It takes the whole health system to improve quality of care for mothers and newborns

A new WHO report on improving quality of care for maternal, newborn, and child health argues that it takes time to bring about changes in quality of care 

In 2017, 10 countries—Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Sierra Leone, Uganda, and the United Republic of Tanzania—formed an alliance to deliver the vision that every pregnant woman and newborn receives quality care with equity and dignity. Together with the World Health Organization (WHO) and a coalition of partners, they established the Network for Improving Quality of Care for Maternal, Newborn and Child Health (MNCH) to share learning around quality of care implementation and generate solutions to the most pressing challenges.1

The network recognized that strengthening the delivery of quality care was critical to achieving their health related sustainable development goals (SDGs) for MNCH and to reaching universal health coverage by 2030. We know this because despite improvements in access to and coverage of live saving MNCH interventions, around 60% of neonatal conditions and half of maternal deaths in low and middle income countries are due to poor quality services.2 Efforts to improve quality of care are often fragmented, project based, and not integrated within government systems. Delivering services with quality is beset by persistent challenges, such as weak infrastructure; limited data; inadequate workforce; and poor water, sanitation, and hygiene (WASH) in facilities.

Resolutions and reports by WHO and the United Nations have called for urgent action on universal health coverage with quality3-6 and to strengthen primary healthcare (PHC).7 But more learning is needed to understand how to deliver quality of care for MNCH in an effective, scalable, and sustainable way. 

A new WHO report shows how the network is informing learning on how to implement and institutionalize quality of care for MNCH across the health system.8 The report is based on four years of implementation and shows that it takes a whole health system to improve quality of care and requires time and commitment to make the necessary activities, structures, and values an integrated and sustainable part of the health system. 

The report demonstrates institutionalizing quality of care into the functioning of health systems has advanced in those countries that have developed, strengthened, and integrated quality of care structures with other ongoing health system strengthening efforts. The implementation of quality of care is reinforced by the adaptation and adoption of WHO standards for improving quality of maternal and newborn care in health facilities.9 The combination of these elements provide the workforce with the tools and the supportive organizational culture needed to deliver quality of care.  

The application of MNCH quality of care standards linked with quality improvement efforts has enormous potential for impact. For example, emerging results from Bangladesh show significantly improved maternal and newborn care outcomes.8 However, quality improvement interventions for MNCH implemented in health facilities will only bring about small scale changes if systemic resource gaps, such as fit for purpose infrastructure, adequate WASH, and qualified staff, are not addressed.

The report shows measurement and learning is at the heart of quality of care efforts. Network countries agreed on a common set of quality of care indicators for maternal and newborn health to measure whether results are achieved. Progress in collecting and sharing these data varies across countries, reflecting the capacity and constraints of the health information system. The facilitated peer to peer platform of collaboration and mentoring has provided a trusted space for country leadership and stakeholders to exchange ideas and solutions to such implementation challenges. Documenting and sharing quality of care lessons can help build more effective programmes when they report and respond to why improvement ideas worked or not. 

But it takes time and long term commitment to establish the structures, workforce capacities, and partnerships that form the basis to sustaining and scaling up quality of care. And it is still too early to say whether these structures will endure once established. For example, during covid-19, the first activities to be suspended were related to quality improvement coaching. This de-prioritization of support to quality in a time of crisis only serves to reinforce that quality of care has still to be considered essential to service delivery. 

What is the way forward for the network?

Quality of care cannot be implemented without broader health system strengthening. Network countries are using the introduction of quality of care standards for MNCH to open this broader discussion on how to change and support services that are delivered with quality. Network countries must continue to develop their quality of care structures and systems from national and sub-national to the point of care, and integrate them to support the delivery of MNCH programmes with quality. Outstanding and emerging priorities, such as the systematisation of community engagement in quality of care design and decision making and accountability, will require attention and action.

The network has stimulated change through enhancing cross-country partnerships and enabling learning on quality of care. Moving forward, the network can aspire to be a bridge that facilitates the exchange of ideas and solutions to implementation challenges for MNCH quality of care, and across programmes, countries, and regions.

Setting up and managing this type of network has required partnership, leadership, and resources from national governments, partners, and WHO. This kind of commitment will continue to be required for the network to achieve its goals. 

Blerta Maliqi is team lead policies, strategies, and programmes in the Department of Maternal Newborn Child Adolescent Health and Ageing at the World Health Organization (WHO) and leads the WHO-based secretariat of the Network for Improving Quality of Care for Maternal, Newborn and Child Health, based in Geneva, Switzerland. 

Rachael Hinton is an independent consultant based in Geneva, Switzerland.

Moise Muzigaba is the quality of care measurement technical officer and leads quality of care measurement for maternal, newborn, and child health in the Department of Maternal Newborn Child Adolescent Health and Ageing at the World Health Organization, Geneva, Switzerland.

Nuhu Yaqub Jr is technical officer for quality management in the Universal Health Coverage – Life Course Cluster at the World Health Organization Regional Office for Africa and coordinates technical support to countries for the Network for Improving Quality of Care for Maternal, Newborn and Child Health. 

Anshu Banerjee is director, Department of Maternal Newborn Child Adolescent Health and Ageing at the World Health Organization, Geneva, Switzerland. 


The authors gratefully acknowledge the contributions of various individuals, organizations, and countries that have contributed immensely to the conception of the Network for Improving Quality of Care for Maternal, Newborn and Child Health as well as the implementation of network activities in participating countries since 2017. 

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

We have read and understood BMJ policy on declaration of interests and declare the following interests: none.


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