questionnaire/en/). Regionalni ured Svjetske zdravstvene organizacije za zapadni Pacifik. Okružni zdravstveni objekti: Smjernice za razvoj i poslovanje. Manila; 1998. 51 Standard 4: Komunikacija sa ženama i njihovim porodicama je efikasna i odgovara njihovim potrebama i željama. Izjava o kvaliteti 4.1: Sve žene i njihove porodice dobijaju informacije o njezi i imaju efektivnu interakciju sa osobljem. Obrazloženje: Učinkovita komunikacija sa ženama i njihovim porodicama pomaže im da se više osjećaju uključenim u svoju brigu, izbjegavaju nepotrebnu tjeskobu, nesporazume i pogrešna očekivanja i daje im se kontrola nad njihovim stanjem, što pridonosi pozitivnom iskustvu. Zdravstveni djelatnici imaju međuljudske komunikacijske i savjetodavne vještine i lahko su pristupačan. Imaju pozitivan stav, koriste jednostavan, jasan jezik da žene i njihovi porodice mogu razumjeti i prepoznaju komunikacijske potrebe i sklonosti svih žena pod njihovom njegom. Mjere kvalitete Ulazne mjere 1. Lahko razumljivi materijal zdravstvene edukacije, u pristupačnom pisanom ili slikovnom formatu, dostupni na jezicima zajednica koje opslužuje zdravstvena ustanova*. (91.01) 2. Medicinsko osoblje jedinice za materinsku njegu je usmjereno i prolazi treninge barem jednom u 12 mjeseci kako bi poboljšali svoje vještine interpersonalne komunikacije i savjetovanja i kulturološke kompetencije*. (85.74) 3. Zdravstvena ustanova ima pisanu, ažuriranu politiku koja naglašava jasno ciljeve, operacionalne planove i mehanizme monitoringa kako bi promovisala interpersonalnu komunikaciju i vještine savjetovanja od strane medicinskog osoblja. (84.69) 4. Medicinsko osoblje u jedinicama za njegu majke imaju podržavajuću superviziju za svoju interpersonalnu komunikaciju, savjetovanje i kulturološku kompetenciju, svaka tri mjeseca. (80.12) Izlazne mjere/mjere procesa 1. Postotak svih otpuštenih žena iz porađaone ili porodilišta zdravstvene ustanove koje su primile pismenu i usmenu informaciju i savjetovanje o sljedećim temama, a prije svog otpusta: ishrana i higijena, razmak trudnoća i planiranje porodice, isključivo dojenje i održavanje laktacije, čuvanje bebe čistom i ugrijanom, komunikacija i igranje sa bebom, mjere opreza kod majke i bebe i kada se javiti u slučaju komplikacija*. (85.83) 2. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi a koje su izjavile da su imale priliku da diskutuju svoje brige i preferencije (82.79) 3. Postotak medicinskog osoblja zdravstvene ustanove koji je demonstrirao sljedeće vještine: slušanje, pitanje pitanja, odgovaranja na pitanja, ustanovljavanje razumijevanja kod žene i njene porodice i podržavanje žena kod rješavanja problema. (76.67) Mjere ishoda 1. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi a koje su se osjećale adekvatno informisanim od strane medicinskog osoblja glede pregleda, postupaka I odluka kod njihove njege. (83.58) 2. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi koje su izjavile da su se njihove potrebe i preferencije razmotrile tokom poroda, rađanja i postnatalno. (80.67) 52 3. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi koje su izrazile zadovoljstvo zdravstvenom njegom. (80.66) 4. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi koje su izjavile zadovoljstvo zdravstvenom edukacijom i informacijama koje su dobili od medicinskog osoblja. (76.25) Izjava o kvaliteti: 4.2: Sve žene i njihove porodice imaju koordiniranu njegu, sa jasnim, tačnim informacijama koje se razmjenjuju između relevantnih stručnjaka iz oblasti zdravstva i socijalne zaštite. Obrazloženje: Koordinisana njega i precizni prenos informacija među zdravstvenim radnicima je ključan kako bi se održao kontinuitet njege pacijenta i kako bi se izbjegla nepotrebna odlaganja tretmana. Koristi se standardni format za razmjenu informacija između zdravstvenih radnika (npr.tokom promjene smjene i upućivanja socijalnoj službi, glede laboratorijskih rezultata), i efektivna verbalna i/ili telefonska komunikacija se koristi između zdravstvenih radnika koji su uključeni u transferu medicinske njege. Postoji blagovremeno obavještavanje rezultata kritičnih dijagnostičkih testova. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima standardnu formu za bilježenje kliničkog napretka i praćenja tokom poroda (partograf), rađanja i nakon poroda kako bi se olakšao pismeni prenos informacija*. (91.75) 2. Zdravstvena ustanova ima pisane, ažurirane protokole za verbalni i pisan prenos informacija o ženama i novorođenčadi tokom promjene smjena, transfera unutar ustanove ili transfera u druge ustanove i prilikom otpusta*. (89.14) 3. Medicinsko osoblje jedicine za majčinu njegu je usmjereno i ima treninge i redovne sesije ponavljanja svakih 12 mjeseci oko politike kliničkog prenosa informacija i komunikacije bitnih informacija tokom tog prenosa, transfera ili otpusta.(81.53) 4. Zdravstvena ustanova ima funkcionalni, pouzdani komunikacijski sistem za razmjenu informacija među relevantnim pružaocima usluga. (78.26) Izlazne mjere/mjere procesa 1. Postotak žena koji se porađao ili je rodio u ustanovi a za koje je kompletiran partograf. (81.87) 2. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi koje su izjavile da se medicinsko osoblje predstavilo i pokazalo dobro poznavanje njene historije i njege koja joj je do tada pružena. (73.47) Mjere ishoda 1. Postotak svih žena koje su se porodile u zdravstvenoj ustanovi koje su izrazile zadovoljstvo pruženom zdravstvenom njegom*. (83.53) 2. Postotak medicinskog osoblja, kadra i socijalnih profesionalaca koji su zadovoljni komunikacijom tokom kliničkog prenosa informacija među članovima tima zdravstvene njege u zdravstvenoj ustanovi. (68.98) 53 Reference za standard 4 de Silva A. Okvir rada za mjerenje odgovora. Ženeva: Svjetska zdravstvena organizacija; 2000 (http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Anderson L, Scrimshaw S, Fullilove M, Fielding J, Normand H. Kulturološki kompetenti sistemi zdravstvene zaštite: sistematski pregled. Am J Prev Med 2003;24:68–79. Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, i sar. Intervencije za pružaoce usluga kako bi se promovisao pristup orijentisan na pacijenta tokom kliničkih konsultacija. Cochrane Database Syst Rev 2012;12:CD003267. Fealy G, Riordan F. Prakse komunikacije i kliničkog prenosa informacija: sistematski pregled. Dablin: University College Dublin and Health Service Executive; 2014. Iedema R, Manidis M. Komunikacija pacijent-kliničar: pregled relevantnog istraživanja I literature protokola kod: Komunikacije (kliničkog prenosa informacija) i usluga za majčinu njegu. Sydney: Australian Commission on Safety and Quality in Health Care and UTS Centre for Health Communication; 2014 (National clinical guideline No. 5) (http://health.gov.ie/wp- content/uploads/2015/01/National-Clinical-Guideline-No.-5-Clinical-Handover-Nov2014.pdf). Johnson A, Sandford J, Tyndall J. Pismene i usmene informacije vs. samo usmene informacije za pacijente koji se otpuštaju iz akutnih bolničkih jedinica kući. Cochrane Database Syst Rev 2003;4:CD003716. Kongnyu E, van den Broek N. Kriteriji za kliničku reviziju njege prijatelj žena i percepcija pružaoca usluga u Malawiju. BMC Pregnancy Childbirth 2008;8:28. National Institute for Health Care Excellence. Iskustvo pacijenta kod NHS usluga. London; 2012 (https://www.nice.org.uk/guidance/qs15/chapter/quality-statement-2-demonstrated- competency-in-communication-skills#quality-statement-2). The Joint Commission. Unaprjeđenje efektivne komunikacije, kulturoloških kompetencija I njege orijentisane prema pacijentu i porodici: kratki prikaz za bolnice. Oakbrook Terrace, Illinois; 2010 (http://www.jointcommission.org). Standard 5: Žene i novorođenčad imaju brigu sa poštovanjem i očuvanjem njihovog dostojanstva. Izjava o kvaliteti 5.1: Sve žene i novorođenčad imaju privatnost za vrijeme porođaja i njihova povjerljivost se poštuje. Obrazloženje: Privatnost i povjerljivost informacija čine da se žene i porodice osjećaju uvaženim sve vrijeme, štite ih od bilo kakve stigme povezane s njihovim problemima i izgrađuju povjerenje prema davateljima zdravstvene njege. Zdravstveni radnici poštuju privatnost i povjerljivost njege i informacija. Platna, zavjese i zasloni dostupni su kako bi se osigurala privatnost, a verbalna i pisana evidencija o ženinim i novorođenčetovim uslovima se čuvaju u tajnosti. Mjere kvalitete Ulazne mjere 3. Fizičko okruženje zdravstvene ustanove omogućava privatnost i pružanje njege pune poštovanja i povjerljivog zbrinjavanja, uključujući raspoloživost zavjesa, zaslona, pregrada i dovoljnog kapaciteta kreveta *. (94,80) 54 4. Zdravstveni objekt ima napisane, ažurirane protokole koji osiguravaju privatnost i povjerljivost svim ženama i novorođenčadi u svim aspektima skrbi *. (89,27) 5. Zdravstveni objekt ima mehanizme odgovornosti za ispravak u slučaju kršenja privatnosti, povjerljivosti ili pristanka. (85.16) Izlazne mjere/mjere procesa 1. Udio postupaka u zdravstvenoj ustanovi koji zahtijevaju pismenu saglasnost za koju postoji povezana evidencija saglasnosti žene *. (86.90) 2. Udio svih žena koje su prolazile kroz preglede ili postupke u zdravstvenoj ustanovi koje su izvijestile da je njihovo odobrenje bilo traženo prije ispitivanja ili postupaka. (84.41) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su bile zadovoljne stepenom privatnosti tokom boravka glede rađanja i porođaja. (85,63) 2. Udio svih ispitanih i liječenih žena u zdravstvenoj ustanovi koje su izrazili zadovoljstvo stepenom privatnosti tokom pregleda i liječenja. (85,48) 3. Udio svih žena koje su rodile u zdravstvenom objektu koje su izrazile zadovoljstvo zdravstvenim uslugama. (81,90) Izjava o kvaliteti 5.2: Niti jedna žena ili novorođenče ne podliježe bilo kojem vidu zlostavljanja, kao što su fizičko, seksualno ili verbalno zlostavljanje, diskriminacija, zanemarivanje, pritvaranje, iznuđivanje ili odbijanja pružanja usluga. Obrazloženje: Svaka žena ima osnovno ljudsko pravo na najveći mogući standard zdravstvene zaštite bez diskriminacije ili zlostavljanja. Zdravstveno osoblje tretira sve žene s ljubaznošću, suosjećanjem, pristojnošću, poštovanjem, razumijevanjem i iskrenošću i čuvaju njihovo dostojanstvo. Žene su slobodne da se žale bez straha od posljedica, i nema ograničenja za njihovo kretanje u ili izvan zdravstvenog objekta. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima napisane, ažurirane, bez tolerisanja diskriminacije, protokole u pogledu zlostavljanja žena i novorođenčadi *. (91,19) 2. Zdravstvena ustanova ima sistem u kojem majke malih, bolesnih novorođenčadi mogu biti blizu i mogu dojiti svoje bebe *. (89,59) 3. Naknade za njegu majki i novorođenčadi su jednake, pristupačne i jasno prikazane *. (89.07) 4. Zdravstvena ustanova ima napisane mehanizme odgovornosti za ispravak u slučaju lošeg tretiranja. (88,50) 5. Zdravstveni objekt ima pisanu, ažuriranu politiku i protokole koji opisuju pravo žena i porodica na pritužbu za primljenu njegu i ima lahko dostupan mehanizam (npr. kutija) za predaju žalbi. (88.34) 6. Zdravstveno osoblje materinske njege dobiva stručno usavršavanje i podržavajuću superviziju u poštivanju prava majki i novorođenčadi, respektabilne njege i mehanizama odgovornost. Novom osoblju se omogućava edukacija. (87.36) 7. Politika zdravstvene ustanove za plaćanje izričito zabranjuje pritvaranje žene ili djeteta zbog neplaćanja. (86,00) 55 8. U zdravstvenoj ustanovi nalazi se kutija za pritužbe, koja je lako dostupna ženama i njihovim porodicama, periodički se prazni i sadržaj se pregledava. (77.22) Izlazne mjere/mjere procesa 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su prijavile fizičko, verbalno ili seksualno zlostavljanje, za sebe ili svoje novorođenče, za vrijeme rađanja ili porođaja ili nakon poroda. (86,68) 2. Udio žena koje su rodile u zdravstvenoj ustanovi i koje su zadovoljne što je ustanova ispunila njihove vjerske i kulturne potrebe. (78,15) 3. Udio žena koje su pristupile zdravstvenoj ustanovi kojima je odbijena njega zbog nemogućnosti plaćanja. (76,97) 4. Udio pritužbi na poštivanje i očuvanje dostojanstva žena i njihovih porodica. (74,37) 5. Udio žena koje su rodile u zdravstvenoj ustanovi koje su bile svjesne postojanja i mjesta kutije za pritužbe. (70,90) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenom objektu koje su izrazile zadovoljstvo zdravstvenim uslugama. (85,93) 2. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izvijestile da su tretirane s poštovanjem i dostojanstvom. (84,13) 3. Udio svih žena u zdravstvenoj ustanovi koje su podnijele žalbu i na čije se pritužbe postupalo bez posljedica po njih. (72.82) Izjava o kvaliteti 5.3: Sve žene su obaviještene o odabiru usluga koje primaju, jasno su objašnjeni razlozi za eventualne intervencije kao i ishodi istih. Objašnjenje: Nužno je da se žene osjećaju uključenim u svoje liječenje i njegu i mogu donositi informirane odluke kako bi poboljšale svoju saradnju i zadovoljstvo tretmanom. Žene su informirane o svojim pravima i mogućnostima njege i poticane da postavljaju pitanja. One su podržane u donošenju odluka o svim aspektima njege i liječenja; poštuju se njihove lične vrijednosti i uvjerenja, a njihov se pristanak dobiva prije nego što se provode postupci. Mjere kvalitete Ulazne mjere 1. Zdravstveni objekt ima pisanu, ažuriranu politiku za dobivanje informiranog pristanka žena prije ispitivanja i postupaka *. (90,98) 2. Zdravstveni objekt ima standardni formular za informirani pristanak koji pomaže osoblju zdravstvene ustanove da pruži lahko razumljive informacije ženama kako bi stekli njihov potpuno informirani pristanak *. (90,39) 3. Zdravstveno osoblje u zdravstvenoj ustanovi prima stručno usavršavanje i podršku nadzora o učinkovitim postupcima informiranog pristanka i ženskom pravu na odabir njege u porodu. Za novo osoblje je omogućena edukacija *. (87,51) 4. Zdravstveni objekt ima napisane mehanizme odgovornosti za ispravak u slučaju da se ženama uskraćuje informirani izbor. (81,41) 56 Izlazne mjere/mjere procesa 1. Udio postupaka u zdravstvenoj ustanovi koji zahtijevaju pismenu saglasnost za koju postoji pridružena evidencija saglasnosti koju potpisuje žena ili član porodice. (84.32) 2. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su se osjećale adekvatno informiranim od strane zdravstvenih radnika glede odluka donešenih tokom njihove njege (80.82) 3. Udio žena koje su primale njegu u zdravstvenoj ustanovi, koje su bile svjesne da imaju pravo prihvatiti ili odbiti liječenje. (78,55) Mjere ishoda 1. Udio žena koje su rodile u zdravstvenoj ustanovi na carski rez i koje su bile svjesne razloga za carski rez. (87,13) 2. Udio svih žena koje su rodile u zdravstvenom objektu i koje su izrazile zadovoljstvo zdravstvenim uslugama. (82,74) 3. Udio žena koje su rodile u zdravstvenoj ustanovi i koje su osjećale da su dijelile odluke o svom porodu, rađanju i postnatalnoj njezi. (75.86) Reference korištene u postavljanju standarda 5 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. Maltretiranje žena tokom porođaja u zdravstvenim ustanovama na globalnoj razini: sistemski pregled mješovitih metoda. PLoS Med 2015;12:e1001847. de Silva A. Okvir rada za mjerenje odziva. Ženeva: Svjetska zdravstvena organizacija; 2000 ( http://www.who.int/responsiveness/papers/paper32.pdf?ua=1). Dwamena F1, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Intervencije za pružatelje usluga pri promicanju pristupa usmjerenog na pacijenta u kliničkim konsultacijama. Cochrane baza podataka Syst Rev 2012;12:CD003267. Međunarodna federacija ginekologije i akušerstva, Međunarodna konfederacija primalja, Savez bijelih vrpci, Međunarodna udruga za djecu, Svjetska zdravstvena organizacija. Porođajne ustanove prijatelji majki i beba. Int J Gynaecol Obstet 2015;128:95–99. Kongnyuy E, van den Broek N. Kriteriji za kliničku reviziju prijateljske njege žena i percepciju pružatelja usluga u Malaviju. BMC Pregnancy Childbirth 2008;8:28. Lothian JA. Ne smetajte: važnost privatnosti u radu, J Perinat Educ 2004;13:4–6. Nacionalni institut za zdravlje i njegu izvrsnosti. Pacijentovo iskustvo u uslugama za odrasle NHSa: poboljšanje iskustva u skrbi za osobe koje koriste usluge za odrasle NHS-a. London; 2012 ( http://www.nice.org. uk/guidance/cg138). Reader TW, Gillespie A. Zanemarivanje pacijenata u zdravstvenim ustanovama: sistemski pregled i konceptualni model. BMC Health Serv Res 2013;13:156. Valentine NB, de Silva A, Kawabata K, Darby C, Murray CJL, Evans DB. Odziv zdravstvenog sistema: pojmovi, domene i mjerenja. U: Murray CJL, Evans DB, urednici, Procjena učinka zdravstvenih sistema: rasprave, metode i empirizam. Ženeva: Svjetska zdravstvena organizacija; ; 2003. Svjetska zdravstvena organizacija. WHO izjava o prevenciji i otklanjanju nepoštivanja i zlostavljanja tokom porođaja u ustanovama. Ženeva; 2015 (http://apps.who.int/iris/bitstream/10665/134588/1/ WHO_RHR_14.23_eng.pdf?ua=1&ua=1). 57 Standard 6: Svaka žena i njena porodica ili pratilac po njenom izboru dobivaju emocionalnu podršku koja odgovara na njihove potrebe i jača ženinu sposobnost. Izjava o kvaliteti 6.1: Svaka žena i njena porodica dobijaju emocionalnu podršku koja je prilagođena njihovim potrebama i koja jača sposobnost žene. Objašnjenje: Bračni drugovi pružaju fizičku, emocionalnu i duhovnu podršku ženama tokom rađanja i porođaja, a time imaju pozitivan učinak na žene i poboljšane rezultate porođajnog ishoda. Ženama je dozvoljeno i potaknute su da biraju drugu osobu da bude prisutna tokom rađanja i porođaja. Pratilac je orijentiran u podupiranju žene tokom trudova i porođaja, a žena i njena pratnja potiču se na aktivno sudjelovanje u ženinoj njezi. Mjere kvalitete Ulazne mjere 1. Rađanje i porođaj su oblasti tako organizirane da omogućavaju fizički privatni prostor za ženu i njenu pratnju za vrijeme rađanja *. (91,59) 2. Zdravstvena ustanovo ima pisani, ažurirani protokol koji se objašnjava ženama i njihovim porodicama, kako bi se potaknulo da sve žene imaju barem jednu osobu po svom izboru, s obzirom na kulturološke prilike, s njima za vrijeme rađanja, porođaja i u neposrednom postnatalnom razdoblju *. (91.25) 3. Zdravstveni radnici u zdravstvenoj ustanovi educirani su i primaju obuku za usavršavanje u struci najmanje jednom svakih 12 mjeseci na dokazima o pozitivnom utjecaju prisustva izabranog pratioca tokom poroda i rađanja. (84.63) 4. Dostupne su edukacijske sesije i informacije (pisane ili slikovne) kako bi se pratilac osposobio u svojoj ulozi u pružanju podrške ženi tokom poroda i rađanja. (83,40) Izlazne mjere/mjere procesa 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su imale pratioca po svom izboru tokom poroda i rađanja *. (91,76) 2. Udio svih pratioca koji su bili zadovoljni edukacijom o njihovoj ulozi tokom poroda i rađanja. (75.19) Mjere ishoda 1.Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izrazile zadovoljstvo zdravstvenim uslugama. (84,84) Izjava o kvaliteti 6.2: Svaka žena dobija podršku sa ciljem jačanja svoje sposobnosti tokom porođaja. Obrazloženje: Svakoj ženi se treba pružiti emocionalna podrška za poboljšanje mentalnog zdravlja, pružiti joj pozitivnu perspektivu i poboljšati ukupne zdravstvene ishode majke i bebe. Njega u ustanovi optimizira biološko, psihološko, društveno i kulturno blagostanje. Žene se potiču na usvajanje položaja po svom izboru tokom poroda, da slobodno 58 hodaju tokom prve faze i da jedu i piju dovoljno kako bi osigurale adekvatnu prehranu i hidrataciju. Identificirane su i podržane žene s kompleksnim emocionalnim potrebama (npr. prethodna smrt novorođenčeta, iskustvo nasilja u porodici na temelju spola, silovanje, problemi s mentalnim zdravljem). Pomoć pri tugovanju se pruža porodicama ukoliko umre majka ili beba. Mjere kvalitete Ulazne mjere 1. Zdravstveno osoblje u području poroda i rađanja pri materinskoj njezi educirano je o nefarmakološkim i farmakološkim metodama ublažavanja boli te je primilo stručno usavršavanje ili sesije najmanje jednom u prethodnih 12 mjeseci *. (87,07) 2. Zdravstvena ustanova ima pisani, ažurirani protokol koji se objašnjava ženama i njihovim porodicama, kako bi se smanjile nepotrebne intervencije, podržao fiziološki porod i ojačale ženine sposobnosti, tako da osjeća kontrolu nad svojim iskustvom u porođaju. (83,21) 3. Zdravstveno osoblje u području poroda i rađanja pri materinskoj njezi je educirano i primilo je najmanje jedanput tokom prethodnih 12 mjeseci obuku ili ponavljanje kako bi ojačali međuljudske i kulturne sposobnosti u pružanju emocionalne podrške. (82,34) 4. Zdravstvena ustanova ima mehanizam preporuke za žene i porodice sa složenim emocionalnim potrebama i upućuje ih na specijalističku njegu. (79,71) Izlazne mjere/mjere procesa 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su to radile u položaju po svom izboru. (82,02) 2. Udio svih žena koje su proživjele smrt ili nepovoljni ishod koje su primile dodatnu emocionalnu potporu osoblja zdravstvenih ustanova. (80.64) 3.Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izvijestile da su imale dovoljno hrane i pića tokom poroda. (80,10) Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su bile pokretne tokom prve etape poroda. (77,30) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izrazile zadovoljstvo zdravstvenim uslugama *. (84,69) 2. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje bi preporučile porođaj u tom objektu *. (84,46) 3. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izvijestile o pozitivnom doživljaju rađanja. (83.23) 4. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su se uvjerile da su poštivani njihovi izbori i preferencije. (82.36) Reference korištene u postavljanju standarda 6 Hodnett ED, Gates S, Hofmeyr G, Sakala C. Kontinuirana podrška ženama tokom porođaja. Cochrane baza podataka Syst Rev 2013;7: CD003766. Međunarodna federacija ginekologije i akušerstva, Međunarodna konfederacija babica, Savez bijelih vrpci, Međunarodno udruženje za djecu, Svjetska zdravstvena organizacija. Ustanove za porod prijatelji majki i beba. Int J Gynaecol Obstet 2015;128:95–99. 59 Nacionalni institut za izvrsnost zdravstvene zaštite. Korištenje organizacijskih promjena kako bi se poboljšalo iskustvo rađanja žena usredotočujući se na normalizaciju rađanja. London; 2013 ( https://www.nice.org.uk/ sharedlearning/using-organisational-change-to-enhance- the-experience-of-women-giving-birth- by-focusing-on-normalising-births). Nacionalni institut za izvrsnost zdravstvene zaštite. NICE smjernice za rutinsku intrapartum njegu (CG 190). London; 2014 (http://www.nice.org.uk/guidance/cg190/resources/ guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf). Renfrew MJ. Optimiziranje doprinosa primaljstva za sprečavanje mrtvorođenih i poboljšanje sveukupne kvalitete njege: potrebno je koordinirano globalno djelovanje. Midwifery 2016;36:99–101. Kraljevski koledž primalja. Emocionalno blagostanje majki i razvoj djece, dobar vodič za primalje, London; 2012 (https://www.rcm.org.uk/sites/default/files/Emotional%2. Wellbeing_Guide_WEB.pdf). Sandall J. Soltani H, Gates S, Shennan, A, Devane, D. Modeli kontinuiteta pod vodstvom primalja u odnosu na druge modele njege za trudnice. Cochrane baza podataka Syst Rev 2013;8: CD004667. Svjetska zdravstvena organizacija. WHO preporuke o postnatalnoj njezi majke i novorođenčadi. Ženeva; 2013 ( http://www.who.int/maternal_child_adolescent/documents/ postnatal-care-recommendations/en/). Svjetska zdravstvena organizacija. WHO preporuke za augmentaciju poroda. Ženeva; 2014 ( http:// www.who.int/reproductivehealth/publications/maternal_perinatal_health/augmentation- labour/en/). Standard 7: Za svaku ženu i novorođenče je uvijek dostupno, kompetentno i motivisano osoblje, sposobno pružiti rutinsku njegu i brigu o mogućim komplikacijama. Izjava o kvaliteti 7.1: Svaka žena i dijete u svakom trenutku imaju pristup najmanje jednom stručnjaku koji nadzire porod te pomoćnom osoblju za rutinsku njegu i brigu u slučaju komplikacija. Obrazloženje: dostupnost zdravstvenog osoblja tokom cijelog dana je neophodna za optimalnu rutinsku i hitnu njegu o pacijentima i pravodobno upravljanje komplikacijama. Postoji i politika za osoblje zdravstvenih ustanova, koja se redovito preispituje i ažurira prema potrebi, koja određuje broj, tipove i potrebnu kompetenciju osoblja kako bi se osigurao odgovarajući broj i splet vještina zdravstvenog osoblja za obim posla, 24 h na dan, 7 dana u sedmici. Kliničko i nekliničko osoblje orijentirano je na svoje specifične uloge i odgovornosti u objektu ili jedinici kojoj su dodijeljeni. Popis osoblja koje obavlja dužnosti i vrijeme kad su dežurni uvijek se ažuriraju i dostupni su. Dostupne su pisane informacije o pristupu uslugama, a znakovi označavaju ključna područja usluge (npr. odjel za hitne slučajeve) i šta treba učiniti u slučaju nužde. Žene se procjenjuju kako bi se odredile prioritetni slučajevi. 60 Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova raspolaže iskusnim osobljem sve vrijeme, dovoljnog broja kako bi se zadovoljio predviđeni obim rada *. (89.50) 2. Zdravstvena ustanova ima pisanu, ažuriranu politiku osoblja koja navodi brojeve, vrste i kompetentnost osoblja, koja se kontinuirano pregledava prema radnom opterećenju *. (89.05) 3. Zdravstveni objekt ima popis koji se prikazuje u svim područjima, dajući imena dežurnog osoblja, vrijeme njihovih smjena i njihove specifične uloge i odgovornosti. (86,43) 4. Zdravstvena ustanova ima pisanu, ažuriranu politiku o trijažama i vremenima čekanja za hitne slučajeve i neophodne konsultacije i liječenje. (86,32) Zdravstvena ustanova ima jasne komunikacijske kanale kako bi informisali dežurno osoblje u svakom trenutku. (82,87) Izlazne mjere/mjere procesa 1. Udio raspoloživih radnih mjesta u zdravstvenoj ustanovi koji su popunjeni osobljem s potrebnim kompetencijama za opis datog radnog mjesta kako bi se ustanovi omogućilo pružanje 24-satne usluge. (80,72) 2. Udio osoblja koji su educirani za svoje funkcije, uloge i odgovornosti u ustanovi ili jedinici kojoj su dodijeljeni. (78,79) Udio žena koje su pristupile zdravstvenoj ustanovi koje su izvijestile o primanju pozornosti u odgovarajuće vrijeme za njihovo stanje prema politici ustanove o trijaži i vremenu čekanja. (73,08) Mjere ishoda 1. Udio žena i njihovih novorođenčadi u zdravstvenoj ustanovi kojem se posvetio iskusni medicinski radnik (kao po definiciji) za vrijeme i nakon porođaja *. (90,11) 2. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su izvijestile da su obaviještene o znakovima opasnosti za nju i njezinu bebu i pripravnosti u hitnim slučajevima. (84.27) Udio žena koje su pristupile zdravstvenoj ustanovi, koje su bile zadovoljne zdravstvenom njegom koju su primile. (80,87) Izjava o kvaliteti 7.2: Stručnjaci za porod kao i pomoćno osoblje imaju odgovarajuće kompetencije i vještine koje zadovoljavaju zahtjeve porođaja i ranog postnatalnog perioda. Obrazloženje: Kvalifikacija, obuka i usmjeravanje osoblja poboljšavaju njihovu ulogu i odgovornost. Svo osoblje ima opis posla koji navodi potrebnu kompetenciju, uloge i odgovornosti, podržane željenim kvalifikacijama i drugim zahtjevima. Obrazovanje, licenciranje ili registracija i ostale referencije propisane zakonom ili pravilnikom provjeravaju se za sve zdravstvene radnike i ažuriraju. Postoje utvrđeni programi za zapošljavanje, zadržavanje, profesionalni razvoj i kontinuirano obrazovanje svih zaposlenika. Svi zaposlenici dobivaju kontinuirano usmjeravanje na protokole i odgovornosti, supervizije podrške i aktivnosti za profesionalni razvoj, uz godišnju ocjenu rada i 61 prepoznavanje dobrih rezultata. Učinkoviti i efikasni sistemi upravljanja su obezbijeđeni kako bi osigurali da pacijenti primaju odgovarajuće, sigurno i pravodobno zbrinjavanje, a osoblje zdravstvene njege može pokazati odgovarajuću sposobnost pri pružanja rutinske njege i menadžmentu komplikacija za majku i novorođenče. Mjere kvalitete Ulazne mjere 4. Zdravstvena ustanova ima program za stalno usavršavanje i razvoj vještina za svo kvalificirano medicinsko osoblje i ostalo osoblje za podršku te provodi redovnu obuku *. (86,62) 5. Zdravstvena ustanova ima standardne postupke i planove za zapošljavanje, implementaciju, motivaciju (priznavanje i nagrade) i zadržavanje svih zaposlenika *. (84.21) 6. Zdravstvena ustanova periodično ocjenjuje sve zaposlenike i ima mehanizam za prepoznavanje dobrih rezultata. (82.76) 7. Zdravstvena ustanova ima dovoljan broj obrazovanog, kompetentnog, licenciranog, motiviranog, reguliranog vještog medicinskog osoblja s odgovarajućom mješavinom vještina, koji rade u multidisciplinarnim timovima. (81,83) 8. Zdravstvena ustanova osigurava poticajno okruženje za profesionalno usavršavanje osoblja, uz redovito nadgledanje i mentorstvo. (79,24) 9. Zdravstvena ustanova olakšava međusobnu saradničku praksu, s jasnim ulogama i odgovornostima temeljenim na profesionalnom obimu prakse i potrebama za njegu tokom poroda, rađanja i ranog postnatalnog razdoblja. (75,82) Izlazne mjere/mjere procesa 1. Udio kvalificiranog osoblja u zdravstvenoj ustanovi koji su primili pisani opis radnog mjesta prilikom prijema u ustanovu *. (85,81) 2. Udio kvalificiranog osoblja u zdravstvenoj ustanovi koji su primili stručno usavršavanje, obnavljanje ili mentorstvo u proteklih 12 mjeseci. (81.80) 3. Broj nadzornih posjeta koje podupiru kliničku kompetenciju i poboljšanje performansi (u protekla tri mjeseca). (80,85) 4. Udio osoblja u zdravstvenoj ustanovi koji su procjenjeni najmanje jednom u proteklih 12 mjeseci. (77,54) 5. Broj timskih sastanaka koji se održavaju mjesečno kako bi se osvrnuli na sposobnosti i aktivnosti poboljšanja kvalitete. (76.33) 6. Broj mjesečnih interakcija s profesionalnim mentorima kako bi se osigurala klinička kompetencija i poboljšala učinkovitost. (75.17) 7. Udio svih radnika u zdravstvenoj ustanovi koji su sudjelovali u najmanje dva aktivna timska sastanka za poboljšanje kvalitete i sudjelovali u aktivnostima poboljšanja kvalitete u prethodnih šest mjeseci. (74.70) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su bile zadovoljne njegom i podrškom osoblja ustanove. (82,51) 2. Udio kvalificiranog medicinskog osoblja i pomoćnog osoblja u zdravstvenoj ustanovi čija je prethodna ocjena rada bila zadovoljavajuća. 3. Udio od kompletnog osoblja u zdravstvenoj ustanovi koji su se za svoj posao izrazili kao "vrlo zadovoljni". (76,35) 4. Udio cijelog osoblja u zdravstvenoj ustanovi koji bi se mogli identificirati i izvijestiti 62 o barem jednoj kliničkoj aktivnosti poboljšanja u kojoj su lično uključeni u proteklih šest mjeseci. (75.97) 5. Udio svih radnika u zdravstvenoj ustanovi koji su aktivno razmišljali o traženju novog posla. (64,26) Izjava o kvaliteti 7.3: Svaka zdravstvena ustanova ima menadžersko i kliničko rukovodstvo koje je kolektivno odgovorno razvijati i primjenjivati odgovarajuće politike te njegu okruženja koje podstiče osoblje na kontinuirano poboljšanje kvalitete. Obrazloženje: Dobro menadžersko i kliničko vodstvo poboljšava performanse pokazujući smjer i nadahnjujući zaposlenike te stvaranjem okruženja potpore osoblju u kontinuiranom poboljšanju kvalitete. Postoji menadžersko i kliničko vodstvo, kolektivna odgovornost, odgovarajuća vladajuća politika i postupci te okruženje koje podržava osoblje u kontinuiranom poboljšanju kvalitete. Postoji definirana struktura i autoritet vodstva, matrice odgovornosti i definirani tim za poboljšanje kvalitete s potrebnim resursima. Uposlenici zajednički razvijaju i provode programe poboljšanja kvalitete i sigurnosti pacijenata te dobivaju podršku, nadzor i mentorstvo. Postoji protokol i plan za upravljanje finansijskim rizicima, a ustanova poduzima redovne revizije (majke i perinatalne smrti i skore propuste), s preporukama za poboljšanje kvalitete. Postoji sistem za redovito pregledavanje prikupljenih podataka, izvještavanje i komunikaciju po pitanjima upravljanja kvalitetom kako bi se usmjerilo donošenje odluka i pratila učinkovitost. Njega i zadovoljstvo pacijenata redovito se pregledavaju, a status poboljšanja kvalitete je dokumentiran. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima pisani, ažurirani plan poboljšanja kvalitete njege i programa sigurnosti pacijenata*. (88,08) 2. Zdravstvena ustanova ima pisanu, ažuriranu strukturu vodstva, sa definiranim ulogama i odgovornostima te matricama odgovornosti za izvještavanje *. (87,19) 3. Zdravstvena ustanova ima određeni tim za poboljšanje kvalitete i odgovorno osoblje *. (85.38) 4. Zdravstvena ustanova ima mehanizam za redovito prikupljanje podataka o zadovoljstvu pacijenata i pružatelja usluga. (84,98) 5. Zdravstvena ustanova ima najmanje jedan mjesečni sastanak za pregled podataka, praćenje performansi poboljšanja kvalitete, preporuke za rješavanje svih identificiranih problema, priznanje onima koji su dobro radili i poticaj osoblju koje stremi poboljšanju. (83,19) 6. Svi standardni upravljački postupci (politike i protokoli) su uspostavljeni i dostupni svom relevantom osoblju. (82,61) 7. Udio svih voditelja zdravstvenih ustanova koji su bili osposobljeni za poboljšanje kvalitete i vođenje promjene (korištenje informacija, usmjeravanje ponašanja, kontinuirano učenje). (81,07) 8. Zdravstvena ustanovo održava najmanje dva godišnja sastanka s interesnim grupama (npr. Zajednicom, korisnicima usluga, partnerima) kako bi pregledali njenu izvedbu, identificirali probleme i dali preporuke za zajedničke akcije za poboljšanje kvalitete. 63 9. Udio svih voditelja zdravstvenih ustanova koji su bili osposobljeni za vodstvo i menadžerske vještine. (80,89) 10. Postoji politika gdje osoblje ima mogućnost da daje povratnu informaciju menadžmentu upravljanja ustanove o poboljšanju kvalitete i njihovom učinku. (80,82) Izlazne mjere/mjere procesa 1. Voditelji zdravstvenih ustanova priopćili su izvedbu ustanove putem uspostavljenih mehanizama za praćenje (npr. nadzorna ploča ključnih mjernih podataka) svom relevantnom osoblju. (79,75) 2. Udio mjesečnih sastanaka o kvaliteti njege koja su se zapravo održala u prethodnih 12 mjeseci. (78,69) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su bile zadovoljne njegom i podrškom osoblja ustanove. (83,95) 2. Dokazi za poboljšanu učinkovitost sistema (prema nadzornoj ploči ustanove). (82.50) Reference korištene u postavljanju standarda 7 Gülmezoglu MA, Lawrie TA. Utjecaj vježbi osposobljavanja na vještine oživljavanja: utjecaj na Milenijske ciljeve razvoja (MDG) 4 i 5. Best Pract Res Clin Obstet Gynaecol 2015); doi: 10.1016/j. bpobgyn.2015.03.018. ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Poboljšanje zdravlja majke i novorođenčeta kroz primaljstvo. Lancet 2014;384:1226–1235. Međunarodna konfederacija primalja. Osnovne kompetencije za osnovnu primaljsku praksu. Haag, 2011 ( http://www.internationalmidwives.org). Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Primaljstvo i kvalitetna njega: saznanja iz novog dokaznog okvira za majčinsku i novorođenačku njegu. Lancet 2014; 384:1129–1145. The Lancet. Midwifery. Izvršni sažetak za The Lancet. London; 2014 ( http://www. thelancet.com/pb/assets/raw/Lancet/stories/series/midwifery/midwifery_exec_summ.pdf). Fond za populaciju Ujedinjenih naroda. Stanje primalja u svijetu: isporuka zdravlja, spašavanje života. New York; 2011. Whittaker S, Shaw C, Spieker N, Linegar A. Standardi kvalitete za zdravstvene ustanove u Južnoj Africi. U: Padarath A, English R, editors. South African Health Review. Pretoria: National Department of Health; 2011:59–68 (http://www.cohsasa.co.za/sites/cohsasa.co.za/files/ publication_pdfs/ chap_5_quality_standards_pgs_59-_68_0.pdf). Svjetska zdravstvena organizacija. Poboljšanje sigurnosti u trudnoći: kritična uloga stručnog liječnika - zajednička izjava WHO, ICM i FIGO. Ženeva; 2004 ( http://www.who.int/maternal_child_adolescent/ documents/9241591692/en/). Svjetska zdravstvena organizacija. Svjetsko zdravstveno izvješće 2005. Učinite da svaka majka i dijete važe. Ženeva; 2005 (http://www.who.int/whr/2005/whr2005_en.pdf). Svjetska zdravstvena organizacija. Svjetsko zdravstveno izvješće 2006. Raditi zajedno za zdravlje. Ženeva; 2006 ( http://www.who.int/whr/2006/en/). Svjetska zdravstvena organizacija. Alat za planiranje implementacije zdravstvene strategije za zdravlje majke i novorođenčeta: praktični alat za jačanje zdravstvenog sistema upravljanja. Ženeva; 2011. 64 Svjetska zdravstvena organizacija. Smjernice o zdravlju majke, novorođenčeta, djeteta i adolescenata, koje je odobrio Odbor za preispitivanje smjernica Svjetske zdravstvene organizacije. Preporuke o zdravlju novorođenčeta. Ženeva; 2013 ( http://www.who.int/maternal_child_adolescent/documents/guidelines-recommendations- newborn-health.pdf). Regionalni ured za Europu Svjetske zdravstvene organizacije. Bolnička njega majke i novorođene bebe: alat za procjenu i poboljšanje kvalitete. Kopenhagen; 2014 ( http://www.euro.who.int/en/ health-topics/Life-stages/maternal-and-newborn- health/publications/2014/hospital-care-for- mothers-and-newborn-babies-quality-assessment- andimprovement-tool.pdf?ua=1). Standard 8: Zdravstvena ustanova ima odgovarajuće fizičko okruženje za majku i novorođenče, kao i odgovarajuću vodu, sanitarije, snabdjevanje energijom, lijekovima, zalihama te opremu za rutinsku brigu i upravljanje komplikacijama. Izjava o kvaliteti 8.1: Voda, energija, sanitarije, higijena ruku i sredstva za odlaganje otpada su funkcionalni, pouzdani, sigurni i dovoljni da zadovolje potrebe osoblja, žena i njihovih porodica. Obrazloženje: Sigurno, čisto i higijensko okruženje s kontinuiranim zalihama čiste vode i električne energije, dobre sanitacije i sigurnog odlaganja otpada osnova je odgovarajuće njege za pacijente, provođenju svih postupaka i intervencija te za kontrolu infekcije. Stalna opskrba čistom vodom dostupna je na licu mjesta sve vrijeme, za piće, čišćenje i pranje ruku u svim kliničkim područjima, uključujući period prije, tokom poroda i neonatalne njege te operativnih sala. Dostupne su usluge sanitacije, koje su jasno odvojene za spolove i dostupne svim ženama, njihovim porodicama i osoblju. Zdravstvena ustanova i njeni pomoćni objekti (npr.dijelovi za osoblje) imaju pouzdan pristup izvoru električne energije (npr. solarni, generator ili mreža) u svakom trenutku. Postoji mehanizam za odvajanje, skupljanje, transport, tretman i sigurno odlaganje otpada. Objekt ima budžet i protokol za rad i održavanje energije, sigurne vode i sanitarnih usluga. Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima funkcionalni izvor čiste vode koja se nalazi u prostorijama i koja odgovara svim potrebama za pićem, ličnom higijenom, medicinskim intervencijama, čišćenja, pranja veša i kuhanja za potrebe osoblja, žena, novorođenčadi i njihovih porodica. (90,90) 2. Zdravstvena ustanova ima nepropusne, pokrivene, označene otpadne spremnike i nepropusne kontejnere dostupne na svakom području liječenja, kako bi se omogućilo odvajanje otpada u četiri kategorije: oštar otpad, infektivan otpad, generalni neinfektivni otpad (npr. hrana , ambalaža) i biološkog otpada (npr. posteljica) *. (90,88) 3. Zdravstvena ustanova ima barem jednu funkcionalnu higijensku stanicu na svakih 10 kreveta, sa sapunom i vodom ili alkoholnim dezinficijensima u svim odjelima *. (89,53) 65 4. Zdravstvena ustanova ima energetsku infrastrukturu (npr. solarni, generator, električna mreža) koja u svakom trenutku može ispuniti sve zahtjeve za električnom energijom objekta i pridružene infrastrukture uz pomoćno napajanje. (89,41) 5. Zdravstvena ustanova ima pisane, ažurirane protokole i materijale za podizanje svijesti (plakati) o čišćenju i dezinfekciji, higijeni ruku, upravljanju i održavanju vodnih, sanitarnih i higijenskih objekata i sigurno upravljanje otpadom; oni se postavljaju na područjima u kojima se aktivnosti obavljaju. (88,05) 6. Zdravstvena ustanova ima uređaje za sanitarnu opremu u prostorima koji su dostupni, noću su prikladno osvijetljeni, dostupni osobama s ograničenom pokretljivošću i odvojeni po spolu za osoblje i pacijente; oni sadrže barem jedan toalet koji odgovara potrebama za menstrualnu higijenu, sa stanicama za pranje ruku i sapunom i vodom (najmanje 1 klozet po 20 korisnika u odjelima sa pacijentima). (87,46) 7. Zdravstvena ustanova ima dovoljno stručno osposobljenog i kompetentnog osoblja na mjestu gdje je to potrebno, s jasnim opisima njihovih odgovornosti za čišćenje, upravljanje i održavanje vode, sanitarne, higijenske i zdravstvene njege (86,44) 8. Zdravstvena ustanova ima dovoljno sredstava za sanaciju, poboljšanje i kontinuiranu upotrebu i održavanje vodnih, sanitarnih, higijenskih i zdravstvenih usluga zbrinjavanja otpada. (83,13) 9. Zdravstvena ustanova ima plan za upravljanje gorivom i lokalnim spremnikom, podržan adekvatnim budžetom za sve potrebe goriva za vozila, kuhanje i grijanje, u svakom trenutku potrebne i u svako doba. (83.02) 10. Zdravstvena ustanova ima preventivni plan rizika za upravljanje i poboljšanje vodnih, sanitarnih i higijenskih usluga, uključujući i za sprečavanje i kontrolu zaraze. (81,34) 11. Zdravstvena ustanova ima plan upravljanja energijom, koji je podržan odgovarajućim budžetom, koji održava odgovarajuće obučeno osoblje i koji je regulirano nadležnim tijelom. (77,26) Mjere ishoda 1. Udio žena i njihovih porodica koji su bili u zdravstvenoj ustanovi i koji su bili zadovoljni vodom, sanitarnim i energetskim uslugama te preporučili zdravstvenu ustanovu prijateljima i porodici. (76,75) 2. Udio svih zdravstvenih djelatnika u zdravstvenoj ustanovi koji su bili zadovoljni vodom, sanitarnim i energetskim uslugama te smatraju da ove usluge pozitivno doprinose pružanju kvalitetne njege. (76,23) 3. Udio žena i njihovih porodica koji su bili u zdravstvenoj ustanovi koji su bili zadovoljni izvorom energije i osvjetljenja te preporučili zdravstvenu ustanovu prijateljima i porodici. (74.20) Izjava o kvaliteti 8.2: Prostorije za porod i postnatalnu njegu su projektovane, organizovane i održavane na način da se svakoj ženi i novorođenčetu može pružiti individualna i kontinuirana njega prema njihovim potrebama. Obrazloženje: Infrastruktura zdravstvene ustanove trebala bi biti primjerena i dobro održavana, uz osnovne usluge, dobru ventilaciju, izvor energije i higijenu. Opća infrastruktura organizirana je u namjenske prostorije u blizini rađaone i prostorija za bebe (recepcija, trijaža i područje procjene, neposredna postnatalna poluintenzivna njega, rooming-in u postnatalnim odjelima ili sobama, područja za njegu novorođenčadi, odjel za bolesnu novorođenčad, odjel za koža na kožu, neonatalna jedinica intenzivne njege, operaciona sala za obavljanje carskog reza) i 66 adekvatno opremljeno za učinkovito i dosljedno pružanje optimalne njege. Područja usluge su čista, dobro prozračena i osvijetljena, naročito noću i pogoduju privatnosti (npr. zavjesa, zid); primjereni, sigurni, čisti i dobro održavani osnovni sadržaji su na mjestu (kreveti, madraci, posteljina, higijena i kupaonica, WC). Mjere kvalitete Ulazne mjere 1. Zdravstvena ustanova ima namjenski prostor u području rađanja i novorođenačke njege za reanimaciju novorođenčadi, koji je adekvatno opremljen stolom i opremom, grijačem, svjetlom i odgovarajućom opremom i materijalom *. (94,67) 2. Zdravstvena ustanova ima radni odjel i odgovarajući broj porađaona ili prostorije za procijenjeni broj rođenih u svom lokalnom prostoru *. (90,12) 3. Zdravstveni objekat ima čiste, prikladno osvijetljene, dobro ventilirane prostorije za porod i rađanje i neonatalni odjel i okruženje koje omogućava privatnost i adekvatno su opremljeni, redovito se čiste i održavaju *. (89,52) 4. Zdravstvena ustanova prakticira i omogućava svim ženama rooming-in tj. omogućavaju mamama i bebama da ostaju skupa 24h dnevno (86,57) 5. Zdravstveni objekat ima prostorije ili sobe za porađajne i predporod koji imaju funkcionalnu, čistu i pristupačnu kupaonicu ili tuš kabinu i WC za korištenje samo za porodilje. (88,94) 6. Zdravstvena ustanova koja nudi hirurške usluge ima adekvatno opremljeno operativnu salu koja se nalazi u blizini i lahko je dostupna iz porađaone i predporađaone. (88,84) 7. Objekat ima namjensku sobu za oporavak ili područje za njegu žena s komplikacijama. (86,54) 8. Zdravstveni objekat ima posvećen odjel za prijem bolesnih i ugroženih novorođenčadi. (86,37) Izlazne mjere/mjere procesa 1. Udio svih trudnica koje su bile u zdravstvenoj ustanovi koje su izvijestile da ima čistu fizičku okolinu koja je pogodna za porod. (82,65) Mjere ishoda 1. Udio svih žena koje su rodile u zdravstvenoj ustanovi, koje su bile zadovoljne okruženjem predrađaone i porađaone uključujući čistoću, blizinu WC-a, opću rasvjetu, stepen napućenosti i privatnost. (81.8) Izjava o kvaliteti 8.3: Dostupna je odgovarajuća zaliha lijekova, potrošnog materijala i opreme za rutinsku njegu i upravljanje komplikacijama. Obrazloženje: Dostupni, adekvatni esencijalni lijekovi, oprema i ostali materijali kritični su za pružanje optimalne i kvalitetne njege. Postoji popis bitnih lijekova i potrepština (npr. laboratorijski reagensi) i njihove upotrebe i uredno, čisto i sigurno skladištenje ovih predmeta, s učinkovitim sistemom za izbjegavanje nestašica. Svi prikladni lijekovi dostupni su u kliničkim područjima (npr. magnezijev sulfat u području poroda i rađanja). Osnovna oprema dostupna je uvijek na pravim mjestima, uz sistem za redovito održavanje i smjernice za odgovarajuću upotrebu opreme. Dostupni su laboratorijski testovi (npr. hemoglobin, 67 krvna skupina, proteini urina) za rutinsku upotrebu i saniranje komplikacija. Krv je dostupna za transfuzijske usluge, a neprekidna opskrba kisikom je dostupna u porodiljnim i neonatalnim područjima. Mjere kvalitete Ulazne mjere 1. Zdravstveno postrojenje ima zalihe antihipertenzivnih agenasa i magnezijevog sulfata u dovoljnim količinama, dostupnim u svim vremenima, u antenatalnim, pretporođajnim, porođajnim i postnatalnim područjima za tretiranje žena s preeklampsijom *. (92,81) 2. Zdravstveni objekat ima uterotonične lijekove i opremu za intravenoznu infuziju (šprice, igle, setove za infuziju, intravenozna tekuća otopina i krv) dostupne u dovoljnim količinama u svim vremenima u području dojenja i postnatalne skrbi za tretiranje žena s postpartalnim krvarenjem *.(92.31) 3. Zdravstvena ustanova ima zalihe antenatalnih kortikosteroida (deksametazon ili betametazon), antibiotika i magnezijevog sulfata koji su uvijek dostupni u dovoljnim količinama za upravljanje prijevremenim porodima *. (92,15) 4. Zdravstvena ustanova ima funkcionalnu esencijalnu opremu i opremu za otkrivanje komplikacija (npr. termometri, sfingomanometri, fetalni stetoskopi, trakice za urin, pulsni oksimetar) u dovoljnim količinama u svim vremenima u jedinicama predrađaone i rađaona. (91,63) 5. Zdravstvena ustanova ima zalihe prve i druge linije antibiotika za injekcije i druge esencijalne lijekove dostupne u svako doba za tretiranje žena i novorođenčadi s infekcijama tokom ili nakon porođaja i ranog postnatalnog razdoblja. (91,48) 6. Zdravstvena ustanova sadrži esencijalna laboratorijska pomagala i testove (glukoza u krvi, volumen hemoglobina ili volumen stanica, krvna skupina i unakrsno podudaranje, bilirubin, protein urina, puni krvni broj, krvna kultura, elektroliti, testovi funkcije bubrega i jetre, sifilis, brzih dijagnostičkih testova HIV-a i malarije) za podršku upravljanja njegom žena i novorođenčadi. (91,12) 7. Zdravstvena ustanova ima bitne zalihe i opremu koja služi za rad (uključujući krevetiće za bebe, vakuum, pincete, inkubatore, vagu, sterilne rukavice) dostupne u dovoljnim količinama u svakom trenutku u predrađaonama i rađaonama. (90,88) 8. Zdravstveni objekat ima opremu i opremu za hitnu njegu i reanimaciju žena (dobro opskrbljen pokretni krevetac za oživaljavanje, usisni uređaj, impulsni oksimetar, intubacija, laringoskop, endotrahealne cijevi, maske za vrećice za odrasle, setovi za infuziju, intravenozne tekućine) u dovoljnim količinama tokom svih vremena na područjima koja su namijenjena za porod i rađanje i postnatalnu njegu. (89,70) 9. Zdravstvena ustanova ima siguran, neprekinuti izvor kisika i pomagala za porod (maska za disanje i kateteri), uključujući kontinuirani nazalni pozitivni pritisak dišnih puteva koji su uvijek dostupni u području poroda i rađanja i neonatalnom području te operativnoj sali (kada je to dostupno) , (89,37) 10. Zdravstvena ustanova ima opremu i opremu za hitnu njegu i reanimaciju novorođenčadi (stol za oživljavanje, dobro opskrbljen neonatalni resuscitator, grijač, usisni uređaj, impulsni oksimetar, laringoskop) koji su dostupni tokom svih vremena na područjima koja su namijenjena za porod i rađanje i novorođenačke brige. (89.02) 11. Zdravstvena ustanova ima apoteku na licu mjesta i sistem za upravljanje zalihama lijekova i opskrbe kojim upravlja obučeni farmaceut ili dispanzer. (88.44) 12. Zdravstveni objekat ima određeni budžet za esencijalne lijekove, opremu (i njegovo održavanje) i medicinske zalihe za njegu majki i novorođenčadi. (84,94) 13. Zdravstveni objekat ima funkcionalni dijagnostički ultrazvučni stroj i obučeno zdravstveno osoblje koje može provesti osnovni akušerski ultrazvuk radi utvrđivanja broja prisutnih fetusa, gestacijskog doba, prenatalne dijagnoze fetalnih anomalija ili rane dijagnoze placentarne insuficijencije.(84.83) 68 Izlazne mjere/mjere procesa 1. Dostupnost esencijalnih sredstava za spašavanje života (oksitocin, magnezijev sulfat, deksametazon, vitamin K, injektabilni i oralni amoksicilin, benzil penicilin, gentamicin, ceftriakson, metronidazol, antimalarijski lijekovi, antiretrovirusni lijekovi i vakcine protiv tuberkuloze, hepatitis B, poliomijelitis) posljednja tri mjeseca. (88,84) 2. Udio svih žena koje su imale tešku pre-eklampsiju ili eklampsiju u zdravstvenoj ustanovi koji nisu primali punu dozu magnezijevog sulfata zbog nedostatka zaliha. (79,38) 3. Udio svih žena koje su rodile u zdravstvenoj ustanovi koje su kupile rukavice i druge potrebne predmete. (70,62) Mjere ishoda 1. Udio svih prvorotki žena sa jednim plodom sa prednjačećom česti na ≥ 37 tjedana trudnoće koje su podvrgnute carskom rezu tokom spontanog poroda (Robson grupa 1). (82,54) 2. Udio nezadovoljene potrebe za carski rez kao rezultat nedostatka zaliha ili osoblja osposobljenih za provođenje carskog reza. (74,81) Reference korištene za Standard 8 Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Sigurno upravljanje otpadom nakon zdravstvenih djelatnosti. Ženeva: Svjetska zdravstvena organizacija; 2014. (http://www.who.int/ water_sanitation_health / publications / wastemanag / hr /). Saradničko vijeće za vodoopskrbu i sanitarnu zaštitu. WASH ciljevi i pokazatelji nakon 2015.: preporuke međunarodnih konzultacija. Ženeva; 2014. (http://www.wssinfo.org/ fileadmin / user_upload / resources / post-2015-WASH-targets-factheet-12pp.pdf). Svjetska zdravstvena organizacija. Osnovni elementi porodnične njege na razini prvih preporuka. Ženeva; 1991 (http://apps.who.int/iris/bitstream/10665/41740/1/9241544244.pdf). Svjetska zdravstvena organizacija. Osnovni zdravstveni standardi zaštite okoliša u zdravstvu. Ženeva; 2008 (http://www.who.int/water_sanitation_health/hygiene/settings/ehs_health_care.pdf.pdf). Svjetska zdravstvena organizacija. Sistemsko razmišljanje o jačanju zdravstvenih sustava. Ženeva; 2009. (http: // www.who.int/alliance-hpsr/resources/9789241563895/en/). Svjetska zdravstvena organizacija. Vrednovanje opcija za obradu vode u kućanstvu: ciljevi utemeljeni na zdravlju i specifikacije mikrobiološkog učinka. Ženeva; 2011 (http://www.who.int/ water_sanitation_health / publications / household_water / hr /). Svjetska zdravstvena organizacija. Procjena dostupnosti i procjene spremnosti. Ženeva; 2014 (http: // apps who.int/iris/bitstream/10665/149025/1/WHO_HIS_HSI_2014.5_eng.pdf). Svjetska zdravstvena organizacija, UNICEF. Napredak na pitkoj vodi i kanalizaciji: Zajednički nadzorni program ažuriran 2014. Ženeva; 2014. (http://www.who.int/water_sanitation_health/ publications / jmp-report-2014 / hr /). Svjetska zdravstvena organizacija, UNICEF. Voda, sanitacija i higijena u zdravstvenim ustanovama. Status u zemljama s niskim i srednjim dohotkom i put naprijed. Ženeva; 2015 (http://apps.who.int/iris/ bitstream / 10665/154588/1 / 9789241508476_eng.pdf). 69 6. Operacionalizacija Na temelju dokaza, učinkovita, poštivajuća, kvalitetna njega i elementi zdravstvenih sistema koji podržavaju optimalnu njegu za žene i novorođenčad opisani u WHO kvalitetima njege trebaju biti operativni primjenom standarda njege i izjavama o kvaliteti. Standardi se trebaju prilagoditi kontekstu svake zemlje kako bi se osigurali detaljni procesi kliničke njege temeljene na dokazima (standard 1), informacijskim sistemima (2), referalnim sistemima (3) iskustvu njege (4-6), osposobljene, motivirane radne snage (7) i odgovarajućih sredstava (8). Standardi su praćeni izjavama o kvaliteti baziranim na dokazima, koje uključuju mjere ulaza, rezultata i ishoda. To će poboljšati i osigurati visok kvalitet njege za majke i novorođenčad. Ideje za provedbu standarda trebale bi se temeljiti na iskustvima regiona i prilagodljivom učenju unutar i između zemalja. 6.1 Diseminacija Okvir, standardi njege i mjere kvalitete objavljuju se u tehničkom referentnom dokumentu koji se može uključiti u strateške dokumente na nivou države. Oni su dio normativnih alata paketa za podršku poboljšanja kvalitete njege majke i novorođenčeta. Oni će biti prevedeni na arapski, francuski, ruski i španski u saradnji s regionalnim uredima Svjetske zdravstvene organizacije (WHO), za širu cirkulaciju i publikaciju. Publikacija će biti dostupna za preuzimanje s web stranica WHO sjedišta, regionalnih i državnih ureda, WHO saradnički centri i partnerske agencije uključene u kvalitetnu njegu majke i novorođenčeta. Printane kopije publikacija bit će objavljene u svim WHO uredima i bit će raspoložive za prodaju od WHO knjižare i njegove distribucijske mreže svim medicinskim bibliotekama i pojedincima. 6.2 Pristup implementacije Kako bi se povećala dostupnost i korištenje standarda njege i mjera kvalitete, radionice usmjeravanja i izgradnje kapaciteta provodit će se u svim regijama WHO-a u saradnji s regionalnim uredima. Ciljana podrška bit će osigurana zemljama, a platforma za učenje će se stvoriti za razmjenu najboljih praksi unutar i među zemljama inovativnim pristupom (Slika 3), što je prilagođen model "Planiraj Uradi Uči Akta" (22) na bazi dokaza, najbolje prakse i iskustva. On pruža plan za kontinuirano poboljšanje kvalitete postavljanjem ciljeva i izgradnjom timova za postizanje željenih ishoda korištenjem promjena paketa (individualne, višeslojne ili složene intervencije, ovisno o kontekstu i potrebama), izgradnji kapaciteta i druge strategije kako bi se povećale šanse za održavanje provedbe. 70 Slika. 3. Pristup implementaciji Osim toga, pružit će se detaljne smjernice za uspostavu sistema za poboljšanje kvaliteta zdravlja majki i novorođenih beba unutar nacionalne kvalitete strategije njege i operativnog plana. Smjernice će biti popraćene potrebnim alatima i ciljanom izgradnjom kapaciteta za snažno vodstvo u zemlji. 71 7. Monitoring i evaluacija Provedba ovih standarda bit će praćena unutarnjim i vanjskim planom praćenja i evaluacije. Unutarnji nadzor i evaluacija bit će integrisani u smjernice te povezani s rezultatima platforme za učenje. Vanjski nadzor i evaluacija provodit će se za različite metode, izvore i nacrte istraživanja kako bi pružili učinkovitost (pragmatični i kvazi- eksperimentalni projekti), proces (kvantitativni i kvalitativni projekti) i ekonomsku učinkovitost. Rezultati unutarnjeg i vanjskog praćenja i evaluacije koristit će se za poboljšanje smjernica provedbe i platforme za učenje. 72 8. Ažuriranje standarda Najbolje prakse koje su prijavljene na platformi za učenje i procjeni provedbe će se prikupiti kako bi se, prema potrebi, pregledali i ažurirali standardi njege i mjera kvalitete. 73 Reference 1. Raven JH, Tolhurst RJ, Tang S, van den Broek N. Kakva je kvaliteta u majčinoj i neonatalnoj zdravstvenoj zaštiti? Primalja 2012; 28: e676-e683. 2. Tuncalp Ö, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R i sar., Kvaliteta brige za trudnice i novorođenčad - SZO vizija. Br J Obstet Gynaecol 2015 122: 1045-1049. 3. Svjetska zdravstvena organizacija. 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Okvir za ocjenu kvalitete njege u porodničkim službama. Southampton: Sveučilište u Southamptonu; 2000. 22. Međunarodna organizacija za standardizaciju. Ženeva (http://www.iso.org/iso/home/ standards.htm do 24. lipnja 2016.) 23. Zajednička komisija. Oakbrook Terrace, Illinois http://www.jointcommission.org/ standards_information / jcfaq.aspx pristupilo se 24. lipnja 2016. godine. 24. Vijeće za akreditaciju zdravstvene službe Južne Afrike (COHSASA). Pretoria (http://www.cohsasa.co.za/ pristupiti 24. lipnja 2016.). 25. Nacionalni institut za zdravlje i izvrsnost u njezi. London (https://www.nice.org.uk/ standardi i pokazatelji kojima se pristupa 24. lipnja 2016.). 26. Pharmaccess grupa. Osnovni zdravstveni standardi za sigurnu njegu. Haag (http: //www.safe- care.org/index.php?page=safecare-standards pristupiti 24. l ipnja 2016). 27. Svjetska zdravstvena organizacija. Standardi za majčinsku i neonatalnu njegu. Skupina 1: Opći standardi njege za zdravu trudnoću i porođaj. Ženeva; 2007 (http: //www.who.int/ reproductivehealth / publications / maternal_perinatal_health / a91272 / hr /) 75 Aneks 1. Učesnici sastanka grupe za razvoj smjernica Ženeva, 3–4 juni 2015 Dr Pierre Barker, Institut za razvoj zdravstvene njege, Cambridge, Massachusetts, USA Mrs Sheena Currie, Integrativni program majčinog i novorođenačkog zdravlja, Agencija za Internacionalni razvoj Sjedinjenih Američkih država, Washington DC, USA Dr Kim Dickson, UNICEF, New York City (NY), USA Ms Claudia Hanson, Karolinska Institute, Stockholm, Sweden Dr Kathleen Hill, JHPIEGO, Washington DC, USA Dr Asia Kassim Hussein, UNICEF, Dar-es- Salaam, Ujedinjena republika Tanzanije Dr Theopista John, WHO državni ured, Dar- es-Salaam, Ujedinjena republika Tanzanije Dr Lily Kak, Globalna partnerstva i novorođenačko zdravlje, Washington DC, USA Dr Senait Kebede, Emory University, Atlanta, Georgia, USA Profesor Joy Lawn, Londonska škola higijene i tropske medicine London, United Kingdom Dr Tess Lawrie, Konsultantska kuća za medicinu zasnovanu na dokazima, Bath, Ujedinjeno kraljevstvo Mr Norman Lufesi, Ministarstvo zdravlja, Lilongwe,Malawi Dr Carolyn Maclennan, Alice Springs Bolnica, Alice Springs, NT, Australija Dr Silke Mader, Evropska fondacija za njegu novorođenčadi, Minhen, Njemačka Dr Md. Ziaul Matin, UNICEF, Daka, Bangladeš Dr Goldy Mazia, Program preživljenja za majku i dijete, PATH, Seattle, Washington, SAD Dr Georgina Msemo, Ministarstvo zdravlja i socijalnog blagostanja, Dar-es-Salaam, Ujedinjena republika Tanzanije Dr Jim Neilson, Profesor ginekologije i akušerstva, Universitet Liverpool, Ujedinjeno Kraljevstvo Mr Lee Pyne-Mercier, Bill & Melinda Gates Fondacija, Seattle, Washington, SAD Dr Isabella Sagoe-Moses, Ministarstvo zdravlja, Accra, Ghana Dr Memuna Tanko, VD, Procjena kvalitete, Autoritet nacionalnog zdravstvenog osiguranja, Akra, Gana Profesor Nynke van den Broek, Centar za majčino i novorođenačko zdravlje, Liverpool škola tropske medicine, Ujedinjeno Kraljevstvo Ms Donna Vivio, Stariji savjetnik za novorođenačko zdravlje, Agencija za Internacionalni razvoj Sjedinjenih Američkih država, Washington DC, USA Dr Nabila Zaka, Stariji savjetnik za zdravlje, UNICEF, Ženeva, Švicarska 76 Aneks 2. Spisak učesnika u Delphi studiji Joel Adze, Kaduna Državni Univerzitet, Kaduna, Nigerija Anna Afugglas, UNFP, Pnom Pen, Kambodža Dr Elnahas Amir, Medicinski i istraživački centar Sidra, Doha, Katar Profesor Surasak Angsuwathana, Medicinski fakultet, Mahidol Univerzitet, Bangkok, Tajland Sir Sabaratnam Arulkumaran, FIGO, London, Ujedinjeno Kraljevstvo Dr Deorari Ashok, All-India institut medicinskih nauka, New Delhi, Indija Ms Joanne Ashton, Joint Commission International, Oakbrook Terrace, Illinois, SAD Profesor Nabhan Ashraf, Ain Shams Univerzitet, Kairo, Egipat Dr Alberta Bacci, Nezavisni konsultant, Lisabon, Portugal Dr Solange Balaga, , Nezavisni konsultant, Kinšasa, Demokratska repulbika Kongo Dr Cyprien Baribwira, Maryland Global Initiative Corporation (MGIC), Kigali, Ruanda Dr Suppawat Boonkasidecha, Queen Sirikit Nacionalni institut za zdravlje djece, Bangkok Tajland Dr Betzabe Butron, WHO Regional Office for the Americas, Vašington DC, SAD Dr Romano Byaruhanga, Kampala Medical Chambers Hospital, Kampala, Uganda Ms Anna Coates, WHO Regional Office for the Americas, Vašington DC, SAD Dr Jeanine Umutesi Condo, Univerzitet Ruanda, Koledž za medicinu i zdravstvene studije, Kigali,Ruanda Dr Dilberth Cordero, WHO Country Office, Tegucigalpa, Honduras Ms Sheena Currie, JHIEGO and Maternal and Child Health Integrated Program, United States Agency for International Development, Vašington DC, SAD Dr Louise Day, LAMB Integrated Rural Health and Development, Daka, Bangladeš Profesor Soo Downe, Istraživanje u porodu i zdravstvena grupa, London, Ujedinjeno Kraljevstvo Atf Gherissi, El Manar University, Tunis, Tunis Profesor Michael English, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenija Profesor Jan Jaap Erwich, Groningen Univerzitet, Groningen, Holandija Profesor Vicki Flenady, Queensland Univerzitet, Herston, Australija Mr Fabrice Fotso, UNICEF West and Central Africa Regional Office, Dakar, Senegal Dr Sabine Gabrysch, Heidelberg Univerzitet, Heidelberg, Njemačka Dr Karima Gholzbhouri, WHO Regional Office for the Eastern Mediterranean, Kairo, Egipat Dr Gathari Gichuhi, Ministry of Health, Nairobi,Kenija Dr Aparajita Gogoi, Whiteribbon Alliance, New Delhi, Indija Dr Rogelio Gonzalez, Centar za perinatalnu dijagnozu, Katolički Univerzitet Čile, Santiago, Čile 77 Profesor Malik Goone wardene, Medicinski fakultet, Univerzitet Ruhuna, Šri Lanka Ms Ana Guerreiro,nezavisni konsultant, Lisabon,Portugal Privat Guie, Polyclinic Internationale sainte Anne Marie, Abiđan, Obala Slonovače Ms Gill Gyte, University of Liverpool, Liverpool Women’s NHS Foundation Trust, Liverpool, Ujedinjeno Kraljevstvo Ms Fransisca Handy, Apotek Puri Satu Kembangan, Džakarta, Indonezija Ms Claudia Hanson, Karolinska Institute, Štokholm, Švedska Dr Jim Heiby, United States Agency for International Development, Vašington DC, SAD Dr Jorge Hermida, Assist/University Research Co., Kvito, Ekvador Dr Kathleen Hill, United States Agency for International Development, ASSIST Project, Vašington, DC, SAD Dr Stephen Hodgins, Save the Children, Vašington DC, SAD Dr Caroline Homer, Tehnološki univerzitet, Sidnej, Australija Ms Petra Hoope-Bender, Instituto de Cooperación Social – Integrare, Barcelona, Španija Dr Grace Irimu, Kenyatta University, Nairobi, Kenija Ms Rima Jolivet, White Ribbon Alliance for Safe Motherhood, Vašington, DC, SAD Dr Theopista Kabuteni-John, WHO Country Office, Dar es Selam, Ujedinjenja republika Tanzanija, Dr Lily Kak, United States Agency for International Development, Vašington DC, SAD Dr Ariel Karolinski, WHO Country Office, Buenos Aires, Argentina Professor Holly Kennedy, Yale University, Boston (MA), SAD Dr Neena Khadka, Maternal and Child Survival Program, Vašington DC, SAD Prof Zulfiya Khodjaeva, Federalni istraživački centar za ginekologiju, akušerstvo i perinatologiju, Moskva, Ruska Federacija Dr Tamar Khomasuridze, United Nations Population Fund, European Regional Office, Ankara, Turska Dr Andre Lalonde, The Society of Obstetricians and Gynaecologists of Canada (SOGC), Otava, Kanada Dr Marzia Lazzerin, Institut za zdravlje majke i djeteta, IRCCS Burlo Garofolo, Italija Dr Li Wenying, Aviation General Hospital of China Medical University, Peking, Kina Dr Jerker Liljestrand, Bill and Melinda Gates Foundation, Seattle, SAD Dr Liu Cheng, Beijing Armed Police Corps Hospital, Peking, Kina Dr Nigel Livesley, University Research Co., Bethesda, SAD Mr Norman Lufesi, ARI/Community Health Service, Ministry of Health, Lilongwe, Malavi Ms Silke Mader, Evropska fondacija za njegu novorođenčadi, Minhen, Njemačka Dr Kuhu Maitra, Abt Associates, Cambridge (MA), SAD Prof Zoe Matthews, Southampton Univerzitet, Southampton, Ujedinjeno Kraljevstvo Dr Goldy Mazia, PATH, Seattle (WA), SAD Dr Alison McFadden, University of Liverpool, Liverpool, Ujedinjeno Kraljevstvo Ms Alison Mcintyre, WaterAid, East Melbourne, Australija 78 Prof Tarek Meguid, Mnazi Mmoja Bolnica, Zanzibar, Ujedinjena republika Tanzanija Dr Tanko Memuna, National Health Insurance Authority, Akra, Gana Dr Abraham Mengistu, Ministarstvo Zdravstva, Adis Abeba, Etiopija Dr Raul Mercer, Universidad Nacional de La Plata, Buenos Aires, Argentina Dr Allisyn Moran, United States Agency for International Development, Vašington DC, SAD Dr Rintaro Mori, Nacionalni centar za zdravlje i razvoj djeteta, Tokijo, Japan Dr Georgina Msemo, Ministarstvo zdravstva, Dar-es-Salaam, Ujedinjena republika Tanzanija Dr Bremen de Mucio, WHO Country Office, Montevideo, Urugvaj Dr Christine Muzel, Philips Healthcare, Amsterdam, Holandija Dr Victoria Nakibuka, Nsambya Bolnica, Kampala, Uganda Dr James Neilson, Liverpool univerzitet, Liverpool, Ujedinjeno Kraljevstvo Dr Hiromi Obara, Bureau of International Medical Cooperation, Tokijo, Japan Dr Dwiana Ocviyanti, Medicinski fakultet, Univerzitet Indonezija, Džakarta, Indonezija Dr Jeanne Odette, Université du Burundi, Bujumbura, Burundi Prof Pius Okong, Health Service Commission, Kampala, Uganda Dr Eduardo Ortiz-Panozo, Centro de Investigaciones Regionales, Mérida, Meksiko Prof Ouadraogo Charlemagne, Centre Hospitalier Universitaire Yalgado, Ouagdougou, Burkina Faso Dr Duran Pablo, WHO Country Office, Montevideo, Urugvaj Dr Imran Pambudi, Ministarstvo zdravstva Indonezija, Džakarta, Indonezija Dr Robert Pattinson, Maternal and Infant Health Care, South Africa Medical Research Council, Kalafong Hospital, Pretoria, Južna Afrika Dr Loveday Penn-Kekana, University of the Witwatersrand, Johannesburg, Južna Afrika Dr Emily Peterson, Centers for Disease Control and Prevention, Atlanta (GA), SAD Dr Cynthia Pileggi, Ribeiro Preto Medical School, University of São Paulo, São Paulo, Brazil Dr Neil Prose, Duke University, Durham (NC), SAD Ms Pamela Putney, Options Consultancy Services Limited, London, Ujedinjeno Kraljevstvo Dr Neena Raina, WHO Regional Office for South-East Asia, New Delhi, Indija Prof Kathryn Ramsey, Columbia University Medical Center, New York, SAD Prof Mary Renfrew, Scottish Improvement Science Collaborating Centre, Dundee, Ujedinjeno Kraljevstvo Dr Alexander Rowe, Centers for Disease Control and Prevention, Atlanta (GA), SAD Prof Irina Ryumina, Research Centre for Obstetrics, Gynaecology and Perinatology, Moskva, Ruska federacija Dr Harshad Sanghvi, JHPIEGO, Baltimore, MD, SAD Prof Ola Saugstad, Univerzitet Oslo, Oslo, Norveška Dr Kerri Schuiling, International Confederation of Midwives, Rochester (MI), SAD Ms Gloria Seguranyes, University of Barcelona, Barcelona, Španija Ms Priti Dave Sen, Children’s Investment Foundation, London, Ujedinjeno raljevstvo 79 Dr Hemantha Senanayake, Medicinski fakultet, Univerzitet Kolombo, Kolombo, Šri Lanka Prof Shi Qi, North Sichuan Medical College, Obstetrics and Gynaecology, Nanchong, Kina Dr Miannes Silvestre, Univerzitet Filipini, Medicinski koledž, Manila, Filipini Dr Jeffrey Smith, JHPIEGO, Baltimore, MD, SAD Dr Howard Sobel, WHO regionalni ured za zapadni pacifik, Manila, Filipini Prof Williams Stones, FIGO, London, Ujedinjeno Kraljevstvo Dr Tang Zengjun, Hebei Provincial People’s Hospital, Shijiazhuang, Kina Ms Nicole Thiele, Evropska fondacija za njegu novorođenčadi, Minhen, Njemačka Dr Paul Vinod, All-India Institute for Medical Sciences, New Delhi, Indija Ms Donna Vivio, United States Agency for International Development, Vašington DC, SAD Dr Gijs Walraven, Aga Khan Development Network, Pariz, Francuska Dr Wang Yeping, Wenzhou City People’s Hospital, Wenzhou, Kina Dr Martin Weber, WHO Regionalni ured za Evropu,Kopenhagen, Danska Prof Zhang Hongyu, Hainan Medical, Haikou, Kina Dr Zhang Jim, Shanghai Jiao Tong University School of Medicine, Šanghaj, Kina Dr Zhou Wei, Chongqing medical university, Chongqing, Kina Dr Nabila Zaka, UNICEF Headquarters, New York, SAD Professor Zhang Huixin, Fourth Hospital of HebeiMedical University, Shijiazhuang, Kina