Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study

BackgroundIn low-resource settings where disease burdens remain high and many health facilities lack essentials such as drugs or commodities, functional equipment, and trained personnel, poor quality of care often results and the impact can be profound. In this paper, we systematically quantify the potential gain of addressing quality of care globally using country-level data about antenatal, childbirth, and postnatal care interventions.Methods and findingsIn this study, we created deterministic models to project health outcomes if quality of care was addressed in a representative sample of 81 low- and middle-income countries (LMICs). First, available data from health facility surveys (e.g., Service Provision Assessment [SPA] and Service Availability and Readiness Assessment [SARA]) conducted 2007–2016 were linked to household surveys (e.g., Demographic and Health Surveys [DHS] and Multiple Indicator Cluster Surveys [MICS]) to estimate baseline coverage for a core subset of 19 maternal and newborn health interventions. Next, models were constructed with the Lives Saved Tool (LiST) using country-specific baseline levels in countries with a linked dataset (n = 17) and sample medians applied as a proxy in countries without linked data. Lastly, these 2016 starting baseline levels were raised to reach targets in 2020 as endline based upon country-specific utilization (e.g., proportion of women who attended 4+ antenatal visits, percentage of births delivered in a health facility) from the latest DHS or MICS population-based reports. Our findings indicate that if high-quality health systems could effectively deliver this subset of evidence-based interventions to mothers and their newborns who are already seeking care, there would be an estimated 28% decrease in maternal deaths, 28% decrease in neonatal deaths, and 22% fewer stillbirths compared to a scenario without any change or improvement in quality of care. Totals of 86,000 (range, 77,800–92,400) maternal and 0.67 million (range, 0.59 million–0.75 million) neonatal lives could be saved, and 0.52 million (range, 0.48 million–0.55 million) stillbirths could be prevented across the 81 countries in the calendar year 2020 when adequate quality care is provided at current levels of utilization. Limitations include the paucity of data to individually assess quality of care for each intervention in all LMICs and the necessary assumption that quality of care being provided among the subset of countries with linked datasets is comparable or representative of LMICs overall.ConclusionsOur findings suggest that efforts to close the quality gap would still produce substantial benefits at current levels of access or utilization. With estimated mortality rate declines of 21%–32% on average, gains from this first step would be significant if quality was improved for selected antenatal, intrapartum, and postnatal interventions to benefit pregnant women and newborns seeking care. Interventions provided at or around the time of childbirth are most critical and accounted for 64% of the impact overall estimated in this quality improvement analysis.

研究背景 在医疗资源匮乏地区，疾病负担居高不下，众多医疗卫生机构缺乏药品耗材、功能完备的设备以及专业培训人员等基本物资，往往导致医疗服务质量低下，其影响深远。本研究依托涵盖产前、分娩及产后护理干预的国家级数据，系统性量化全球范围内改善医疗服务质量可带来的潜在收益。

研究方法与结果 本研究针对81个中低收入国家（low- and middle-income countries, LMICs）的代表性样本，构建确定性模型以预测改善医疗服务质量后的健康结局。首先，将2007至2016年间开展的医疗卫生机构调查（如服务提供评估[Service Provision Assessment, SPA]与服务可及性及准备度评估[Service Availability and Readiness Assessment, SARA]）的现有数据，与家庭调查（如人口与健康调查[Demographic and Health Surveys, DHS]及多指标类集调查[Multiple Indicator Cluster Surveys, MICS]）进行关联，以此估算19项核心母婴健康干预措施的基线覆盖率。其次，借助生命拯救工具[Lives Saved Tool, LiST]构建模型：对于拥有关联数据集的17个国家，采用其本国特异性基线水平；对于无关联数据的国家，则以样本中位数作为替代指标。最后，基于最新DHS或MICS人群报告中的本国特异性医疗服务利用率（如完成4次及以上产前检查的女性占比、医疗机构分娩占比），将2016年的初始基线水平提升至2020年的终期目标。研究结果显示，相较于未对医疗服务质量做出任何改变或提升的情景，若高质量医疗卫生体系能够为已寻求医疗服务的孕产妇及其新生儿有效提供该系列循证干预措施，预计可使孕产妇死亡数下降28%、新生儿死亡数下降28%，死胎数减少22%。在2020日历年中，若按当前利用率水平提供合格的高质量医疗服务，81个国家总计可挽救8.6万例（区间：7.78万~9.24万）孕产妇生命、67万例（区间：59万~75万）新生儿生命，并避免52万例（区间：48万~55万）死胎发生。本研究存在一定局限性：一是缺乏足够数据以在所有中低收入国家中单独评估每项干预措施的医疗服务质量；二是需做出必要假设，即拥有关联数据集的样本国家所提供的医疗服务质量，可代表整体中低收入国家的水平。

研究结论 本研究结果表明，即使在当前的医疗服务可及性或利用率水平下，缩小医疗服务质量差距的举措仍可带来显著收益。若针对选定的产前、分娩期及产后干预措施提升质量，使寻求医疗服务的孕产妇及新生儿获益，预计平均可使死亡率下降21%~32%，该初步提升将带来可观的收益。在本次质量改善分析中，分娩期间及临近分娩时提供的干预措施最为关键，其贡献占总影响的64%。