Table 2.

Summary of main quality gaps emerging from the baseline assessments: provision of effective, safe and respectful care to pregnant women and mothers (compared with WHO standards 1, 2, 4, 5 and 6) [7]

WHO quality standards	Areas where serious gaps were identified in at least 1/3 of the health facilities	Examples of gaps
Standard 1: Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO guidelines	Monitoring of maternal and foetal conditions during labour and birth	Partographs often filled in a posteriori.
		Fetal Heart Rate (FHR) rarely auscultated more than 4-hourly, usually at time of vaginal examinations, when missing recordings are frequently filled in.
		Maternal heart rate never taken alongside the FHR, and never recorded.
		In-out fluids and medications rarely recorded.
	Excess and/or inappropriate intervention	Excess of episiotomies.
		Potentially harmful procedures: catheterization shortly after delivery in the absence of postpartum haemorrhage, routine vaginal examination after vaginal delivery for the extraction of clots.
Standard 2: The health information system enables use of data to ensure early, appropriate action to improve the care of every woman and newborn		Unnecessary use of combination of drugs, eg, antihypertensive drugs.
	Early identification and management of emergencies	Women left without assessment of progress for over 5 h.
		Insufficient measurement of blood loss and inappropriate management of 3rd stage of labour.
		Use of IV oxytocin to augment labour not recorded on partograph, nor anywhere else. Oxytocin used in absence of close monitoring, including FHR.
		Vaginal delivery after previous Caesarean Section (CS) offered, but without closer monitoring of maternal and foetal conditions.
		Lack of basic emergency procedures such as correctly positioning the patient.
		No coordinated reaction when an emergency occurs.
	Management of complications	Inappropriate/outdated management of severe preeclampsia.
		Administration of Magnesium Sulphate without indication of timing, delays between prescription and administration of drugs, blood and urine tests requested but results not recorded.
		Women who experienced complications discharged too soon.
	Caesarean section indications and procedures	General anaesthesia used for CS.Indications for CS not reported, sometimes questionable: (eg, obstructed labour when the partograph action line has not been crossed; foetal distress when FHR is not measured).
Standard 4: Communication with women and their families is effective and responds to their needs and preferences	Effective communication	Women not told about indications for CS and not given information about their baby’s conditions.
		Women poorly informed about appropriate care after discharge.
		Women not involved in decisions regarding care for them and their baby.
Standard 5: Women and newborns receive care with respect and preservation of their dignity	Respect and dignity	Freedom to move in labor not ensured
		Lack of privacy during birth.
		Disrespectful attitude, inadequate consideration of feelings.
		Users’ needs neglected in ward lay-out.
Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman’s capability	Emotional support	Companion’s presence not allowed/ encouraged during labour and birth.
		One-to-one care not ensured.