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Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview
  1. Manisha Nair1,
  2. Sachiyo Yoshida2,
  3. Thierry Lambrechts2,
  4. Cynthia Boschi-Pinto2,
  5. Krishna Bose2,
  6. Elizabeth Mary Mason2,
  7. Matthews Mathai2
  1. 1National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Manisha Nair; manisha.nair{at}npeu.ox.ac.uk

Abstract

Objective Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children.

Study design Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews.

Settings Health systems of all countries. Study outcome: QoC measured using surrogate indicators––effective, efficient, accessible, acceptable/patient centred, equitable and safe.

Analysis Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHO's framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers.

Results We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHO's framework––information, patient–population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, ‘communication’ and ‘satisfaction’, were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups.

Conclusions The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.

  • Public Health

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https://doi.org/10.1136/bmjopen-2013-004749

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    Strengths and limitations of this study

    • This is the first comprehensive synthesis of robust evidence from systematic reviews to identify barriers and facilitators to improving quality of healthcare for pregnant women, newborns and children.

    • This metareview provides a situational analysis of the cross-cutting issues in achieving quality of care (QoC) for maternal, newborn and child health using an existing WHO's framework for organisational management strategies.

    • The process of interpreting evidence from the literature and using it to recommend priorities in practice and policy to improve QoC is complicated. There is neither a single definition of QoC nor are there set criteria against which QoC could be measured. This metareview was conducted within these limitations.

    • There could be many other unidentified facilitators and barriers to improving QoC, particularly country-specific issues, but this metareview of systematic reviews could be considered to be the first step in exploring and compiling the existing knowledge about the global situation.

    • This metareview could be particularly informative for policy makers as a guide to evidence-based effective interventions which can be adopted to strengthen the health systems of countries.

    Background

    The persistent problems of high maternal, infant and child morbidity and mortality1–4 demand improved healthcare which does not pertain to coverage of health services alone.5 Recently, there is a growing interest in the quality of healthcare services provided.6 ,7 The health issues of pregnant women, mothers, infants and children cannot be addressed without due attention to quality of care (QoC) for the simple reason that the healthcare services will not be effective, efficient, acceptable and safe.8 However, it is not easy to conceptualise QoC and there are several definitions. Avedis Donabedian,9 a pioneer in introducing QoC into the health system, defined QoC as: that kind of care which is expected to maximise an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.

    The WHO provides a framework of organisational management strategies to improve QoC (figure 1) in order to help the healthcare system achieve its desired goals.8 This is a general framework which suggests that overall the health systems should focus on improving six domains of organisational management strategies to improve QoC—information, leadership, engagement with patients and population, use of regulation and standards, developing organisational capacity and models of care.8 However, it is not known to what extent the current global issues in improving QoC for maternal, newborn and child health fit into the WHO framework. The objective of this study was to conduct a global situational analysis to identify the current facilitators and barriers to improving QoC for pregnant women, newborns and children with respect to the WHO's quality improvement framework.

    Figure 1
    Figure 1

    The six domains of quality interventions (source: WHO8).

    Methods

    We conducted a metareview of high-quality systematic reviews and the grey literature which examined QoC from a health system's perspective. All efforts were made to adhere to the underlying principles of ‘reproducibility and transparency’ in conducting metareviews.10 The scope of this metareview was to identify facilitators and barriers to QoC from the health system's perspective; thus, the primary outcome of interest was QoC. Since there is neither a single definition of QoC nor a single method to measure QoC, we used the six desired goals of the health system—effective, efficient, accessible, acceptable/patient centred, equitable and safe8 as surrogate indicators of QoC for the purpose of conducting the literature searches. We restricted the metareview to published and unpublished systematic reviews and/or meta-analyses of interventions to improve QoC in the areas of maternal, newborn and child health between January 2000 and March 2013. No language restriction was applied. We excluded systematic reviews/meta-analyses of therapies and drug interventions, and of specific disease or health conditions. There is a wide range of literature on these topics; hence, it is a subject of specialised review. Other exclusion criteria were—systematic reviews withdrawn by the journal/authors due to any reason and systematic reviews of health promotion strategies/programmes undertaken by sectors other than the health sector. Databases searched for published literature were Cochrane, MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed Clinical Queries, Database of Abstracts of Reviews of Effects (DARE), Health Services Research (HSR) PubMed Queries and Regional databases of the WHO—Global health library. In addition, we hand searched all 16 volumes of the journal—Quality and Safety in Health Care (previously Quality in Health Care)––and the reference lists of the included studies. The grey literature searches were restricted to dissertations, reports and conference proceedings. The two recognised databases ‘Index to theses’ and ‘Proquest Dissertations and Theses’ were used. In addition, a number of databases in the areas of health services, QoC, maternal health, newborn health and child health were searched. Details of the database searches and key words are provided in online supplementary appendix A. The 11-item AMSTAR (Assessment of Multiple Systematic Reviews) tool was used to assess the methodological quality of the systematic reviews included in this study.11 This tool has been used in other published metareviews12 ,13 and is considered to be a valid and reliable instrument for assessing the quality of reviews.10 ,14

    We used standard data extraction formats relating to methods, participants, intervention and outcome for each of the population groups (pregnant women, newborns and children). We used Donabedian's15 suggested approach to organise the extracted data into the three levels of healthcare: structure (setting, material, human resource, organisational structures, regulations and standards); process (of giving and receiving care) and outcomes (improvements in health outcomes, health behaviours and patients’ knowledge and satisfaction). This was performed to filter out data that did not relate to health systems and to organise the substantial amount of extracted data for ease of analysis. All efforts were made to adhere to Donabedian's15 definition of ‘structure’, ‘process’ and ‘outcome’, but some information extracted from the literature could not be strictly fitted into any one category. In this case, the authors through a consultation process identified a category that was most suitable to house the information for the purpose of analysing the data. No attempt was made to use Donabedian's framework to analyse the data.

    Data analysis was conducted in two phases

    1. Qualitative synthesis of the extracted data to identify and group the facilitators and barriers to QoC for each of the three population groups (pregnant women, newborns and children) into the six domains of the WHO's framework (see box 1 for brief description of the domains) and explore new domains (if any).

    2. An analysis grid16–18 was drawn on paper to aid the organisation of the phase-1 findings to map the common facilitators and barriers to QoC across the population groups.

    Box 1

    Scope of the six strategic organisational management domains of the WHO's health systems framework for improving quality of care (QoC)

    1. Leadership is the first domain in the framework because a strong and committed leadership is considered to underpin the other five domains. While the framework suggests the requirement of effective leadership at all levels that is external and internal to the health system, this metareview focused only on ‘leadership’ within the healthcare system.

    2. Information includes an information system in any shape and form (papers, checklists to computer-aided prompts) that enables service providers to deliver standard best practices and help patients and communities to manage their own health.

    3. Patient and population engagement is described as central to quality improvement strategies because, ‘either directly or indirectly, they will be financing care, they will be working in partnership with health workers to manage their own care and they will sometimes be the final arbiter of what is acceptable and what is not across all the dimensions of quality’. Thus, it is suggested that interventions are required to engage patients and communities in shaping the health system such that it is responsive to their needs. Within the scope of this domain are also included the strategies to improve health literacy, knowledge about self-care, users’ engagement in decision-making, etc.

    4. Regulations and standards based on evidence of best practices are required to be adhered to in order to improve the performance of the health system. They are the means for checking the credibility of the healthcare system and thus are usually monitored by an agency external to the health system. These agencies could be governmental or non-governmental, but their role is to inspect and accredit the healthcare systems. Although the WHO's framework includes ‘audit’ within the domain of ‘organisational capacity’ as a mechanism that supports organisations to improve quality, for the purpose of this review it was felt that ‘audit’ would fit best as a mechanism to ensure adherence to regulations and standards, thereby helping in improving QoC. Thus, any interventions related to audit were included under ‘regulations and standards’.

    5. Organisational capacity is the fifth domain and ‘issues of quality within this domain apply throughout the health system’ from the organisation and structure of the healthcare system to the knowledge and capacity of the service providers. This is suggested to be the interface at which providers and users interact and directly experience QoC-related issues.

    6. Models of care, although included within the framework, do not fall under organisational management strategies. It is suggested that the interventions within ‘models of care’ should be such that they should aim to improve the continuum of care and all the other domains of organisational management for QoC and therefore may include strategies that extend beyond the health system. An example provided in the report is the ‘Chronic Care Model’ to improve QoC and management of chronic diseases. However, for the purpose of this review, only those models that were related to the health system were included.

    Considering the heterogeneity of the outcomes, interventions, population and settings, no attempt was made to conduct a metaregression of the reported meta-analyses data. MN carried out the searches, reviewed the papers and extracted the data which were assessed and finalised by all coauthors.

    Findings

    The details of the schematic search strategy for published literature are presented in figure 2. We included a total of 98 systematic reviews—97 published and 1 unpublished; all were in English, except for one which was in Portuguese. The lists of included and excluded studies with reasons for exclusion are provided in online supplementary appendix B. A total of 1951 studies were included in the 98 systematic reviews (maternal=1178, newborn=359 and child=414) which comprised all types of study designs. The sample sizes ranged from 8 to 2 787 744; the sample populations were from rural and urban areas of countries belonging to all income groups (high-income, middle-income and low-income countries). AMSTAR scores ranged from 2 to 11 (details provided in online supplementary appendix C). Reviews with scores <3 are flagged to indicate poor methodological quality. Four systematic reviews (of 98) scored 2 on the AMSTAR tool, but these were not removed from the analysis in order to retain the comprehensive approach adopted for the review. The citations were managed using EndNote X5. The 98 selected systematic reviews included 110 interventions and the outcomes spanned the six goals of the health system—effective, efficient, accessible, acceptable, equitable and safe. Only a few papers explicitly set out to measure QoC as an outcome. One review used the Institute of Medicine's QoC outcomes19; in two reviews, quality was defined in terms of adherence to standard guidelines such as active management of labour and continuity of midwifery care,20 ,21 and in yet another in terms of augmentation of labour and delivery.22

    Figure 2
    Figure 2

    Process of selection of published literature through a systematic search strategy.

    Facilitators and barriers to improving QoC with respect to the WHO's framework

    Within each quality domain of the WHO's organisational management framework, facilitators and barriers to improving QoC identified from the review were further subdivided into the structure, process and outcome levels of healthcare (table 1). Two new domains were generated, ‘communication’ and ‘satisfaction’, for the priorities that could not be grouped under the six existing domains. ‘Communication’ was included as a subdomain under ‘information’ of the WHO's framework and ‘satisfaction’ as a new domain.

    View this table:
    Table 1

    Priorities in QoC

    Information

    Inadequate provision of information was an important barrier to improving QoC identified by users and providers.23–29 A metasynthesis of the experiences of women from Australia, the USA, Finland, the UK, Canada and Japan, who underwent caesarean section, showed that they associated lack of information and knowledge with loss of control and powerlessness during the process of childbirth.23 Another review of studies from the USA, the UK and Canada showed that lack of information on the full range of health services available was a major challenge for marginalised women to accessing healthcare.24 Information provided merely for the sake of providing it was not considered to be of any use.30 Information systems such as ‘Computerized Decision Support Systems’ for minimising errors in calculating medicine doses,31 Paediatric Alert Criteria,32 Computerized Physician Order Entry33 and flow sheets for decision-making28 improved effectiveness,31 ,32 efficiency31 ,33 and provider satisfaction.28 Language was an important barrier to receiving adequate information among the migrant population.25 A key finding was that all interventions to improve the provision of information among users and providers were found to be from high-income countries (HICs), except for one study in Thailand.34

    Communication

    Effective ‘communication’ could be a bridge, linking information to health literacy, knowledge and awareness for shared decision-making and user satisfaction. The WHO's framework of organisational management strategies to improve QoC does not emphasise interpersonal communication as a specific strategy for improving QoC. However, issues related to ‘communication’ were highlighted in several studies.23 ,24 ,35 ,36 Furthermore, a systematic review of interventions to improve communication between health professionals and pregnant women during maternity care suggested that improved interpersonal communication could increase acceptability and satisfaction,30 but its AMSTAR score was <3 and thus ranked low in methodological quality.

    As noted above, language barriers25 ,37–39 and lack of qualified interpreters could also pose a challenge to effective communication. A passive flow of information from providers to users was not effective in improving users’ knowledge and awareness about their health condition for shared decision-making.30 ,40 ,41 The greatest benefits were observed when a decision support technique was implemented in the form of counselling from a care provider involving information, discussion of options and clarification of values.42 Two reviews found that regular frequent discussions with healthcare providers were more effective than a one-off contact.27 ,35 Active communication between providers and parents using biomedical informatics43 was more effective than passive ones such as video games and text messaging services.34 ,44 ,45 Interactive workshops and educational meetings were shown to be more beneficial in improving provider compliance to standard guidelines compared to receiving information leaflets and didactic lectures.26

    Patient and population engagement

    Barriers to patient and population engagement were lack of health literacy, knowledge and awareness about health services,25 ,29 ,35 ,36 ,46–50 lack of opportunity for shared decision-making38 and lack of trust and confidence in the healthcare providers.37 In addition, users’ and community's perception of quality of healthcare20 ,47 and their past experiences,25 lack of effective interpersonal communication23 ,24 ,37 ,38 ,43 ,51 and poor relationship between providers and users38 ,52 were other important barriers. Power difference between users (women, parents and carers of children) and healthcare providers prevented active engagement of users in decision-making and was an important hurdle in patient and population engagement.30 ,53 Respect, confidentiality and healthcare providers’ time and attention were identified as other process-related factors from studies worldwide that influenced user satisfaction and engagement with the healthcare system.38 ,47 ,54

    Satisfaction

    Several systematic reviews included in this metareview reported users’ satisfaction with healthcare as key to their engagement22 ,28 ,34 ,36 ,40 ,42 ,45 ,50 ,54–67 and thus merited an independent domain. The included systematic reviews highlight the problem of health systems not eliciting information about users’ perception of care with regard to the provision and costs of healthcare as well as lack of standard tools to measure patient satisfaction. Health systems often do not account for users’, particularly women's, perception and their opinion about the care that they receive.25 ,68 Women's satisfaction with healthcare influences utilisation of health services22 and their ability to be in control of their own health.55

    Several factors were identified from the included reviews that improved user satisfaction, such as family-centred care in which parents actively participated in healthcare of their children,69 effective communication50 and interventions that improved education and awareness about newborn care.67 Users’ dissatisfaction was mainly related to the uncaring, disrespectful, insensitive and abusive attitude of care providers,23 ,52 ,70 ,71 but it was also found to be associated with practices that were not compatible with their culture22 and concepts of health and illness.25 Comfort and support were identified as other important factors which determined satisfaction.23 ,54 ,61 However, the factors that improved satisfaction among providers were different from that of the users and included decision support systems and other technical supports.28 ,32 ,33

    Regulation and standards

    The included systematic reviews that evaluated the impact of standard care practices such as Emergency Obstetric Care (EmOC), skilled birth attendance,72 standard packages of care during birth,46 ,56 Baby Friendly Hospital Initiative (BFHI),73 Kangaroo or mother/baby skin-to-skin care74 did not find strong evidence of their effectiveness in improving health outcomes, especially in low-income and middle-income countries (LMICs). However, effectiveness of the Integrated Management of Childhood Illness (IMCI) strategy in improving health outcomes was demonstrated by studies from 17 LMICs.51 Lack of effectiveness of recommended standard care strategies could be related to a number of structure-related and process-related issues (table 1). Primarily, the packages of care were found to vary to a greater or lesser extent from recommended standards. In some instances, these were bundled for the convenience of management rather than as evidence of efficacy.56 Lack of regular quality supervision and evaluation was an important barrier to improving the effectiveness of standard care practices.72 ,75 Audit and feedback could be a useful tool in improving adherence to regulations and standard care and improving their effectiveness across countries worldwide,20 ,26 ,76–79 but there are challenges related to quality,26 ,77 ,78 sustainability76 and acceptance of audit,77 especially when enforced by an external agency.76

    Organisational capacity

    Shortage of healthcare workers and issues related to their retention were important barriers to QoC.75 ,80 A few interventions suggested that task shifting could address these issues,60 ,81 but reservations about task shifting75 were a challenge which should be included under ‘leadership’-related issues.75 In addition, non-availability of drugs and necessary equipment could compromise quality and thus health outcomes.37 ,47 ,82 Users’ perception of provider skills and the actual gap between providers’ skill and knowledge were important determinants of QoC.22 Furthermore, the type of providers also had an impact on patient acceptability and health outcomes. Midwives and community health workers (CHWs) were found to be as acceptable and effective as doctors and specialists in studies from HICs,60 ,70 ,83 ,84 but there were challenges related to their training, supervision and regulation.80 ,85 ,86

    It was observed that settings other than the clinics and hospitals, such as the home, maternity waiting facilities and outpatient setting, were relatively more successful in improving user satisfaction and at least as effective as the hospitals in terms of effectiveness.61 ,68 ,69 ,82 ,87 ,88 However, the safety of such settings could not be ascertained, particularly safety related to planned home birth/abortion59 ,82 ,89 ,90 and induction of labour in the home or community setting.68

    Provider attitude was an important factor determining QoC in healthcare provision. Training in general improved the providers’ knowledge and level of confidence,91–94 engagement and communication with the users80 ,95 and enabled them to increase adherence to regulations and standards.21 ,92

    Leadership

    As discussed in the WHO's general framework, leadership is central to the strategic management domains of QoC. However, issues related to ‘leadership’ were not perceptible from the included studies. Inability to identify priority issues does not indicate that ‘leadership’ as a strategic management domain is less important. On the contrary, it suggests that there is an urgent need for research in this area. However, it ought to be acknowledged that leadership issues are difficult to ascertain as there are no fixed criteria to measure the facilitators and barriers to effective leadership.

    Models of care

    Among the models of care, those that provided integrated care,96 continuity of care97 and comprehensive care19 had positive impacts on the health system goals. However, trade-offs were observed for some interventions. For example, interventions to reduce the number of antenatal visits could reduce healthcare costs, but were found to be associated with more perinatal deaths in the reduced visit group, particularly in the LMICs, and less acceptable to pregnant women.57 ,58 ,66 Reducing the number of antenatal visits in LMICs without improving care would increase the risk of adverse health outcomes considering the already compromised public health services in many LMICs.66 Interventions that provided continuous support during labour improved maternal satisfaction and health outcomes, but the effects appeared to vary with the type of providers.64 Health professionals were less effective than a trained doula or childbirth educator or a family member mainly because the health professionals, who had to balance their hospital duties along with provision of support, were unable to provide continuous undivided attention to women.64 Furthermore, two systematic reviews that analysed the effect of a group model antenatal care compared with conventional one-on-one care found the group model to improve women's knowledge and satisfaction, but there was no evidence of the effect on health outcomes and provider satisfaction.36 ,65 Although internet-based interventions to support successful breastfeeding were reported to be beneficial in terms of round-the-clock availability of support, time and travel savings for users, these were not found to have a significant effect on breastfeeding outcomes.98 Another review that examined the effect of music as a therapy found positive effects on children's coping behaviour, but there was limited evidence of the effect on clinical outcomes.99

    Common facilitators and barriers to improving QoC for pregnant women, newborns and children

    We found several facilitators and barriers to improving QoC to be common across the population groups within each of the eight domains (table 2). Interventions that involve delivery of information through active and regular communication between users and providers could improve users’ knowledge, awareness and health literacy, which are important factors for patient and population engagement. ‘Decision aids’ for users could also be important tools of communication. Language could be a barrier to information and communication among certain population groups. Information systems such as ‘decision support systems’ could improve providers’ efficiency and help them adhere to standard care guidelines and regulations.

    View this table:
    Table 2

    Common facilitators and barriers to improving QoC for pregnant women, newborns and children

    In addition to adequate information and effective communication, understanding users’ perception about QoC is important in ‘patient and population engagement’. There is lack of evidence with regard to the concerted efforts made by health systems to assess users’ perception. Another issue within this domain that needs attention is that of trust and confidentiality. The ability of users to trust and confide in the providers is important. This also relates to issues of insensitivity, inappropriate attitude and behaviour on the part of the providers. Training and regular audit and feedback could help to address some of these issues, but effective leadership could prevent the emergence of these problems.

    The level of satisfaction among users was determined mainly by the process of care (attitude of providers, respect, support, comfort, cultural sensitivity, attention) and effective communication (perceived to empower users for decision-making and taking control of their own or their children's health condition) rather than the health outcome alone.

    The shortage of well-trained healthcare providers, drugs and equipment in healthcare facilities is an important barrier. While CHWs were found to be effective in delivery of health services, particularly in LMICs, and could help address the problem of staff shortage through task shifting, training, supervision and regulation of CHWs could be an important challenge. Healthcare settings other than the hospitals and clinics, such as home-based or community-based care, were more acceptable to users and improved their level of satisfaction. It appears from the review that patients and carers perceived having greater comfort and confidence within a known environment than within hospitals and clinics. With regard to the process of care, in addition to the providers’ attitude and behaviour, and the perception of QoC among users, the providers’ attitude towards change in terms of adopting new strategies and guidelines is important. Furthermore, providers’ competencies to build trust, comfort and patient-centredness are essential to improve QoC over and above their technical skills.

    Discussion

    The facilitators and barriers to improving QoC for pregnant women, newborns and children identified in this metareview can be grouped into the six strategic management domains of the WHO's framework (information, patient and population engagement, regulations and standard, leadership, organisational capacity and models of care). However, there is a need to focus on user–provider communication and satisfaction by incorporating ‘communication’ as a subdomain under ‘information’ and ‘satisfaction’ as a new domain. Information provided through effective communication was more likely to improve user knowledge, health literacy and involvement in shared decision-making, thus leading to improved ‘patient and population engagement’. In Donabedian's concept of interpersonal care, communication is a major aspect that could directly influence QoC,9 and in recent years, communication in healthcare, particularly between healthcare professionals and patients, has attracted an increasing amount of attention.30 Besides user–provider communication, effective communication between healthcare providers and among different levels of the health system could improve efficiency and effectiveness of care provision.100

    ‘Satisfaction’ of users and providers is another important quality management strategy that should be focused on.101 ,102 User ‘satisfaction’ is important for ‘patient and population engagement’, and ‘satisfaction’ in turn was found to be influenced by ‘patient and population engagement’, adequate information, communication and ‘organisational capacity’. Wilson and Goldsmith101 defined QoC as “the sum of its four components: technical quality (measured by patients’ health status improvement), resource consumption (measured by the costs of care), patient satisfaction (measured by patient perception of the subjective or interpersonal aspects of care), values (measured by the acceptability of any trade-offs that must be made among the three previous outcomes).” Pittrof et al102 in their definition of QoC for maternal health stated that childbirth being a culturally and emotionally sensitive area, other aspects of care could be more important than the health outcomes. This conforms to the findings of the metareview which showed that providers’ attitude, behaviour, sensitivity and attention are important priorities for QoC from the perspective of the users. However, there could be other factors that influence satisfaction and need to be understood.

    Since the facilitators and barriers to improving QoC were in general common for pregnant women, newborns and children, the following interventions could facilitate improvement in QoC across these population groups:

    1. Health systems should set minimum standards of communication between users and providers, and also among providers across the various levels of the healthcare system to improve effectiveness and efficiency of care provision.

    2. Language barriers, especially among the migrant and minority population, could be addressed with the help of qualified interpreters. Where necessary, health systems should recruit and train a cadre of qualified interpreters with effective communication skills. This would be particularly important considering the inequities and disparities in care provision faced by certain sections of the population in all countries.

    3. Training on communication skills should be incorporated as an integral part of health professionals’ education. Regular training of providers could also be an effective means of addressing several issues related to healthcare provision through improving the technical and communication skills, competence, confidence, cultural sensitivity, attitude and behaviour of providers. However, it ought to be acknowledged that training without an enabling environment will not improve the overall health outcomes and QoC.

    4. CHWs have proven to be effective in mobilising and engaging users and communities in several LMICs. It is important for health systems to train and retain this valuable resource.

    5. Midwives were found to be a valuable resource in HICs, and services provided by them were as effective and acceptable as that provided by doctors. This resource should be utilised well in LMICs by building their capacity through training and supportive supervision.

    6. Audit and feedback, and training of providers are important strategies to improve adherence to regulations and standards. However, efforts are required to address the implementation challenges and methodological issues of audit and feedback to achieve greater benefits.

    A number of gaps in evidence to improve QoC were identified which could be addressed through further studies. There is a requirement for studies and interventions in LMICs to assess the information and communication needs of a population with varying socioeconomic and education levels. Technical support through ‘decision support systems’ improved provider satisfaction; thus, studies are required to assess the feasibility of implementing essential low-cost ‘decision support systems’ within the healthcare system. However, in general, there is a dearth of knowledge with regard to the facilitators and barriers related to providers’ satisfaction. Understanding this is equally important because motivation and satisfaction among providers are known to influence the QoC provided by healthcare professionals. Furthermore, good-quality observational studies are required to measure the effectiveness of standard care practices and the barriers to implementing these in LMICs, and to understand the key leadership issues in QoC.

    Common measurement tools for maternal, newborn and child healthcare can be developed to assess the facilitators and barriers to good-quality healthcare. There is an urgent need to develop specific tools to measure users’ and providers’ satisfaction, and to incorporate tools to assess users’ and communities’ perceptions related to QoC in the mechanisms of audit and feedback. It is important that lessons learnt through measuring QoC using such tools are used by healthcare providers, health system managers and policy makers to continuously monitor and improve care provision.

    Limitations

    Although the included papers and extracted data were reviewed, discussed and finalised by all authors, we acknowledge the limitation of not having two researchers independently review and extract the data. Considering that the scope of a metareview is limited to gathering evidence from systematic reviews and meta-analyses, it is quite likely that we might have missed information on facilitators and barriers to improving QoC discussed in other types of studies and reports. For example, we did not find systematic reviews or meta-analyses dedicated to analysing measurement methods and tools to measure QoC. We acknowledge that the quality of the methods used to measure QoC is as important as identifying the facilitators and barriers; however, no information could be found in the included systematic reviews. This suggests the requirement for a systematic review that synthesises the existing evidence in this area.

    It is recognised that the process of interpreting evidence from the literature and using it to recommend priorities in practice and policy to improve QoC is complicated. There is neither a single definition of QoC and nor are there set criteria against which QoC could be measured. This metareview was conducted within these limitations. There could be many other unidentified priorities facilitators and barriers to improving QoC, particularly country-specific ones, but this metareview of systematic reviews could be considered to be the first step in exploring and compiling existing knowledge about the global situation. The facilitators and barriers identified could be considered as basic to health systems in all countries, although the weight given to the identified issues may vary. The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects on QoC for these population groups. Adopting the identified facilitators of good quality of healthcare would help countries strengthen their health systems and ensure high-quality care for all.

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    Footnotes

    • Contributors MN developed the concept, conducted the literature searches, reviewed the papers, extracted and analysed the data and wrote the paper. All other authors developed the concept, reviewed the included and excluded papers and edited the paper.

    • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests MN was commissioned by the Department of Maternal; Newborn, Child & Adolescent Health, WHO, 1211 Geneva, Switzerland to write a report on the quality of care for maternal, newborn, child and adolescent health, of which this paper is a part. SY, TL, CB-P, KB, EMM and MM currently work for the WHO.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Excel files of extracted data from the systematic reviews can be made available through email requests to the corresponding author.