Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study
Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study
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DOI：
10.1371/journal.pmed.1002990
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发表时间：
2019-12-01
期刊：
影响因子：
15.8
通讯作者：
Kanyangarara, Mufaro
中科院分区：
文献类型：
--
作者：
Chou, Victoria B.;Walker, Neff;Kanyangarara, Mufaro
作者摘要 为什么要做这项研究？在低收入和中等收入国家，卫生系统努力为有需要的孕妇及其新生儿提供高质量的医疗服务。提供关键的卫生干预措施对于在高负担环境中拯救生命并预防发病率和死亡率至关重要。人们对现有的或较差的护理质量对人口水平的影响知之甚少，而量化提高那些已经寻求或获得护理的人的质量的好处将是确定优先顺序的关键的第一步。研究人员做了什么并发现了什么？为了研究护理质量改善的全球影响，我们使用了一种链接方法，该方法结合了卫生设施和人口水平的调查数据来估计重要循证干预措施子集的基线。通过将目前报告的利用率水平设定为 2020 年具体国家的最终目标，对 81 个国家的干预覆盖率趋势进行了建模。如果寻求医疗救助的人到达资源充足的重新设计的设施并接受高质量的护理，我们的系统统计表明，如果护理质量的差距得到消除，2016 年至 2020 年期间，近四分之一的孕产妇死亡、新生儿死亡和死产是可以预防的。这些发现意味着什么？各国和当前的卫生系统还远远不能确保拥有充足供应的熟练提供者能够为现有有需要的人群提供及时和适当的医疗保健。我们对潜在收益的分析量化了这些错失机会的后果，范围从产前到产后。提高护理质量是一个重要的检查点，因为提高利用率的努力将依赖于弱势群体目前获得护理的相同卫生系统。随着更多的注意力集中在跟踪国家一级的进展上，有望获得更多数据来有效监测关键孕产妇和新生儿干预措施覆盖范围的变化。随着这些参数或输入得到更好的定义，建模可以通过提供一种知情方法来检查护理质量差距，从而制定更好的策略来改善寻求护理的母亲及其子女的健康，从而为知识体系做出贡献。 背景 在疾病负担仍然很高、许多卫生机构缺乏药品或商品、功能设备和训练有素的人员等必需品的资源匮乏环境中，往往会导致护理质量差，而且影响可能是深远的。在本文中，我们利用有关产前、分娩和产后护理干预措施的国家级数据，系统地量化了解决全球护理质量问题的潜在收益。方法和结果 在这项研究中，我们创建了确定性模型来预测如果在 81 个低收入和中等收入国家 (LMIC) 的代表性样本中解决护理质量问题的话，其健康结果。首先，将 2007-2016 年进行的卫生机构调查（例如，服务提供评估 [SPA] 和服务可用性和准备情况评估 [SARA]）中的可用数据与家庭调查（例如，人口统计和健康调查 [DHS] 和多指标类集调查 [MICS]）联系起来，以估计 19 项孕产妇和新生儿健康干预措施核心子集的基线覆盖率。接下来，使用挽救生命工具 (LiST) 构建模型，使用具有关联数据集的国家 (n = 17) 的国家特定基线水平，并在没有关联数据的国家中应用样本中位数作为代理。最后，根据最新的 DHS 或 MICS 基于人口的报告，根据具体国家的利用率（例如，参加 4 次以上产前检查的妇女比例、在医疗机构分娩的百分比），提高了 2016 年起始基线水平，以在 2020 年达到终点目标。我们的研究结果表明，如果高质量的卫生系统能够有效地向已经寻求护理的母亲及其新生儿提供这一循证干预措施，与护理质量没有任何改变或改善的情况相比，孕产妇死亡率估计会减少 28%，新生儿死亡率会减少 28%，死产率会减少 22%。如果按照目前的利用水平提供足够的优质护理，到 2020 年，81 个国家总共可挽救 86,000 名（范围，77,800-92,400）名孕产妇和 67 万（范围，59 万-75 万）新生儿生命，并可预防 52 万（范围，48 万-55 万）死产。局限性包括缺乏数据来单独评估所有中低收入国家每项干预措施的护理质量，以及必要的假设，即具有关联数据集的部分国家提供的护理质量与中低收入国家整体具有可比性或具有代表性。结论 我们的研究结果表明，在当前的获取或利用水平上，缩小质量差距的努力仍将产生巨大的效益。估计死亡率平均下降 21%-32%，如果提高选定的产前、产时和产后干预措施的质量，使寻求护理的孕妇和新生儿受益，那么第一步的收益将是显着的。在分娩时或分娩前后提供的干预措施最为关键，占本质量改进分析中估计总体影响的 64%。
Author summaryWhy was this study done? In low- and middle-income countries, health systems struggle to provide high-quality medical care to pregnant women and their newborns in need. Delivery of key health interventions is critical to save lives and prevent morbidity and mortality in high-burden settings. The impact of extant or poor quality of care at a population level is poorly understood, and quantifying the benefits of improving quality among those already seeking or accessing care would be a critical first step for prioritization. What did the researchers do and find? To examine the global impact of improvement in the quality of care, we used a linking approach, which combines health facility and population-level survey data to estimate baseline for a subset of important evidence-based interventions. Intervention coverage trends were modeled in 81 countries by setting current levels of reported utilization as the final country-specific targets for 2020. If those seeking medical attention arrived at facilities reimagined with adequate resources and receive high-quality care, our systematic tally indicates that almost one quarter of the maternal deaths, neonatal deaths, and stillbirths would be preventable during the period 2016-2020 if the gaps in quality of care were eliminated. What do these findings mean? Countries and current health systems are far from ensuring that skilled providers with adequate supplies are providing timely and appropriate healthcare to existing populations in need. Our analysis of potential gains quantifies the consequences of these missed opportunities, ranging from the prenatal to postnatal periods. Bolstering the quality of care is an essential checkpoint because efforts to increase utilization will rely on the same health systems where vulnerable populations are presently accessing care. With greater attention focused on tracking country-level progress, more data will hopefully become available to effectively monitor changes in coverage for key maternal and neonatal interventions. As these parameters or inputs are better defined, modeling can contribute to the body of knowledge by offering an informed approach to examine quality of care gaps so that better strategies can be developed to improve health among mothers and their children seeking care in this context.Background In low-resource settings where disease burdens remain high and many health facilities lack essentials such as drugs or commodities, functional equipment, and trained personnel, poor quality of care often results and the impact can be profound. In this paper, we systematically quantify the potential gain of addressing quality of care globally using country-level data about antenatal, childbirth, and postnatal care interventions. Methods and findings In this study, we created deterministic models to project health outcomes if quality of care was addressed in a representative sample of 81 low- and middle-income countries (LMICs). First, available data from health facility surveys (e.g., Service Provision Assessment [SPA] and Service Availability and Readiness Assessment [SARA]) conducted 2007-2016 were linked to household surveys (e.g., Demographic and Health Surveys [DHS] and Multiple Indicator Cluster Surveys [MICS]) to estimate baseline coverage for a core subset of 19 maternal and newborn health interventions. Next, models were constructed with the Lives Saved Tool (LiST) using country-specific baseline levels in countries with a linked dataset (n = 17) and sample medians applied as a proxy in countries without linked data. Lastly, these 2016 starting baseline levels were raised to reach targets in 2020 as endline based upon country-specific utilization (e.g., proportion of women who attended 4+ antenatal visits, percentage of births delivered in a health facility) from the latest DHS or MICS population-based reports. Our findings indicate that if high-quality health systems could effectively deliver this subset of evidence-based interventions to mothers and their newborns who are already seeking care, there would be an estimated 28% decrease in maternal deaths, 28% decrease in neonatal deaths, and 22% fewer stillbirths compared to a scenario without any change or improvement in quality of care. Totals of 86,000 (range, 77,800-92,400) maternal and 0.67 million (range, 0.59 million-0.75 million) neonatal lives could be saved, and 0.52 million (range, 0.48 million-0.55 million) stillbirths could be prevented across the 81 countries in the calendar year 2020 when adequate quality care is provided at current levels of utilization. Limitations include the paucity of data to individually assess quality of care for each intervention in all LMICs and the necessary assumption that quality of care being provided among the subset of countries with linked datasets is comparable or representative of LMICs overall. Conclusions Our findings suggest that efforts to close the quality gap would still produce substantial benefits at current levels of access or utilization. With estimated mortality rate declines of 21%-32% on average, gains from this first step would be significant if quality was improved for selected antenatal, intrapartum, and postnatal interventions to benefit pregnant women and newborns seeking care. Interventions provided at or around the time of childbirth are most critical and accounted for 64% of the impact overall estimated in this quality improvement analysis.