GENERAL TITLE: QUALITY OF CARE STUDY

The general goal of perinatal care is to improve and maintain the health and well-being of mothers, children and families. It involves assessment and continuous monitoring of the state of women’s health and their newborn children.

Assessment of maternal and neonatal care is often considered the responsibility of loca[U1]l and republicanorganizations. However, in 2005,the Ministry of Healthcare issued Order No. 237 regulating self-evaluation of maternities. This meant that each ward’s medical worker and personnel should participate in the assessment to determine the success of ensuring available, accessible, appropriate, and affordable care for mothers, children, and families.

Assessment of medical care includes, but is not limited to, the following:

-Continuous quality improvement, which involves feedback and audit activities;

-Implementation of policies and procedures based on current information, which are reviewed on a regular basis;

-Education of all staff;

-Assessment of the outcome, to include at least a review of maternal and neonatal mortality, major morbidity, and significant incidents;

-Use of hospital services;

-Assessment of the mother’s and child’s integration into the community, including breastfeeding support.

However, external assessment by independent evaluators has certain advantages: the main being impartiality, ensuring transparency of the information obtained for the medical service, the Ministry of Healthcare, international organizations, thus achieving useful information for maternities, “raions,” [local boundaries], regions and the national level.

This study was conducted as part of the projects “Mother and Child Health” and “Modernizing Moldovan Perinatology System,” both supported by SDC. The decision to conduct the study was made by representatives of the SDC Office, the UNICEF Representative Office, the Ministry of Healthcare, and the project implementation agency – the Association of Perinatal Medicine,to measure the impact of the Perinatology Program on mother and child healthat the end of its implementation.

To conduct this study andin order to obtain comparable results, the same methodology as the one used in the 2001assessment study was applied using WHO questionnaires and other questionnaires developed by local authors.

GENERAL PART

The National Perinatology Program was implemented in the Republic in two stages: the first phase, entitled “Improvement of Medical Perinatal Care in the Republic of Moldova” took place from 1998 to 2002, and the second phase,“Promoting Quality Medical Perinatal Care”,was completedbetween2003 and2008, with the support of the Government and the Ministry of Healthcare of the Republic of Moldova, the Swiss Agency for Cooperation and Development, represented by the Cooperation office in Moldova, the Japanese Government and WHO.

The National Program and its outcomes were assessed twice: in the final year of the first stage one (2001) and at the end of the second stage (2008).Both assessment studies were meant to assess the impact and efficiency of the Program on mothers’ and children’s health and on the evolution of medical practices used in perinatal care.

The objectives of the study were as follows:

-to know the level of implementation of mother and child care technologies recommended by WHO;

-to appreciate the level of awareness of mothers regarding postnatal care technologies, including care for the newborn and the child within his/her first year of life, child nutrition, as well as access to medical care;

-to assess the level of knowledge of healthcare workers implementing medical perinatal care technologies promoted by WHO;

-to assess the quality of medical practices in maternity wards;

-to collect information about medical perinatal care in perinatology centres of different levels.

Methodology

Both studies were carried out at the national level, using a wider geographical representation. The method used for both studies in the evaluated localitieswas descriptive-comparative. In the 2001study, the results received from the raions at different stages of implementation were compared and assessed as follows: advanced (Orhei, Ciadir Lunga and Balti), average (Chisinau, maternity 2 and Lapusna) and initial (Tighina).

Given the fact that in 2008 all the localities in the Republic were involved in the program implementation at the same time, the same localities were selected, to be able to compare the progress and in order to ensure a larger representation of localities, adjacent localities from the North and South of the Republic were included.

The study from 2001 included 21 raions and municipalities, while the 2008 study includes24 raions and municipalities (Table 1).

Table 1: Localities covered by the assessment study (2001, 2008)

Team / 2001 / 2008
No. 1 / Balti, Riscani, Glodeni, Singerei, Falesti / Balti, Riscani, Glodeni, Singerei, Briceni
No. 2 / Hincesti, Cimislia, Leova, Basarabeasca, Carpineni / Hincesti, Cimislia, Leova, Basarabeasca, Falesti
No. 3 / Comrat, Ciadir Lunga, Vulcanesti, Taraclia / Comrat, Ciadir Lunga, Vulcanesti, Cahul, Cantemir
No. 4 / Orhei, Telenesti, Rezina, Soldanesti / Orhei, Telenesti, Rezina, Soldanesti, Nisporeni
No. 5 / Chisinau (maternity No. 2), Causeni, Stefan Voda / Chisinau (PerinatologyCenter, Municipal Hospital No. 1), Causeni, Stefan Voda, Anenii Noi

Sampling

The sample size was calculated in the same way for both studies, based on the number of deliveries registered in participating maternities. Considering that the size of the sample was different for every maternity, the localities included in the study were divided into 3 types of sectors:

  • Type I with 600 deliveries, error 10%, expected prevalence 50, design effect 2, confidence interval (CI) 95%, sample size 166;
  • Type II with 1,000 deliveries and sample size 176;
  • Type III with 2,500 deliveries and sample size 186 with the same characteristics.

Questionnaires

During the 2001 study, 4 questionnaires were used,as compared with 10 questionnairesused in2008 (Table 2). This difference is explained by the fact that in 2003, 12 questionnaires recommended by WHO were introduced for the assessmentsof perinatal care, which were more specific and allowedto obtain more information about the services provided in maternities.

WHO questionnaires were adjusted to the conditions in the Republicof Moldovaby including additional questions reflecting the specificities of the Moldovaprogram.

To assess the quality of and access to medical care during pregnancy, the questionnaire “Interview with the Primary Healthcare Worker”, which was developedin 2004, was used in the recent study.

The questionnaire for the assessment of the Medical Perinatal Card (Form 113) and of the Individual Card of the Pregnant and Postpartum Woman (Form 111) was developed and used for the first time in the last study.

The questionnaires “Interview With the Mother (postnatal)” and “Assessment of the Obstetrical and Neonatal Observation Card” were modified for the 2008 study to include questions covering activities and measures carried out in recent years withthe support of the SDC office in Moldova, (information campaigns “For a Beautiful and Healthy Child” and “Childhood without Risk”).

Table 2: Questionnaires used in the Perinatology Program Assessment Studies

(2001, 2008)

2001 / 2008
No. / Name / No. / Name
1. / Questionnaire of the institution included 2 parts: / 1. / Questionnaire of the institution
a) information about the institution
b) data from observation within the maternity ward / 2. / The results of the assessment of labour management, as well as of mother and neonate medical care
2. / Interview with the mother (postnatal) / 3. / Interview with the mother (postnatal)
3. / Interview with the healthcare workers included:
The obstetrician and the midwife
The neonatologist and medical care
The family doctor and his nurse / 4. / Interview with the obstetrician- gynecologist
5. / Interview with the midwife
6. / Interview with the neonatologist
7. / Interview with the nurse
8. / Interview with primary healthcare workers (family doctor, family nurse)
4. / Assessment questionnaire of the Obstetrical and neonatal observation card / 9. / Questionnaire for the assessment of the Obstetrical and Neonatal Observation Card
10. / Questionnaire for the assessment of the Medical Perinatal Card (Form 113) and of the Individual Card of the Pregnant and Postpartum Woman (Form 111)

The questionnaires included in both studies are listed in Table 3.

Table 3: The number of questionnaires included in both studies

Name / No. of collected questionnaires / Name / No. of collected questionnaires
Questionnaire of the institution No. 1. Part 1 / 21 / Questionnaire of the institution No. 1. Part 1 / 24
Part 2. The observation data from the maternity / 144 / Results of the assessment of labour management, as well as of mother and neonate medical care / 136
Interview with the mother (postnatal) / 3,274 / Interview with the mother (postnatal) / 4,046
Interview with the healthcare workers:
- family doctors
- family nurses
- midwives
- obstetricians-gynecologists
- maternity nurses
- neonatologists / 1,270
290
684
99
90
76
31 / Interview with the healthcare workers / 1,429
Interview with primary healthcare workers:
- family doctors
- family nurses
-obstetricians
-consultants / 359
721
28
Interview with the obstetrician-gynecologist / 95
Interview with the midwife / 109
Interview with the neonatologist / 33
Interview with the nurse / 73
Questionnaire for the assessment of the Obstetrical and Neonatal Observation Card / 3,280 / Questionnaire for the assessment of the Obstetrical and Neonatal Observation Card / 4,043
Questionnaire for the assessment of the Medical Perinatal Card (Form 113) and of the Individual Card of the Pregnant and Postpartum Woman (Form 111) / 3,887
3,959
The fieldwork method

In both studies, field data were collected by five teams, consisting of three field operators, a team coordinator and a driver. Each team travelled in a rented car with a driver, who was member of the team.

Both studies were carried out within fiveto six weeks.

The first destination was the local maternity, where the team leaderselected the sample for the study on the basis ofthe registry of deliveries from the previous year.

The sampling interval was calculated by dividing the number of deliveries which took place in the maternity in 2007 by the sample size, according to the sector type (for example, to calculate the interval for a Type II sector, the number of deliveries is divided by 176). The obtained interval was 5,68 rounded to 6. Thus, each sixth woman, starting with the last woman who delivered before the team arrived to the maternity, was included in the study.

The number of women selected corresponded to the size of the sample for each sector type. The sample size was representative for each raion (ME=10%, IÎ 95%).

All women included in the study were visited at home in the localities where they live. Obstetrical and neonatal cards of women were taken from the archive and examined by the team leader (an obstetrician-gynaecologistby profession) who remained in the maternity throughout the study and, in addition to the examination of cards, supervised medical practices during deliveries and interviewed healthcare workers of the maternity.

Members of the fieldwork team visited the womenincluded in the study, examined their Medical Perinatal Cards (Form 113), interviewed primary healthcare workers (family doctors, family nurses) and examined the Card of the Pregnant and Postpartum Woman (Form 111).

Data processing and analysis

The data wasintroduced and processed by four operators in the Statistics and Mathematical Analysis Department of the Cardiology Institute. The analysis of statistical data was carried out using the SPSS program.

For each questionnaire the frequency at the raion, region and national level was calculated.

1

CHAPTER 1- knowledge, skills and information of mothers on perinatal care
PartI. General information

Within the 2008study, 4’046 women were interviewed, compared to 3,274 women in 2001.

Overall, over 50% of the total number of women included in both studies were19 to 25 years old, the most active reproductive age.An absolute majority (about 80 %) of interviewed women had 1-3 pregnancies. About 45-60 % delivered once, 30 % twice and 10-15 % three times. In the 2008 study, 1, 6 % of all interviewed mothers stated that they had had 1-2 stillbirths, compared to 3, 5 %in 2001.

The rate of VLBW neonates in interviewed women, before the last delivery, was practically halved, with 7% in 2001 and 4, 5 % in 2008.

For 96 % of women interviewed in 2001 and 97, 7 % of those interviewed in 2008, the last pregnancy ended with a live birth in term. In 2008 the share of mothers who delivered a preterm baby was 1, 5 times smaller (3, 9 %), than in 2001 (6, 2 %).

The last delivery was natural in 96 % of the cases in 2001 and in 91 % in 2008, the number of children born through caesarean section being higher in 2008 (8, 3 % compared to 4, and 3% in 2001).Furthermore, in 2008,the ventousewas used in 0, 3 % of deliveries, while in 2001 there was no such case as vacuum-extractors were provided to all first level maternities in the Republicin 2007 with the support of the first Swiss Grant.

In the majority of cases, the child was with the mother during the interview (99, 3% in 2008, compared to 97, 7 in 2001). 2, 3% (67) children were not with their mothers during the interview in 2001, compared to 0, 7% (30) in 2008. Of the children who were not with their mother in 2008, 11 (42%) were abandoned (being placed in orphanage), which is twice the number in 2001 (15 children or 22,4%), 8 (30,8%) were with their grandparents, compared to 16,4% in 2001 (11 children), the rest of them were with somebody else: 1 (4%) with relatives, 6 (23,1%) with occasional people[U2], compared to data from 2001 (3% (2 children) with relatives and 58,2% (39 children) with occasional people, respectively).

Both studies included more women from the rural area (70% in 2001 and 66, 3 % in 2008) than from the urban area (30% in 2001 and 33, 4 % in 2008).

Part II. PRENATAL CARE

Registering during pregnancy

The comparison of data shows that the rate of early registration (before 12 weeks of pregnancy)of pregnant women with the doctor is 30% higher in 2008 (81, 90%) compared to 2001 (51, 2%).

According to official statistics (2008), 77,1% of pregnant women were registered early, which represents a slight decrease, compared to 2007 (78%).

Prenatal care provider

The key person providing healthcare during pregnancy and after discharge from maternity is the family doctor(FD) together with the perinatal nurse.

Inthe 2008study, when asked which specialist supervised women during pregnancy, 91,6% mentioned the family doctor (compared to 68%in 2001, 77%in 2004), 0,6% the obstetrician-gynecologist (compared to 93,9% in 2001), 6,2% the nurse (12,4% in 2001) and 0,1% other specialists (compared to 50,2% midwife and 4,1% some other specialist). 98,5% of women who were permanently supervised by the family doctor were seenby the gynaecologist.

The results thus show that the share of women consulting the family doctor increased in sevenyears by 24%.There is a large coverage ofantenatal care provided by qualified healthcare workers in the Republic of Moldova and the survey reveal an increased trust bywomen in the family doctor.

The number of prenatal visits

An increase in the application of the standard on the number of visits to the family doctor during pregnancy: if in 2001, 44, 3 % respondents made 6-9 visits to the doctor during pregnancy, in 2008 the share increased up to 75, 2 %. It is worth noting that the number of women who visited the doctor 10 times and more decreased by 20%, from 39, 4% in 2001 to 1, 8% in 2008.

On the level of the visits to the obstetrician –gynaecologist, in 2008, 40,7% of the respondents visited this practitionerthree times during the last pregnancy, and 9,3% visited him/her more than 3 times, which does not correspond to national standards in case of physiological pregnancy.

Women’s preferences regarding the specialist to supervise them during pregnancy

Of all women interviewed in 2008, 60,8% mentioned that they prefer to be supervised during pregnancy by the family doctor, 34,3% of them by the obstetrician-gynecologist, 4,8% by the midwife and the nurse.

51% women mentioned that they want to have the specialist who supervises them during pregnancy present during delivery.

Medical care and procedures during pregnancy

During prenatal visits, an increasing majority of women were provided with medical care and underwent the procedures listed in the Program of investigations during pregnancy:

BP measurement- 99,5% (2008) vs. 98,6% (2001)

blood count - 98,7% women (2008) vs. 98,4% (2001)

urinalysis - 98% women in 2008 vs. 96,7% in 2001

weighing-97,3% women in 2008 vs. 92,4% women in 2001

abdominal girth measurement - 94,5% women (2008) vs. 92,6% (2001).

The data indicate that the care and procedures provided to women during pregnancy comply with the Program of investigations during pregnancy.

Medical advice

In 2008, 95,2 % of women were recommended to take iron supplements, 80,4% to take folic acid, and 73% received information about appropriate nutrition during pregnancy and behaviour in case of danger signs. Compared to 2001, the level of counselling on these procedures significantly increased, as 7 years ago, 58% women were recommended to take iron supplements, 31% women were recommended to take folic acid, 55,8% were advised behaviour in case of emergency.

Manyfewer women received advice on the following issues during the reference years: advantages of natural nutrition (73,5% in 2001 compared to 59% women in 2008), the place where they should deliver (54,3% in 2001 compared to 47% in 2008), family planning/contraception (52% in 2001 compared to 43% women in 2008), child care (64,7% in 2001 compared to 49% women in 2008). Information about signs of labour was only provided to 45,9% women in 2008.

Obviously, in 2008 fewer women were given advice on certain issues.

Doctor’s advice on pregnant woman’s diet

The healthcare worker supervising the pregnancy counsels the pregnant woman on nutrition, during every prenatal visit.

The 2008 study reveals that primary healthcare workers gave less adviceabout appropriate nutritionto pregnant women than 2001:

  • to eat as much as they want in 50,3% cases (2001) and 33,7% cases (2008)
  • to consume more protein in 61,8% (2001), compared to 41,4% cases (2008)
  • consume fibre in 47,8% cases (2001), compared to 33% cases (2008)
  • fruit and juice in 85,6% cases (2001) compared to 78% cases (2008)
  • calcium in 62,9% cases in 2001, compared to 70% in 2008
  • vitamin D (42,2% in 2001, compared to 47% in 2008)
  • to reduce fat consumption (56,3% cases in 2001, compared to 49% in 2008)
  • sugar consumption (58,1% in 2001, compared to 46% in 2008)
  • salt consumption in 65,8% in 2001, compared to 57% cases in 2008
Administration of iron supplements to pregnant women

Between 2001 and 2008, the share of women who used iron supplements increased by almost 30% (from 68% to96,6%). Being asked about the duration of taking iron supplements, 10,1% respondents mentioned one month, 13,6% mentioned two months, 17,2% - 3 months and 59% women- more than three months.

Folic acid

Between 2001 and 2008, the share of pregnant women who took folic acid increased by 50% (fig. 9),which is due to the effect of the national communication campaign “For AHealthy and Beautiful Child” on the behaviour of pregnant women.