In the last 25 years, the global maternal mortality ratio (MMR) declined nearly 44%.[1] Despite this global decline, the burden of maternal mortality differs considerably by country economic development status and geographic region.[1] For example, low- and middle-income countries (LMICs) account for approximately 99% of global maternal deaths.[1] Among high-income countries (HICs), MMR rates steadily declined from 1990 to 2015, with the United States having the highest rates of maternal deaths compared to its peer HICs.[2] In 2015, all United Nations member countries adopted the 2030 Agenda for Sustainable Development.[3] The agenda outlines 17 Sustainable Development Goals (SDGs) and 169 targets that represent a call to action for all countries—developed and developing—to “ensure healthy lives and promote wellbeing for all at all ages”.[3] In particular, the aim of SDG Target 3.1 is to “reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. [3] Available evidence suggests that if all participating countries meet SDG Target 3.1, the lives of an estimated 1.6 million women could be saved.[4] There is growing consensus that targeting maternal care quality will be a necessary approach to achieving the SDG Target 3.1. [5–7]
The burgeoning literature suggests that increasing maternal healthcare access alone is insufficient for achieving SDG Target 3.1.[6] First, access to maternal healthcare services does not guarantee high quality care. For example, women across multiple country contexts report experiences of poor quality maternal care which often can deter them from seeking or utilizing necessary maternal care services even if they are readily accessible. [5, 8–11] Second, access to maternal healthcare does not appear to guarantee significant reductions in maternal mortality. For instance, one study found that high coverage of essential maternal health interventions was not associated with reduced maternal mortality in over 300 health facilities across 29 countries.[12] The authors suggest that both maternal healthcare access and maternal care quality need to be addressed in order to dramatically reduce adverse maternal health outcomes.[12] Thus, targeting maternal care quality may be a crucial step towards reducing the global burden of maternal mortality.[6]
In order to reduce the global burden maternal mortality and achieve SDG Target 3.1, health practitioners and researchers must be able to continuously measure and assess maternal care quality. This requires appropriate indicators that will facilitate the identification and tailoring of suitable maternal and child health interventions. To date, there is no gold standard for the definition, conceptualization, and measurement of maternal care quality. An example of a contemporary definition of maternal care quality is “the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights.”[13] Several frameworks have also been developed to conceptualize maternal care quality.[13–16] Based on the literature, maternal care quality is a multidimensional, contested and complex concept that presents challenges in conceptualization and measurement.[17] A key example is the work of Donabedian (1988) that outlined three components of care quality: structure (e.g., material resources, human resources, organizational structure), process (e.g., what is done in giving and receiving care), and outcomes (e.g., effects of care on the health status of patients and populations).[14] However, there have been challenges with the measurements of these domains either separately or holistically. The lack of consensus and heterogeneity in theoretical frameworks limits studies’ generalizability and comparability. [15, 18]
In terms of measurement, most of what has been developed are clinical indicators that focus either on a single or multiple aspects of maternal care quality. Less is known about patient-reported measures of maternal care quality, which can be useful for monitoring and improving factors known to influence women’s health outcomes and healthcare utilization behaviors. Furthermore, there are a number of limitations that beset existing measures and clinical indicators. Most of these constructs and indicators do not have formative work, have not been systematically validated for assessing routine antenatal, intrapartum, and immediate postpartum care, and differ in geographical use. [6] Also, existing measures and indicators are often long, difficult to administer, and require significant financial and human resources to implement.[19, 20] The large number of indicators increases difficulty with routine assessment and the likelihood of measurement errors.[19–22]
Scoping Review Objectives
The objectives of this scoping review are to (1) understand how maternal care quality has been defined, conceptualized, and measured; and (2) identify, evaluate, and summarize existing patient-reported measures of maternal care quality.
Prior reviews on maternal care quality and measurement have largely focused on clinical indicators rather than patient-reported measures; and developing countries rather than multiple country contexts. [18, 21, 23, 24] To our knowledge, our scoping review will be the first to summarize the ways in which patient-reported maternal care quality is defined, conceptualized, and measured across low-, middle-, and high-income countries; and to provide a summary of existing high-quality, validated patient-reported measures and their corresponding country context.