WHO recommendation on community participation in quality-improvement processes

Two speakers in a community radio studio discussing maternal health

WHO recommendation on community participation in quality-improvement processes

 

Recommendation

Community participation in quality-improvement processes for maternity care services is recommended to improve quality of care from women's, communities' and health care providers' perspectives.

Communities should be involved in jointly defining and assessing quality. Mechanisms that ensure women's voices are meaningfully included are also recommended.

(Strong recommendation, low-quality evidence)

 

Publication history

First published: 2015

Updated: No update planned

Assessed as up-to-date: 2015

 

Remarks

  • Additional research is required

 

Background

In 2003 the World Health Organization (WHO) published "Working with individuals, families and communities to improve maternal and newborn health", (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons - over and above what happens in clinical services - why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter's health promotion components(2) were translated into MNH programme language and 12 promising interventions - identified through reviews of country experiences and the literature - were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

As indicated in the IFC Framework concept and strategy paper,(1) it is recognized that in order to assume a role in improving MNH, communities need information regarding local maternal and newborn health needs. There are different methodologies and tools designed for health systems to gather information regarding maternal and newborn death and morbidity. Several of these recognize the value of the community as a source of information.

In recent years, particularly under the UN Secretary- General's Global Strategy for Women's and Children's Health(3) and the Commission on Information and Accountability, increased attention has been given to Maternal and Perinatal Death Surveillance and Responseas it contributes to better information for action by promoting routine identification and timely notification of maternal deaths, review of maternal deaths, and implementation and monitoring of steps to prevent similar deaths in the future.

Community participation in this process may help provide more accurate information on the number of deaths and where and why the women died. Community participation in analysing information and in identifying possible solutions may help address social determinants, meet community needs, and incorporate a range of actors in the response. Members of the community may participate as family informants for maternal (and perinatal) death inquiries or in presentations of summary data to identify ways to improve health outcomes. Levels of participation can vary, e.g., providing views versus full decision-making. Delivery mechanisms can include involving community representatives in the MDSR coordinating group, or holding community group meetings to discuss maternal deaths, their causes and possible solutions.

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the "WHO handbook for guideline development", guided by the GRADE approach.(4) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(5)

A systematic review was conducted on interventions to involve communities in the analysis and dissemination of information from maternal and perinatal death.(6) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • What interventions to involve communities in quality improvement processes for maternity care services are effective in increasing birth with a skilled birth attendant/ institutional birth and improving other key maternal and newborn health outcomes?

 

Evidence summary

Evidence on interventions to involve communities in quality-improvement processes was extracted from a systematic review conducted by Marston et al. (forthcoming).(7) The review was based on literature identified through the MASCOT/MH-SAR mapping and through an additional systematic review conducted by Marston et al. (2013).(8) Five studies were included. One study was primarily aimed at increasing use of skilled care for obstetric complications.(9)

Modified from the International Association for Public Participation, 2004

Participation processes and mechanisms varied between studies. There was not sufficient evidence to determine which of the strategies or which combination of strategies were most effective. Table 4 summarizes the characteristic of participation within each included study.

Weak evidence was reported for the key outcomes, although qualitative evidence points to some positive effects of the intervention. Some studies examine the effect of packages including some evidence of community participation in quality improvement but do not necessarily examine participation effects on their own.

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence ranged from very low to moderate.

One cluster RCT (Bjorkman and Svensson, 2009) conducted in Uganda reports a significant increase in facility births. Moderate-quality evidence.(10)

Four observational studies also report increases in facility births. In three studies the increase is significant: a pre and post study in Peru (Gabrysch et al., 2009) reports an increase in births in the health centre between baseline and follow-up and an increase in SBA; a controlled before and after study in Kenya (Kaseje et al., 2010) reports significant increases in facility births at intervention sites; and a pre and post study in India (Sinha, 2008) reports significant increases in births at primary health centres and government hospitals. A before and after study (Purdin, Khan and Saucier, 2009) reports the proportion of births in an EmOC facility increased following the intervention in a refugee population in Pakistan. Very low-quality evidence.(11-15)

For those studies whose focus was increasing access to skilled care for complications:

A study in rural Bangladesh (Hossain and Ross, 2006) reports significant increases in the intervention and comparison groups but not in the control group. The study design is not clearly stated, but it seems to be a quasi-experimental pre and post study with a control group. Very low-quality evidence.(9)

For the outcome of care with a skilled birth attendant or in a facility in case of maternal complications, the quality of the evidence was rated as very low.

One study conducted in rural Bangladesh (Hossain and Ross, 2006) reports significant increases in the intervention and comparison groups; the control group also shows a very small increase. As described above the design is not clearly stated. (9)

For the outcome of ANC attendance, the quality of the evidence ranged from very low to moderate.

One cluster RCT (Bjorkman and Svensson, 2009) conducted in Uganda reports a non-significant increase in ANC use. Moderate-quality evidence.(10)

Three observational studies report increases in ANC visits: a controlled before and after study in Kenya (Kaseje et al., 2010) reports increases in four or more visits but no significant differences between control and intervention sites, a pre and post study in India (Sinha, 2008) where the difference in the number of women who made at least one and more than three visits is significant between baseline and endline, and a retrospective before and after study reports complete ANC coverage (three or more visits) increased from baseline to endline in Afghan refugee women in Pakistan (Purdin, Khan and Saucier, 2009). Very low-quality evidence.(13-15)

For the outcome postpartum visits for women, the quality of the evidence was rated as very low.

Purdin, Khan and Saucier (2009) showed that coverage of postpartum care within 72 hours of birth increased over time following the intervention in a setting with Afghan refugee women in Pakistan. Very low-quality evidence.In addition to the critical and important outcomes, the GDG had requested information on the effect of the intervention on woman's satisfaction with services. Only one study (Gabrysch et al., 2009) reported on women's satisfaction using qualitative interviews.(12, 15)

 

Implementation considerations

  • Collaboration among community members and service providers to jointly define and improve quality can be an effective approach when a supportive dialogue process is facilitated well and involves and takes into account the perspectives of all diverse participants.
  • It is important to ensure that pregnant women have a voice and that there is adequate diversity in perspectives of both community members and service providers in quality-improvement processes.
  • Quality-improvement committees can be an effective structure to support ongoing collaboration among communities and service providers when all members understand and are committed to the purpose of the group, roles and responsibilities are clear and acceptable to all members and group governance practices support participation.
  • Joint assessment of health services and care is helpful to support informed decision-making. Ongoing monitoring of data helps to inform adaptation of strategies as necessary for continual improvement and accountability.
  • Health facility leadership that supports collaboration with communities is necessary for this approach to be effective.
  • Discussion at national and local levels is required for adaptation to context and to ensure a meaningful degree of decentralization so that an appropriate level of budget and resources are assigned to support the process.
  • This intervention should be seen as a dynamic process. It takes time to build trust between the different actors and the capacity of the different actors to plan together and to work together will develop over time.
  • Data must be presented in ways that can be understood by all participants, taking care to communicate health issues effectively to those within and outside of the health sector with varying levels of education and experience.
  • While NGOs may have experience in facilitating and organizing community involvement, the work should be linked to government services and embedded in ongoing processes, when and where they exist.
  • It is important to include voices and perspectives from diverse groups in the community.

 

Research implications

The GDG suggested it would be useful to have more information about:

  • Dialogue between community and health services and the dynamics of the community-service interface in various settings (decentralized, centralized, conflict/fragile states).
  • Community/provider action planning processes, such as how strategies are agreed upon and how they change over time.
  • Data for decision-making to support joint qualityimprovement efforts and accessible ways of presenting data to highlight progress and trends.
  • Community feedback on services and the role of communities in holding services accountable for quality care. Similarly, mechanisms for providers to provide feedback to communities on aspects within individual, family and community control to improve quality care.
  • Advocacy and its role in improving the quality of services (either the community alone or jointly with service providers to obtain resources, change management practices, etc.).
  • The effects of participation in quality improvement on community dynamics, self-efficacy, identity, power relations, etc.
  • The role of evolving technologies to support community participation in improving qualityof care (improved access to information, better communication through mobile devices, data collection possibilities, etc.).
  • How to ensure confidentiality when sharing data for decision-making.
  • Assessing the impact of experiences in high-income countries and identifying the lessons learned.

 

Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015) –full document and evidence tables

 

Supporting systematic reviews:

Marston C, Sequeira M, Portela A, Cavallaro F, CR M. Systematic Reviews on community participation and maternity care seeking for maternal and newborn health.

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

  1. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.
  2. The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.
  3. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO statement. 2014.
  4. 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. Reproductive Health. 2014;11(1):71.
  5. WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.
  6. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.
  7. Marston C, Sequeira M, Portela A, Cavallaro F, CR M. Systematic Reviews on community participation and maternity care seeking for maternal and newborn health. (forthcoming).
  8. Marston C, Renedo A, McGowan CR, Portela A. Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PloS one. 2013;8(2):e55012.
  9. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2006;92(3):320-8.
  10. Björkman M, Svensson J. Power to the people: evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics. 2009;124(2):735-69.
  11. Iap2 public participation spectrum. Wollongong, Australia: International Association for Public Participation; [23 January 2015]. year https://wwwiap2orgau/documents/item/84.
  12. Gabrysch S, Lema C, Bedriñana E, Bautista MA, Malca R, Campbell OMR, et al. Cultural adaptation of birthing services in rural Ayacucho, Peru. Bulletin of the World Health Organization. 2009;87(9):724-9.
  13. Kaseje D, Olayo R, Musita C, Oindo CO, Wafula C, Muga R. Evidence-based dialogue with communities for district health systems' performance improvement. Global public health. 2010;5(6):595-610.
  14. Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh: Population Council; 2008.
  15. Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2009;105(1):82-5.

 

Citation: WHO recommendation on community participation in quality-improvement processes (2015). WHO Reproductive Health Library; Geneva: World Health Organization