Defining Quality of Care and Its Importance

The progress made over the last decade to reduce maternal mortality has stagnated and, in many countries, even reversed. This shocking reality has put a much-needed spotlight on the quality of care women receive.¹ Access to services and the provision of good clinical care are no longer enough. The World Health Organization (WHO) defines quality of care as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes.”² To achieve this, health care must be safe, effective, timely, efficient, equitable, and people centered. How women experience care is essential to quality. The provision of quality care can mean the difference between life and death;  increasing evidence links quality of care to the prevention of mortality, morbidity, and disability. The Lancet Commission on High Quality Health Systems reports that high quality health systems alone could prevent half of all maternal and newborn deaths.³ Additionally, quality health services are necessary for achieving the Sustainable Development Goals (SDGs) related to health including Universal Health Coverage, gender equality, and poverty reduction.²

Reproductive, maternal, and newborn child health (RMNCH) services particularly rely on high quality of care to prevent and manage conditions in late pregnancy, childbirth, and the early newborn period. Services that consider the clients’ experience of care encourage utilization of services and contribute significantly to a reduction in maternal deaths, stillbirths, and early neonatal deaths.² Utilization of reproductive health services such as family planning also contributes significantly to maternal and child well-being.

Dimensions of Quality of Care in RMNCH

WHO’s framework for the quality of maternal and newborn health care lays out eight domains for assessing quality of care²:

Domains addressing provision of care:

• Evidence-based practices for routine care and management of complications.
• Actionable information systems.
• Functional referral systems.

Domains addressing experience of care:

• Effective communication.
• Respect and preservation of dignity.
• Emotional support.

Cross-cutting:

• Competent motivated human resources.
• Essential physical resources.

Including client experience of care elevates it to the same level as clinical care as a core component of quality of care.

Client Experience of Care as a Component of Quality of Care

A woman’s experience of care is a key component of quality of care, as it captures factors such as how providers and staff communicate with her, whether or not they treat her with respect and empathy, if they allow her a support person throughout labor and delivery, and whether or not she is involved in decision making. Given how much a woman’s experience of care can impact overall levels of quality, addressing morbidity and mortality holistically in RMNCH requires not just best practices in clinical care, but also ensuring that clients’ basic human rights are protected.⁴

Health Worker Behavior as a Determinant of Client Experience of Care

Health worker behavior can be defined as what health workers do and do not do in their professional capacity. It includes behavior before, during, or after an interaction with a client in a health facility. Health worker behavior is a key determinant of client experience, as it influences how clients perceive and interact with the health system. Health worker behavior affects client experience of care either positively or negatively, depending on the degrees of professionalism, competence, courtesy, and compassion displayed by the health worker.²

Health workers’ individual characteristics and preferences influence their behavior, as do the working environment and conditions of the health system. These factors can include motivation, incentives, attitudes, workload, client behavior, supervision, community and workplace norms, policies, training, feedback, and organizational culture. Changing health worker behavior requires a comprehensive and multi-level approach that addresses both individual and systemic factors.²

Respectful Care in the Context of Maternal and Child Health Services

The interactions between a woman and a health worker during childbirth, particularly how respectfully the provider treats the client, dramatically affect how women view their experience of care. Respectful maternity care maintains the dignity, privacy, and confidentiality of pregnant and birthing women, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and birth.⁵ The ability to provide women with respectful maternity care has significant consequences for their health outcomes and their future health care-seeking behaviors. Unfortunately, many women experience mistreatment, rather than respect. Mistreatment has been defined to include physical, verbal, or psychological abuse, discrimination, neglect, coercion, or denial of care.⁶ Mistreatment can lead to dissatisfaction, distrust, trauma, and avoidance of care. Addressing experience of care requires both promoting respectful care and preventing mistreatment.

The emphasis on respectful maternity care in the last few years has expanded to include the newborn. In 2019 the White Ribbon Alliance included the newborn in the Respctful Maternity Care Charter to acknowledge that newborns themselves have rights to respectful care, and how they are treated matters. Including newborns in assessing respectful care also helps elevate the mother/baby dyad in provider priorities, as the well-being of mothers and their newborns are deeply interconnected. As such, providers need to give care with respect for and the best interests of both mother and newborn in mind.⁴

Respectful Care in the Context of Sexual and Reproductive Health Services

Respectful care is especially relevant to sexual and reproductive health services, given their sensitive and personal nature. Privacy and confidentiality enable trusting, respectful interactions with the health system and health workers. The respectful care components needed include equitable and compassionate care, regardless of parity, marital status, age, or socio-economic status, as well as showing respect for client preferences, autonomy, and culture. Using family planning as an example, respectful care entails empowering and supporting clients to make informed choices about their contraceptive use without coercion and in keeping with their preferences, beliefs, and culture.⁷

Challenges and Barriers to Quality of Care

Quality of care in RMNCH faces several challenges including the fact that many quality improvement initiatives have not sufficiently focused on the systems, whereas quality of care is really a product of the system. Many initiatives only focus on individuals (especially on health workers) but less so on improving the system and structures around them that might enable quality care. Recent trends show promising shifts toward more systemic approaches. Some other challenges are highlighted below.

• Limited access to necessary resources: Many health systems lack the necessary human, financial, and material resources to provide adequate and quality care. This can result in shortages, stock-outs, delays, and inefficiencies that compromise the access, availability, and utilization of health services.
• Inadequate evidence base: While a wealth of information is available on certain issues, information on other health areas is hugely lacking. Additionally, many health systems lack the capacity and mechanisms to generate, synthesize, and use evidence to inform and improve the quality of care.
• Weak accountability systems: Many health systems struggle to coordinate structures and processes that ensure the accountability and transparency of the health system. This can result in poor governance, weak regulation, and low responsiveness to the needs and feedback of the population.
• Need for more awareness of rights and responsibilities: Many health systems lack the strategies and channels to raise the awareness and knowledge of the population and the health workforce about the quality of care. This can result in low demand, expectations, and participation in the improvement of quality of care.
• Lack of an enabling environment for behavior change: Many health systems lack the interventions and incentives to change the behaviors and norms of both the population and the health workforce. This affects the quality of care, resulting in low adherence, compliance, and performance in the provision and utilization of health services.

SBC and Quality of Care

Social and behavior change (SBC) is an evidence-driven approach to improve and sustain changes in individual behaviors, social norms, and the enabling environment. SBC programs follow a systematic process (e.g., the P Process or SBC Flow Chart) to design and implement interventions at the individual, community, and societal levels that support the adoption of healthy practices.⁸

SBC is key to addressing normative, attitudinal, structural, and other influences on care quality. SBC can be applied at different levels of the health system, such as individual, interpersonal, community, organizational, and policy levels, and across the continuum of care, from pre-pregnancy to postnatal and child health.⁹ Implementing programs can also integrate SBC with other interventions and strategies, such as quality improvement and human-centered design, to enhance the effectiveness and sustainability of quality of care in RMNCH.

Sample SBC Approaches, Strategies SBC can change behaviors, norms, and structures relevant to quality of care
Human-centered design Audience analysis Community engagement Social accountability Counseling cues and supports Interpersonal communication training Advocacy Provider behavior change Games and apps Outreach and education	Client empowerment Site walk-throughs Peer navigators Service branding Client flow improvements Quality medicines Mentorship Empathy, compassion building Mass media

SBC can address challenges and barriers to quality of care in RMNCH in the following ways:

• Increasing resources: SBC approaches can help stakeholders mobilize and allocate resources for improving quality of care by advocating for increased funding, improving supply chain management, and enhancing efficiency and effectiveness of health services.
• Increasing evidence: SBC approaches can generate evidence through processes such as audience analysis and human-centered design. Practitioners can then use the evidence in people-centered decision making processes and quality improvement initiatives.
• Increasing accountability: SBC can ensure the accountability and transparency of the health system, by promoting governance, leadership, regulation, and participation in the improvement of quality of care.
• Increasing awareness: SBC practitioners can raise the awareness and knowledge of the population and the health workforce about the quality of care, through social marketing and mass media campaigns, community engagement, outreach, and client education. Through this, clients and communities are empowered to demand high quality care, and health workers are supported to meet this demand.
• Increasing behavior change: SBC approaches help change the behaviors and norms of the population and the health workforce that affect the quality of care, through client empowerment, provider behavior change, community engagement, advocating for legal/policy/protocol changes, normative initiatives, service branding, and creating supportive and enabling environments.

This trending topic brings together a curated collection of resources to aid understanding of the role of SBC in quality and experience of care for RMNCH services. If you have related materials you would like to share with us, please upload the items, or contact us at info@thecompassforsbc.org.

Contributors
Shanon McNab – MOMENTUM Country and Global Leadership Heather Hancock – Johns Hopkins Center for Communication Programs Oluwakemi Akagwu – Johns Hopkins Center for Communication Programs

References

1. van den Akker, T., D’Souza, R., Tura, A. K., Nair, M., Engjom, H., Knight, M., Donati, S., & International Network of Obstetric Survey Systems (2024). Prioritising actions to address stagnating maternal mortality rates globally. Lancet, 403(10425), 417–419. https://doi.org/10.1016/S0140-6736(23)02290-0
2. World Health Organization. (2018). Standards for improving quality of maternal and newborn care in health facilities. https://www.who.int/publications/i/item/9789241511216
3. Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., … Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3
4. White Ribbon Alliance. (2020). The Respectful Maternity Care Charter: The universal rights for women and newborns. https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf
5. World Health Organization. (2014). The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO statement. https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf
6. Bohren, M. A., Hunter, E. C., Munthe-Kaas, H. M.,  Souza, J. P., Vogel, J. P., & Gülmezoglu, M. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: A qualitative evidence synthesis. Reproductive Health 11, 71. https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-11-71
7. Harris, S., Reichenbach, L., Hardee K. (2016). Measuring and monitoring quality of care in family planning: are we ignoring negative experiences? Open Access Journal of Contraception. 7:97–108. https://doi.org/10.2147/OAJC.S101281
8. High Impact Practices in Family Planning (HIP). (2022). SBC Overview: Integrated Framework for Effective Implementation of the Social and Behavior Change High Impact Practices in Family Planning. https://www.fphighimpactpractices.org/briefs/sbc-overview/
9. Carlson, O. & Hancock, H. (2020). From vision to action: Guidance for implementing the Circle of Care Model. Breakthrough ACTION; Johns Hopkins Center for Communication Programs. https://breakthroughactionandresearch.org/wp-content/uploads/2021/01/From-Vision-to-Action.pdf