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Considerations for Maternal Health Program Evaluations

Comprehensive evaluations of rural maternal health programs should address both process and outcomes. Process data can be used to improve program components and implementation, while outcomes data can demonstrate achievement of outcomes. Important concepts to consider when planning and conducting an evaluation are:

  • Coverage
  • Equity
  • Quality
  • Person-centered maternal healthcare
  • Value-for-money

Each of these dimensions can be measured according to three standards: theoretical, best possible, or best achievable.

Coverage in maternal health refers to the proportion of eligible women who are participating in the maternal health program being evaluated. Coverage is also known as the “use” of an intervention or “crude coverage”. In recent years, public health researchers have measured “effective coverage”. Effective coverage considers the availability and access to programs (as crude coverage does) as well as the quality or efficacy of the program received by the population.

Equity means that a health program is delivering healthcare and services without variation in quality due to personal characteristics. Maternal health disparities are more pronounced in rural settings due to a range of social determinants of health, which are linked to the same inequities that rural communities experience in the larger social context. As discussed in Module 1, rural women suffer a disproportionately higher burden of chronic diseases and experience higher rates of maternal mortality than their urban counterparts.

Quality is defined by the Institute of Medicine (now the National Academy of Medicine) as

“the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Many quality measures in healthcare are binary (Yes/No). Examples of this are maternal mortality and giving birth at term. However, in maternal health programs, binary measures may not account for multiple determinants that influence outcomes. The quality of maternal care is sometimes measured to account for the content of the care (the procedures) that the woman has received as a key factor of her care. For example, a component of an intervention aiming at preventing iron deficiency in pregnant women might be receiving a blood test or receiving iron supplements.

Person-centered maternity care (PCMC) is a concept that extends beyond the clinical aspects of care to address satisfaction, quality, and human rights in maternal healthcare. PCMC is a new healthcare quality model for maternal health that focuses on the perspective of the individual seeking and receiving care.

This framework has been recently translated into a validated scale for measuring PCMC. This international PCMC scale can be used by researchers, government officials, or health facility administrators and health providers to measure the whole patient experience. While this scale has only been applied in low and middle income countries, it can likely be adapted to rural maternal health programs in the U.S.

Value-for-money (VfM) is the cost-effectiveness of the programs in which stakeholders and donors are investing. The components of a VfM assessment include economy, effectiveness, efficiency, and cost-effectiveness. The goal of a VfM assessment is to see how resources are being used, and ensure they are serving the greater good for the most people. Due to the complexity of maternal health programs, a VfM assessment can be quite challenging. At the same time, a successful VfM assessment can secure a maternal health program's sustainability in a market of limited resources, as funders require increasing assurances that their money is being used appropriately.

Resources to Learn More

Advancing a Conceptual Model to Improve Maternal Health Quality: The Person-centered Care Framework for Reproductive Health Equity
Document
Proposes a framework for improving the quality of reproductive health, addressing determinants of health equity, women's health-seeking behaviors, and quality of care.
Author(s): Sudhinaraset, M., Afulani, P., Diamond-Smith, N., et al.
Citation: Gates Open Research, 1(1)
Date: 2017

Implementing Quality Improvement Projects Toolkit
Document
Designed to help healthcare teams implement the Maternal Safety Bundles developed by the Council on Patient Safety in Women's Health Care to support and sustain quality improvement (QI) and improve maternal health outcomes. Covers team representation, goal setting, measures and metrics, building sustainability, and models for change.
Organization: Council on Patient Safety in Women's Health Care, American College of Obstetricians and Gynecologists (ACOG)
Date: 5/2016