Measurement and Evaluation in Maternal and Child Healthcare: Diagnosing Poor Quality and Testing Solutions

Abstract

The burden of maternal and child mortality remains high in sub-Saharan Africa (SSA). Over the past 15 years use of health services for childbirth has increased, however there is growing evidence that higher use does not guarantee improved health outcomes. These finding suggest problems with quality. This dissertation diagnoses problems with quality of maternal and child healthcare in SSA (papers 1 and 2), and tests the effect of a quality improvement intervention on quality (paper 2) and use (paper 3) of maternal health services. In the first paper we use cross-sectional data from 16,352 visits for sick children in seven SSA countries to assess the level, predictors, and outcomes of provider-patient communication. We find that communication is low, and higher communication is associated with higher caregiver and provider education. In the second and third papers we test the impact of a quality improvement intervention that targeted both supply- and demand-side elements of maternal healthcare. The second paper uses difference-in-differences analyses to assess the impact of the intervention on process and outcome measures of quality. We find that quality was low across all 18 indicators and the intervention was associated with an increase in one of the 18 indicators. Failure of the intervention to make large improvements in quality was likely due to both low implementation of the intervention and issues in theory. In the third paper we use difference-in-differences analyses to assess the effect of the intervention on use of health facilities for childbirth. The intervention led to a large increase in facility utilization for childbirth among women whose previous delivery was at home and a modest increase among the general population. Overall, this dissertation contributes to the growing evidence that the quality of maternal and child healthcare is low in SSA, and provides new evidence that while clinic-level quality improvement interventions may not be effective in improving measures of quality of labor and delivery care, investment in quality can improve utilization of health facilities for childbirth. Additional research and policy efforts should focus on improving the quality of care for mothers and children in SSA.