Article Text

Original research
Intrapartum care measures and indicators for monitoring the implementation of WHO recommendations for a positive childbirth experience: a scoping review
  1. Lauren Hannah Vallely1,2,
  2. Anna Shalit1,2,
  3. Renae Nguyen1,3,
  4. Fernando Althabe4,
  5. Verónica Pingray5,
  6. Mercedes Bonet4,
  7. Elizabeth Armari1,
  8. Meghan Bohren6,
  9. Caroline Homer1,
  10. Joshua Peter Vogel1,2
  1. 1 Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
  2. 2 School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  3. 3 School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  4. 4 Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
  5. 5 Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
  6. 6 Centre for Health Equity, University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
  1. Correspondence to Dr Joshua Peter Vogel; Joshua.vogel{at}burnet.edu.au

Abstract

Objective We aimed to identify all available studies describing measures or indicators used to monitor 41 intrapartum care practices described in the 2018 WHO intrapartum care recommendations, with a view to informing development of standardised measurement of implementing these recommendations.

Design Systematic scoping review.

Methods We conducted a scoping review to identify studies reporting measures of intrapartum care published between 1 January 2000 and 28 June 2021. Primary and secondary outcome measures included study characteristics (publication year, journal, country and World Bank classification) and intrapartum care measure characteristics (definition, numerator, denominator, measurement level and measurement approach). We searched MEDLINE, EMBASE, CINAHL, Cochrane Library, the Maternity and Infant Care Database, Global Index Medicus and grey literature using structured search terms related to included recommendations, focusing on respectful and supportive care, and clinical practices performed throughout labour and birth. The measures identified were classified by the WHO recommendation and their characteristics reported.

Results We identified 150 studies which described 1331 intrapartum care measures. These measures corresponded to 35 of the 41 included WHO recommendations, and represented all domains of the WHO recommendations (care throughout labour and birth, first stage of labour, second stage of labour, third stage of labour). A total of 40.1% (534 of 1331 measures) of measures were related to respectful maternity care. Most studies used a questionnaire or survey measurement approach (522 of 1331 measures, 39.2%).

Conclusion This scoping review presents a database of existing intrapartum care measures used to monitor the quality of intrapartum care globally. There is no clear consensus on a core set of measures for evaluating the practice of the WHO’s intrapartum care recommendations. This review provides a foundation to support the development of a core set of internationally standardised intrapartum care measures for the WHO intrapartum care recommendations, highlighting key areas requiring consensus and validation, and measure development.

  • obstetrics
  • maternal medicine
  • quality in health care
  • protocols & guidelines

Data availability statement

Data are available upon reasonable request. The data extraction workbook will be made available upon request from JPV (joshua.vogel@burnet.edu.au) from the Burnet Institute, Melbourne.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • We performed a broad and comprehensive search of multiple scientific databases to identify as many papers as possible, ensuring a large number were eligible for analysis.

  • To improve accuracy and ensure consistency of individual results, all data were screened in duplicate for eligibility, and random-sample data checking was performed by two independent reviewers.

  • Using a scoping review methodology resulted in the creation of a database of global intrapartum care measures, which is a critical first step to inform further development of standardised measurement of the WHO intrapartum care recommendations.

  • We acknowledge that scoping reviews do not assess the quality of individual studies; thus, we cannot speak of the quality of research undertaken in the included papers nor the validity and reliability of the intrapartum care measures we identified.

  • We also acknowledge that subtle linguistic and measurement differences among the identified measures may have influenced the number of unique measures.

Introduction

The intrapartum period is a time of particular risk for women, during which life-threatening complications can arise, including obstructed or prolonged labour, postpartum haemorrhage and eclampsia, leading to severe morbidity or maternal death.1 2 Globally, intrapartum care quality has been described as having two extremes, where adverse maternal outcomes result from either suboptimal, unavailable or withheld intrapartum care, in contrast to overmedicalisation with ineffective or harmful interventions or inappropriate use of interventions.3 However, effective implementation of evidence-based intrapartum care practices has been shown to prevent maternal death, specifically through more efficient and prompt detection of complications.2

In 2018, the WHO4 published 56 evidence-based recommendations on intrapartum care practices to promote a positive childbirth experience.5 The WHO encourages all countries to adopt these recommendations to improve women’s childbirth experiences, as well as to optimise the use of intrapartum interventions, use healthcare resources efficiently and ensure quality intrapartum care is routinely available in facilities where women give birth.5 Notably, the recommendations emphasise respectful maternity care practices to improve experiences of care that are often overlooked or de-prioritised in maternity care settings, including labour companionship, effective communication, pain relief and encouraging women to mobilise and adopt a birth position of choice during labour.5–12

Monitoring and evaluation include collecting and regularly assessing data on predefined indicators that can reliably measure the use of selected clinical practices as well as important health, experience and satisfaction outcomes.13 14 Standardised monitoring of the implementation of clinical guideline recommendations is essential to the delivery of evidence-based care, as monitoring can help to identify areas of strength and areas for improvement. Robust systems for monitoring are therefore critical—they can drive better outcomes for women and newborns through assessment of routine intrapartum care provision and improve recognition of trends in health outcomes.15 16 The WHO defines indicators as ‘identified and measured variables which help to show changes directly and indirectly relevant to goals, objectives and targets’,17 and quality measures as ‘criteria for assessing, measuring and monitoring the quality of care’ of a quality indicator or statement.5 18 Historically, two indicators—the proportion of women attending facilities for childbirth and those who were attended by skilled birth personnel during labour19—have been used for national reporting and international comparisons.20 However, as coverage indicators, they provide a restricted view of the impact of intrapartum care provision, as they do not measure quality of clinical care or care context, nor reflect women’s experiences or satisfaction with care provided.14 21 Further, many settings (particularly limited-resource settings) do not have reliable data systems that can routinely collect and report on intrapartum care-related indicators.22 Despite extensive work to establish evidence-based intrapartum care quality measures, and previous efforts to consolidate international recommendations regarding use of such measures, global maternal and newborn care organisations often use different, non-overlapping measures.23 Where measures are shared, definitions of similar measures are diverse. The WHO recommendations provide an opportunity to review the measurement landscape of evidence-based intrapartum care practices, with a view to developing a consensus-based set of measures specific to the WHO recommendations. This would provide a comprehensive and systematic approach to the measurement and monitoring of intrapartum care quality internationally. We performed a scoping review, as this methodology is well suited to create maps of the existing literature in a reproducible and transparent manner.24

The aim of this study was to systematically collate available measures used to monitor the provision and quality of care provided to women giving birth in healthcare facilities. We specifically sought to identify any measures related to 41 of the care practices described in the 2018 WHO intrapartum care recommendations.5

Methods

We developed a scoping review protocol according to the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews which was registered online (https://osf.io/bd6vc/).25 The review findings are reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).25 26

Patient and public involvement

There was no patient or public involvement in the co-production of this research.

We included 41 out of the 56 intrapartum care recommendations described in the 2018 WHO guideline in this review. Fifteen recommendations pertaining to the prevention of postpartum haemorrhage, and care of the newborn or woman after birth were not included in order to focus on care practices pertaining to care throughout labour and birth, noting these recommendations were integrated from other WHO guidelines, which already specify measures.5 27 The 41 WHO intrapartum recommendations considered for this review are organised in four domains: (1) care throughout labour and birth has four recommendations; (2) first stage of labour domain has 28 recommendations, (3) second stage of labour has eight recommendations and (4) third stage of labour has one recommendation (online supplemental file 1 lists the recommendations). For this review, we adopted the WHO definitions of indicators and quality measures.5 17 18

Supplemental material

Eligibility criteria

We aimed to systematically identify all studies that reported a measure related to 1 or more of the included 41 included recommendations. Primary research studies, reviews and government publications were potentially eligible. Editorials, conference abstracts, congress papers and protocols (where no primary data were presented) were not eligible.

Studies were eligible if they related to healthy pregnant women or adolescent girls in the intrapartum period, or skilled health personnel providing intrapartum care.19 The WHO intrapartum care recommendations are specifically for healthy pregnant women, defined by the WHO as ‘pregnant women and adolescent girls who have no identified risk factors for themselves or their babies, and who otherwise appear to be healthy’.5 Thus, studies that described measures in the context of a population with a defined disease or risk factor (such as women with gestational diabetes) were not eligible. However, if a paper described the same measures for a distinct group of ‘healthy’ pregnant women, they were eligible. Further, as the WHO explicitly advises the implementation of the WHO recommendations as a package of care in facility-based settings,5 articles reporting only on births at home or in community settings outside of health facilities were excluded. Studies from all geographical locations and of all languages were eligible. To ensure this review comprehensively mapped the existing literature, studies published from 1 January 2000 to 28 June 2021 were included.

The main outcome of interest was any measure aligned with the clinical or supportive care practices of 1 or more of the included 41 WHO intrapartum care recommendations. We included studies if the measure was clearly defined, a rationale for use was provided, and a description of the methodology for reporting or assessing the measure was specified. Individual studies were not critically appraised, as per the JBI Evidence Synthesis Manual and PRISMA-ScR methodological guidance.25 26

Literature searching, data collection and analysis

Using predefined search strategies (online supplemental file 2), searches of MEDLINE, EMBASE, CINAHL, Cochrane Library, the Maternity and Infant Care Database, and WHO Global Index Medicus were conducted between 28 June 2021 and 2 July 2021. Two reviewers (LHV and AS) independently screened all titles and abstracts, then assessed full-text articles of all potentially eligible studies. Any disagreements during screening were resolved through discussion or consulting a third reviewer (RN or JPV). Covidence software was used for title, abstract and full-text screening.28

Supplemental material

The search was supplemented by grey literature searching of selected websites: WHO (https://www.who.int/), UNICEF’s Multiple Indicator Cluster Surveys (https://mics.unicef.org/), the Demographic and Health Survey Program (https://www.dhsprogram.com/), US Agency for International Development’s MEASURE Evaluation (https://www.measureevaluation.org/), Countdown 2030 (https://www.countdown2030.org/) and EURO-PERISTAT Indicators (https://www.europeristat.com/). The grey literature search strategy was informed by the Canadian Agency for Drugs and Technologies in Health’s grey literature checklist.29 These websites were searched for articles, publications or reports discussing intrapartum care, measures and indicators of intrapartum or maternity care, and the maternal experience of care.

A data extraction form (Microsoft Excel) was developed for this review, pilot-tested on five papers and refined. Two reviewers (LHV and RN) charted data from included studies into the form. Data were extracted by one reviewer for each study, and we randomly sampled 20% of studies that were checked by a second reviewer, which had a high concordance rate. Data extracted included study characteristics (author, year of publication, journal, country of origin and World Bank classification, WHO region, study methodology, sample size) and characteristics of the relevant measure. Characteristics of the measures included the definition, numerator and denominator, application level of the measure (ie, whether it was measuring at woman, provider or policy level), measurement level (individual, population, facility, subnational, national, international) and measurement approach (ie, whether it was collected by questionnaire, direct observation, clinical records or other methods, as described by the authors). Measures were also classified according to the measurement categories described in the Donabedian model of healthcare quality, that is, input, output or outcome measures.18 Input measures are the components (ie, physical or human resources) that are required to provide effective care, output measures are related to the process and results of delivering care, and outcome measures are the experience or consequences of receiving care.18

For each measure, the associated domain (care throughout labour and birth, first stage of labour, second stage of labour, third stage of labour), WHO recommendation number and measurement items (key elements of the recommendations, ie, dignity, privacy, continuous cardiotocography, routine episiotomy) were identified.5 In a separate spreadsheet, the 41 included WHO recommendations were tabulated alongside those studies that described measures relevant to each recommendation (online supplemental file 3). Thus, for each individual WHO recommendation, we could determine whether and how many corresponding measures were published (table 1).

Supplemental material

Table 1

The WHO intrapartum care recommendations, domain and number of identified measures

Results

Figure 1 depicts the PRISMA flow chart of included studies. A total of 18 861 citations were identified from database searching, and a further 19 studies from grey literature searching. A total of 150 unique studies were included, published between 2002 and 2021. More studies were published in the last 10 years (2011–2021, 122 studies) compared with 10–20 years ago (2000–2010, 28 studies) (figure 2). A total of 42 studies (28.0%) were from the African region, mostly from Ethiopia (13 of 42 studies, 31.0%). The European and Americas regions each accounted for 19.3% (29 of 150 studies). Thirteen studies (8.7%) reported data from multiple geographical regions. Almost half of single-country studies (48.2%, 66 of 137 studies) were from low-income and lower middle-income countries.30

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart of literature screening process.

Figure 2

Number of studies per publication year (2000–2021).

Across the 150 studies, 1331 different intrapartum care measures were identified. At least one measure was identified for 35 of the 41 included WHO intrapartum recommendations (table 1). In total, 151 (11.3%) were input measures, 1152 (86.6%) were output measures and 28 (2.1%) were outcome measures (table 2). A total of 763 measures (57.3%) were measured at the woman level, such as whether the woman had a birth companion present or if they were provided with pain relief upon request. A total of 536 measures (40.3%) were measured at the provider level, such as the performance of auscultation or fundal pressure by the care provider during labour. A total of 32 measures (2.4%) were measured at a policy level, which included measures regarding the presence or absence of available hospital policies for common practices, such as maternal position during birth or the timing of umbilical cord clamping.

Table 2

Intrapartum care measures by measurement approach, measurement level and Donabedian classification

Most measures were measured at a facility level (795 of 1331 measures, 59.7%). For provider-level measures, direct observation of the clinical care provided during labour and birth was the most common measurement approach (45.7%, 245 of 536 measures). However, for woman-level and policy-level measures, data collection via questionnaire was the most common measurement approach: (woman level: 25.7%, 196 of 763 measures; policy level: 59.4%, 19 of 32 measures).

More than half of the measures identified (693 of 1331 measures, 52.1%) related to the care throughout labour and birth domain, followed by the first stage of labour (37.7%, 503 of 1331 measures), second stage of labour (7.3%, 95 of 1331 measures) and third stage of labour (2.9%, 39 of 1331 measures) (table 1). Respectful maternity care (recommendation 1) had the largest number of measures (534 of 1331 measures, 40.1%) of any single recommendation. The most common measure items were informed choice (9.5%, 127 of 1331 measures), dignity (8.9%, 118 of 1331 measures), and mistreatment or abuse (8.5%, 113 of 1331 measures) (online supplemental file 4). Most studies reporting measures of respectful maternity care were published in the 10 years between 2012 and 2021 (63 of 71 studies, 88.7%), with 35.2% (25 of 71 studies) published after 2018.

Supplemental material

No measures were identified for 6 of the 41 included WHO recommendations. Of these, four were recommendations for the first stage of labour (definitions of the latent and active first stages of labour, clinical pelvimetry on admission, pain relief for preventing labour delay, antispasmodic agents), and two were recommendations for the second stage of labour (definition and duration of the second stage of labour, birth position).

Eighteen of the 41 WHO intrapartum recommendations describe intrapartum care practices that the WHO does not recommend implementing, due to evidence the practice is harmful or has limited benefit. Of these, 15 ‘not recommended’ clinical practices accounted for 19.9% of all measures (265 of 1331 measures). The most frequent related to the cervical dilatation rate (5.0%, 67 of 1331 measures) and continuous cardiotocography during labour (2.5%, 33 of 1331 measures). No measures were identified for the ‘not recommended’ clinical practices related to clinical pelvimetry on admission (recommendation 11), pain relief for preventing labour delay (recommendation 23) and antispasmodic agents (recommendation 31).

Discussion

We conducted a scoping review of all measures published between 2000 and 2021 that related to the WHO’s 2018 intrapartum care recommendations for a positive childbirth experience. We identified 150 studies using 1331 different measures, corresponding to 35 of the 41 included WHO recommendations. The majority were output measures, and there was considerable variability among measures with respect to measurement approaches and at what level they were measured (table 2).

The WHO highlights that the Standards for improving maternal and newborn care in health facilities are the appropriate foundation for developing measures corresponding to the WHO recommendations.18 Currently, there is no clear consensus on a core set of measures for evaluating implementation of the WHO’s intrapartum care recommendations. Thus, this database of measures is a critical next step to informing further development of recommendation-specific standardised measures. Further, classification according to the Donabedian model highlighted the uneven distribution of measures across the metric categories. This provides additional direction for measure development, noting that having measures span the metric categories strengthens a measurement framework.31 Our review revealed that respectful maternity care accounted for 40.1% of all measures, the greatest proportion of any recommendation identified. The substantial growth in the field of respectful maternity care and measuring women’s experiences in maternity services is likely to have contributed to this.8 32 While more attention on these issues is welcomed, the diversity of measures identified for respectful maternity care reflects a lack of consensus regarding the most appropriate measures of, and methods for, measuring respectful maternity care.32 33 For example, one included study regarded both labour observation and postpartum surveys as accurate and effective approaches to measure the prevalence of mistreatment of women during childbirth.33 34

Contrastingly, some recommendations (routine assessment of fetal well-being on labour admission, perineal/pubic shaving, fundal pressure) were represented by a small number of studies in the scoping review, which used one or few measures. A few hypotheses that might explain this include (1) possible consensus on the most useful measures for these recommendations, (2) these are comparatively less complex to measure than women’s experiences of respectful care or (3) possible overlooked areas that warrant further research. Further research to converge and validate a reliable set of measures for respectful maternity care, as well as other recommendations with a wide range of measures, including labour companionship and non-pharmacological techniques for pain management, is a logical next step.

A major challenge in this review was accounting for subtle differences in definitions and phrasing of numerators and denominators between measures. Nuances in language, the use of synonyms, differences in measurement approaches, or slight differences in numerator or denominator populations meant that many measures were similar, but not identical, which limits comparison across studies and contexts. For example, the six output measures related to oral food and fluid intake (recommendation 24) were all measured by direct observation, yet differed in language (‘encouraged’ vs ‘allowed’), alternately described behaviours or practices as ‘encouraged’ or ‘restricted/prohibited’, or used different denominator definitions (table 3).

Table 3

Illustrative example of three measures for each WHO care domain

These linguistic and measurement nuances can complicate efforts to harmonise and compare maternal and newborn health indicators.23 In some instances, measures identified in different studies were derived from the same indices or scoring frameworks. In these cases, the relevant tool (eg, Bologna Score or QoPIIPC Index) was reported alongside the report characteristics. In situations where two or more measures were very similar but would be applied or interpreted differently, we defined them as different measures. As argued by Lattof et al in their 2019 scoping review on antenatal care measures, these measures are most useful when they are validated and reliable, but also standardised in terms of definition, method and level of data collection.35 Achieving such a core set of measures, potentially by adopting an approach similar to core outcome set development performed for clinical trials, would allow comparability of data on intrapartum care practices across facilities, countries and time points, in addition to reducing inconsistencies in measurement and reporting bias.36 Additionally, this may strengthen global data systems by providing a consensus-based framework for global intrapartum care measurement. Further, this set of measures would serve to identify bottlenecks to improving quality of care, and determine whether new intrapartum care policies are having an effect on maternal and newborn health.

Questionnaires or surveys were the most common measurement approaches used (522 of 1331 measures, 39.2%). This aligns with a 2016 literature review by Tripathi which identified interviews or surveys of facility staff, and data from medical records and databases as the most common measurement approaches for quantitative intrapartum care measures.37 Further, in their 2020 scoping review, Larson et al reported self-administered or interviewer-administered questionnaires as the most common measurement approach for quantitative measures assessing women’s experiences of pregnancy and childbirth.32

Our scoping review did not identify measures for six recommendations. Of these, two recommendations outline definitions for the first and second stages of labour.5 The lack of literature reporting measures related to these definitions may be due to a historical lack of consensus about definitions of labour onset and duration.38 A further three recommendations (clinical pelvimetry on admission, pain relief for preventing labour delay and antispasmodic agents) are for practices not recommended by the WHO—the absence of literature on reporting measures may reflect they are not prioritised in monitoring and evaluation activities. It may nonetheless be relevant to measure these practices, particularly if they can cause avoidable harm.

Strengths and limitations

Strengths of this review include the use of a prespecified review protocol, a broad and comprehensive search strategy (including grey literature), duplicate eligibility screening and random-sample data checking. Nonetheless, we acknowledge some limitations. Twenty-three studies could not be located despite extensive searching and contacting authors. While the final results may differ if these studies were included, this difference is likely to be modest given the large number of studies in the review. As previously described, it was difficult to make judgements on the degree of difference between measures that used similar but not identical definitions.

Scoping reviews do not generally assess the quality of individual studies; however, it is possible that lower-quality studies may be poorer in terms of definitions of measures and measurement approaches. We plan to conduct additional analyses of this database to explore possible differences in the validity and reliability of the intrapartum care measures we identified.

Conclusion

The global ambition to deliver woman-centred intrapartum care that optimises the woman’s health outcomes and experience of labour and childbirth relies on the effective implementation and measurement of evidence-based intrapartum care. Some recommendations, such as respectful maternity care, have a wide range of measures currently in use, highlighting the need to reach a consensus on what measures and methods should be used to evaluate implementation of supportive care during labour and childbirth. This review provides the evidence base from which a core set of reliable, valid intrapartum care measures can be developed for use internationally.

Data availability statement

Data are available upon reasonable request. The data extraction workbook will be made available upon request from JPV (joshua.vogel@burnet.edu.au) from the Burnet Institute, Melbourne.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval was not required as this is a review of published data.

References

Supplementary materials

Footnotes

  • Twitter @CarolineHomer, @josh_vogel

  • Contributors The study was conceived and planned by JPV and LHV with input from CH, FA, VP, MB and EA. LHV conducted the searches, and LHV, AS and RN conducted screening. LHV, RN and AS conducted data extraction and checking. LHV prepared the initial analysis, which was revised following input from JPV and CH. LHV wrote the first draft, which was revised by AS, RN, FA, VP, MB, EA, CH, MB and JPV. LHV is responsible for the overall content as guarantor for this review. All authors reviewed and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.