title: The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'.
abstract: BACKGROUND
  A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example.
  
  
  METHODS
  We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi.
  
  
  RESULTS
  Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks.
  
  
  CONCLUSIONS
  The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.
authors: Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany.
authors: Stephan
authors: S
authors: Brenner
authors: Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany.
authors: Manuela
authors: M
authors: De Allegri
authors: Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany.
authors: Sabine
authors: S
authors: Gabrysch
authors: Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi.
authors: Jobiba
authors: J
authors: Chinkhumba
authors: Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany.
authors: Malabika
authors: M
authors: Sarker
authors: Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi.
authors: Adamson S
authors: AS
authors: Muula
mesh_terms: D000328:Adult; D003141:Communicable Diseases / Q000175:diagnosis / Q000628:therapy; D036861:Delivery, Obstetric; D003906:Developing Countries; D004632:Emergency Medical Services / Q000191:economics / Q000458:organization & administration; D005260:Female; D006268:Health Facilities / Q000191:economics; D006801:Humans; D007231:Infant, Newborn; D008295:Malawi; D018743:Perinatal Care / Q000706:statistics & numerical data*; D006473:Postpartum Hemorrhage / Q000175:diagnosis / Q000628:therapy; D049590:Postpartum Period / Q000502:physiology; D011225:Pre-Eclampsia / Q000175:diagnosis / Q000628:therapy; D011247:Pregnancy; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012307:Risk Factors; D000078329:Workforce