Quality assessment of maternal and neonatal health care services using the WHO tool in two national reference maternity hospitals, Djibouti City

¹Clinical Epidemiology and Medico-Surgical Science Department, Center for Doctoral Studies of the Faculty of Medicine and Pharmacy, Rabat, Morocco, ²National School of Public Health, Rabat, Morocco, ³Orangers Maternity Hospital, Rabat-Mohamed V University, Ibn Sina University Hospital, Rabat, Morocco

^&Corresponding author
Yacoub Arbahim Hassan, Clinical Epidemiology and Medico-Surgical Science Department, Center for Doctoral Studies of the Faculty of Medicine and Pharmacy, Rabat, Morocco

Introduction    

The quality of care provided to mothers and newborns is a global challenge that is particularly acute in developing countries [1]. Maternal and neonatal health are major public health issues in Djibouti. As part of the country's commitment to reducing maternal, neonatal, and child mortality, considerable efforts are being made to improve the health of mothers and children, and significant results have been achieved over the past two decades. Maternal mortality fell by nearly 50% between 2000 and 2020, from 740 to 383 per 100,000 live births [2,3]. Between 2002 and 2012, neonatal mortality fell from 45 per 10,000 live births to 36 per 10,000 live births [3].

However, maternal mortality (383 per 100,000 live births), infant and child mortality (68 per 1,000 live births), and neonatal mortality (36 per 1,000 live births) remain high. The causes of maternal and neonatal mortality and morbidity are largely preventable and are mainly due to unequal access to maternal and neonatal healthcare, as well as the limited quality of care and general dysfunctions within the healthcare system [4]. Thus, in response to the Global Strategy for Women's, Children's and Adolescents' Health 2016-2030 and to achieve the 2030 Sustainable Development Goals for maternal and neonatal health, the Djibouti Ministry of Health developed in 2022 the National Strategy for Accelerating the Reduction of Maternal and Neonatal Mortality 2022-2026, based on the vision that all women of childbearing age and newborns in Djibouti enjoy good health, benefiting from accessible, equitable and high-quality healthcare and services.

This objective will be achieved through the adoption of health measures that comply with World Health Organization recommendations, are evidence-based, effective, and have a significant impact on maternal mortality rates, thereby preventing avoidable maternal and neonatal deaths in Djibouti.

To this end, the country has set key targets to reduce the maternal mortality rate to 180 per 100,000 live births and the neonatal mortality rate to 15 per 1,000 live births by 2026. To achieve this, several initiatives have been implemented by the Ministry of Health, including the 2022-2026 strategy for the accelerated reduction of maternal and neonatal mortality with five priority areas. These aim to ensure continuous, comprehensive and integrated healthcare in order to achieve universal health coverage. As part of efforts to improve the quality of maternal and neonatal care in tertiary facilities, we conducted a study to assess the quality of care in two maternity wards using WHO guidelines. The study demonstrated the relevance of using WHO tools to improve the quality of maternal and neonatal care [5,6].

The objective of this study is to identify deviations from WHO standards in the two national reference maternity wards and to propose recommended strategies.

Methods     

Study design: the study was designed as a quality improvement study and is reported in accordance with the WHO 2017 guidelines and standards for improving the quality of maternal and neonatal care in health facilities, ISBN 978-92-4-251121-5 [7].

Settings: the study was conducted between May 2024 and September 2024 in the two national referral maternity wards of the Djibouti University Hospital, a tertiary care facility located in Djibouti City. Each year, approximately 7,000 mothers give birth in the Dar El Hanan maternity ward, and 4,000 give birth in the Cheiko Hospital maternity ward.

Intervention: the intervention comprised three main phases. Phase I was an awareness-raising and training phase, during which hospital staff were informed about the key concepts of respectful care and the existence of WHO standards, ISBN 978-92-4-251121-5 [7]. Phase II aimed to conduct a situation analysis in the form of an observational survey by trained assessors (assessment with WHO grid adapted to improve hospital support services, case management, policies and service organisation). It also involved completing questionnaires adapted to the context and WHO standards among service users (mothers) and service providers (hospital staff) in order to explore their direct experience of QMNC during childbirth and at the place of delivery. Then phase III, based on the survey results, aimed to identify priorities for action and develop recommendations, using a participatory approach, to improve QMNC in both maternity wards.

Phase I: preparation and training for assessment: as part of the assessment of the quality of maternal and neonatal care in hospitals, a workshop was organised to adapt the WHO quality assessment tools and train the assessors. The external peer review at the Dar Elhanan Hospital maternity ward and Cheiko Hospital maternity ward was then conducted over a four-day period, from 6^th to 9^th May, 2024. The assessment was conducted by a team of surveyors trained in the use of the WHO tool.

Phase II: assessment of the quality of maternal and neonatal care

Data collection: this included the main areas of assessment: hospital support services, case management, policies and service organisation. The approach was based on a descriptive, using a mixed qualitative and quantitative approach at three levels of analysis: organisational, managerial, and obstetric and neonatal care. The investigators assessed the Maternal, Newborn, and Child Health (MNCH) services in accordance with the sections of the WHO assessment tool (WHO assessment grid and questionnaire adapted to the context). They also conducted individual interviews with women (11 pregnant women) and health professionals (10 health professionals and students) for each facility.

Information was collected from three sources: direct observation of patient care, review of clinical records, and interviews with hospital staff and women receiving the service, in parallel with observation of the premises. The preliminary results were discussed and validated during the workshop held after the data collection period, on Thursday, 9^th May, 2024. This workshop enabled the evaluation data to be reported and the scoring to be standardised. The results were also transcribed into a pre-prepared Excel file for the survey.

Data analysis and scoring: the assessment of case management is carried out in accordance with the country's current standards of care. For each piece of information collected, the team was asked to assign a score of 3 to 0 for each component evaluated: 3) care meets national and international standards (good, no improvement needed or only minor improvements needed); 2) care is below standard, but there is no significant direct danger to health or violation of human rights (acceptable, improvement needed to reach standard care); 1) inadequate care with serious risks to health or violation of women's and/or children's rights, e.g. omission of evidence-based interventions or information with consequent risk to health or violation of human or children's rights (low, substantial improvement needed to meet standard care); 0: very poor care with systematic and severe risks to the health of mothers and/or newborns (very poor, systematic omission of potentially life-saving interventions or lack of essential safety requirements for key procedures such as cesarean section (CS), blood transfusion, neonatal resuscitation, etc.). NA: the function or activity does not exist in the facility.

Each chapter or sub-chapter is calculated as the sum of the scores divided by the number of items in each chapter. Each chapter and sub-chapter is assessed using the same 0, 1, 2, and 3 scoring system, based on compliance with standards. All data collected using assessment grids and individual interviews with patients and health professionals were considered in the data analysis.

Phase III: the results and recommendations: the primary objective of this phase was the development of recommendations, with a participatory approach, to improve QMNC. A 1-day workshop was organised in order to present results of the survey, identify main gaps in the QMNC, and agree actions for improvement. During the workshop, the results of the assessment of the QMNC were presented by the rapporteur of each assessment group, and time was set aside for a plenary discussion. The participants agreed on the recommendations of every section. Finally, to improve the quality of care, the results and recommendations of priority actions were presented to each facility for the month of September 2024 for the two maternity facility staff.

Ethical consideration: authorization to consult the archives of medical and administrative records and to carry out the evaluation was obtained. All participants gave their consent before the training sessions on the evaluation tools. Anonymity and confidentiality were strictly respected throughout the entire data collection period. Authorization from the Ethics Committee of the National Institute of Public Health of Djibouti was obtained with reference (No.067/INSPD/2024). The authors declare that they have no conflicts of interest related to this study and its results.

Results     

The results of the service quality assessment were obtained through triangulation of the data collected by the investigators. This method allowed each element in the three assessment areas to be given a score: hospital support services, case management, and service policies and organisation. We will therefore present the scoring results for these three areas, in accordance with the WHO tool.

Phase I: preparation and training for assessment: awareness-raising and training three- and two-day training sessions were organised between May and June 2024. A total of 30 health professionals participated in the training. Of these, 13 (43.3%) successfully completed the assessment procedures and carried out assessments of two maternity wards, using the WHO assessment tools. The educational content was rated as ‘effective or very effective´. Phase II: assessment of the QMNC of the physical structure of maternity wards; support services; care provided to pregnant women; organisation and policy of maternity wards. A total of 17 assessment grids were used to assess these three areas, and 20 hospital staff members and 22 patients responded to the survey.

Phase II: assessment of the quality of maternal and neonatal care

Hospital support services: this section presents an overview of hospital support services. These include infrastructure, staffing levels, hospital statistics, health information systems, patient records (including obstetric records), essential medicines, blood products, laboratories, and guidelines and procedures. The quality of care depends on the level of infrastructure, equipment, materials, and management. The tables below show the scores given to each component of hospital support services at Cheiko Hospital and Dar El Hanan Hospital (Table 1).

Physical facilities, staff and basic services: with regard to standards relating to infrastructure, staff and basic services, although a written document on the standard is not available, the Dar El Hanan maternity ward and the Cheiko Hospital maternity ward ensure strict compliance with these standards. However, efforts are needed to improve the allocation of human resources. As for the material resources needed to care for mothers and newborns, efforts to improve are needed to meet standards. At the Cheiko Hospital maternity ward, there is a shortfall in terms of the availability of physical structures and basic services compared to the standards. The maternity ward at Dar El Hanan Hospital offers very satisfactory basic services and provides good accommodation conditions for women. However, improvements are needed in terms of hygiene and cleanliness of the premises.

Statistics, information systems, medical files: with regard to hospital statistics in the two maternity wards, the evaluation results show that statistics and information are available and used by managers for decision-making purposes. In addition, patient records are kept in such a way as to guarantee the confidentiality of information. However, there are still significant shortcomings in the availability of relevant information and statistical indicators on maternal and neonatal health, as well as in the quality of medical record keeping.

Pharmacy management and availability of medications: with regard to medication management, both maternity wards have a list of essential medicines, with compliance with the cold chain and availability of essential medicines. Efforts to improve the organisation and storage of medicines are also necessary, as are labelling and recording. The lack of a system for reporting and recording side effects and medication errors is critical and requires urgent measures to establish this system, which is essential for improving the quality of care in national referral maternity wards.

Equipment and supplies: both maternity wards have the necessary equipment and supplies for obstetric and neonatal care, although some need to be upgraded to meet standards. In addition, the maternity wards have sufficient consumables to ensure adequate care for mothers and newborns; healthcare staff use the equipment at their disposal appropriately. It should be noted that at the Cheiko Hospital maternity ward, critical shortages at the time of the assessment included a lack of transport incubators, CPAP machines, neonatal ventilators and RCF machines.

Laboratory stand: the evaluation results indicate that the laboratory operations of two maternity wards are considered satisfactory and compliant with standards, including in terms of quality control and the use of tests in clinical practice. However, immediate improvements are needed to increase the availability of blood and priority tests as close as possible to delivery rooms and emergency departments in both maternity wards of the university hospital.

Pavillon infrastructure: at two maternity wards, the survey results reveal that hygiene conditions, beds, and the identification system do not comply with standards. Good hygiene conditions in maternity wards are essential to prevent cross-contamination. However, the maternity ward does not have an isolation area in case of infection of the mother and newborn, which is crucial to prevent contamination within the maternity ward. In addition, shortcomings have been identified in terms of accommodation conditions and the management of the department's pharmacy. At the Cheiko maternity ward, there is a need to improve the premises; the gynecology and obstetrics operating theatres and the waiting room need to be reorganised in accordance with standards.

Assessment of the care provided to pregnant women

Labour and vaginal delivery: with regard to the management of normal labour and delivery, the evaluation results reveal very satisfactory data in terms of compliance with standards for the identification and admission of women, as well as maternal monitoring during labour and delivery. However, at the Dar El Hanan University Hospital, the lack of space in the admission room, the absence of a neonatal resuscitation table near the delivery area, and the need to improve electronic foetal monitoring during labour were noted. Particularly in the maternity ward at Cheiko University Hospital, there is an insufficient number of tocographs, with poor conditioning of babies before transfer to the neonatal unit. It is also necessary to improve care during delivery, particularly the management of the fourth stage of labour, in order to prevent postpartum haemorrhage (PPH) (Table 2).

Preeclampsia (PEC) for cesarean sections: with regard to the practice of caesarean sections in the maternity ward, emergency caesarean sections are performed in accordance with standards in terms of indications and treatment time, and the surgical technique used. However, the assessment revealed shortcomings in terms of compliance with aseptic rules in the operating theatre and post-operative follow-up of women. In particular, at the Cheiko Maternity Hospital, we observed non-compliance with the structure of operating theatres for caesarean sections (Table 2).

Support for maternal complications: although maternity ward staff are qualified and trained in managing complications, this section presents several shortcomings that require improvement, including inappropriate use of antibiotic prophylaxis, lack of isolation in cases of septicaemia, and poor monitoring of prevention of mother-to-child transmission of HIV. Coordination between level 3, 2 and 1 care facilities for emergency transfers needs to be strengthened (Table 2).

Newborn care: according to the results of the assessment of routine care provided to newborns at birth and in the first two hours of life, it appears that newborn care is satisfactory, with qualified staff, equipment and essential medicines available. However, there is a need to set up a more suitable kangaroo care unit for the care of premature and low birth weight (LBW) newborns (Table 2).

Care for sick newborns: the results of the assessment concerning sick newborns indicate that general care and treatment conditions are generally satisfactory in both maternity wards. However, regular simulation training on emergency life-saving care for newborns at birth is necessary (Table 2).

Advanced care for newborns: the assessment of the relevance and safety of the standard approach for newborns with health problems in both maternity wards indicates satisfactory results in terms of care provided in the neonatal intensive care unit, particularly with regard to the appropriate use of medication, communication with parents and discharge procedures. However, efforts are needed to address shortcomings in nutritional indicators and the transport of newborns in critical condition. Communication with parents of babies also needs to be improved at Dar El Hanan (Table 2).

Control and monitoring: with regard to monitoring and follow-up, the evaluation data indicate that the monitoring of sick newborns complies with standards, with multiple daily reassessments by doctors and organised follow-up after discharge. However, there is a lack of visibility regarding follow-up after 28 days of life (Table 2).

Assessment of policies and service organization

Infection prevention: nosocomial infections very often complicate the provision of health services in all facilities, hence the need to apply strict control measures to prevent their spread. The survey assessed the availability of sterilisation equipment, final disposal of healthcare-related waste, the availability of soap and running water, hand washbasins, latex gloves, masks and gowns, but also, and above all, standards and protocols for precautionary measures. The results of the assessment indicate that the facility lacks a standards-compliant infection prevention policy. Hence, the need to implement guidelines for hand hygiene, healthcare waste management, and laundry services (Table 3).

Guidelines and audit: according to the survey results, in both maternity wards, there is a need for ongoing training on guidelines for professionals in order to improve their skills in caring for mothers and newborns. At Dar el Hanan University Hospital, guidelines and protocols (printed, distributed, and easily accessible for use in the areas concerned) are available. In addition, case reviews and clinical audits have been introduced. At Cheiko University Hospital, printed guidelines and protocols are not available, and case reviews and clinical audits have yet to be implemented (Table 3).

Access to hospital care and continuity of care: this section assesses whether there are gaps in access to care and continuity of care for mothers and newborns. The results of the assessment highlight the easy accessibility of both maternity wards for the population. However, there is poor coordination with primary health care facilities. Hence, the importance of establishing a coordination plan between level 3 maternity wards and community health centres (Table 3).

Rights of the mother and newborn: the objective of this section is to assess the recognition and respect of patients' rights, particularly those concerning pregnant women, women in labour and newborns. The assessment data from the two maternity wards indicate a satisfactory level of respect for rights and acceptability for mothers and newborns. Indeed, the patient charter has been implemented in the maternity wards, although staff training has yet to be put in place. In addition, the assessment indicates that the patient charter is rarely presented to family members and patients during their stay (Table 3).

Recommendations validated: following the quality assessment, the proposed recommendations were presented to the management of each maternity unit and have been validated by them (Table 4).

Discussion     

This study represents, to our knowledge, the first systematic assessment of the quality of maternal and newborn care (QMNC) conducted in two national referral maternity hospitals in Djibouti; Dar EL Hanan University Hospital Center and Cheiko University Hospital Center, using the World Health Organization standardized assessment tool. The findings provide a comprehensive overview of structural, organizational, and clinical dimensions of care and highlight both areas of satisfactory performance and critical gaps that may adversely affect maternal and neonatal outcomes.

Overall, the results suggest that while essential components of care delivery are in place, significant deficiencies persist, particularly in infrastructure, infection prevention, continuity of care, and quality assurance mechanisms. These findings are consistent with evidence from other low- and middle-income countries, where improvements in service coverage have not always been accompanied by parallel gains in quality of care.

Hospital support services and health system readiness: hospital support services constitute a fundamental prerequisite for safe and effective maternal and neonatal care. In the present study, the availability of essential medicines and the functionality of the cold chain were generally adequate in both facilities. Efforts are needed to improve the allocation of human resources, particularly midwives in the two maternity facilities. Several findings from the literature confirm the links between low numbers of midwives and the quality of maternal and neonatal care [8-10]. However, important structural and organizational shortcomings were identified. Partial compliance with infrastructure standards, including inadequate space, insufficient specialized neonatal equipment, and suboptimal hygiene conditions, mirrors challenges commonly reported in maternity facilities across. Similar results were observed in a study conducted in 32 health facilities in Ethiopia [11].

The absence of dedicated isolation units for maternal and neonatal care, combined with deficiencies in environmental hygiene and the lack of neonatal transport incubators, raises concerns regarding infection prevention and the management of high-risk newborns. Previous studies have demonstrated that such infrastructural limitations are strongly associated with increased risks of healthcare-associated infections and neonatal mortality in resource-constrained settings [7,12].

Health information systems also emerged as a critical weakness. Although routine hospital statistics were available, deficiencies in medical record completeness and the lack of standardized clinical indicators limited the ability to monitor quality of care and clinical outcomes. According to the literature, similar results are observed in developing countries, where incomplete and unreliable data compromise evidence-based decision-making, both at the clinical and managerial levels [13-15]. Medication management was another area of performance. While the availability of essential medicines is a positive observation, the absence of formal mechanisms for reporting medication errors and adverse drug reactions reflects a gap in patient safety practices. Similar deficiencies in hospital-based pharmacovigilance systems have been widely documented in sub-Saharan Africa, highlighting the need to integrate medication safety into broader quality-of-care frameworks [16].

Quality of clinical care during childbirth and obstetric complications: the clinical management of labor and delivery was generally aligned with recommended admission criteria and monitoring practices. Nonetheless, the limited availability of monitoring equipment, particularly cardiotocography, may hinder the early detection of labor complications and negatively affect maternal and neonatal outcomes. Moreover, shortcomings in the management of the fourth stage of labor are of particular concern, given the well-established role of postpartum hemorrhage as the leading cause of maternal mortality both nationally and globally. The acceptable quality of care obtained by our study and the relevance of conducting regular assessments are supported by similar findings in the literature [17]. Another study conducted in the Loire Region of France also demonstrates the impact of following recommendations on reducing maternal and neonatal morbidity and mortality [16,18-19].

Cesarean section care largely adhered to standard indications and surgical techniques. However, observed lapses in aseptic practices and inadequate postoperative follow-up raise concerns regarding the risk of surgical site infections and other postoperative complications. These results are consistent with studies conducted in similar contexts, where shortcomings in infection prevention and post-operative care remain important factors in maternal morbidity [20,21]. Although healthcare providers had received training in the management of obstetric and neonatal complications, gaps persisted between theoretical knowledge and clinical practice. Inappropriate use of antibiotic prophylaxis, the absence of isolation for septic cases, and limited implementation of prevention of mother-to-child transmission of HIV indicate systemic barriers to effective care delivery. As highlighted by Freedman et al. such gaps are often driven by structural and organizational constraints rather than individual provider competence [22].

Neonatal care and continuity of services: neonatal care capacities had both strengths and limitations. The presence of qualified staff and essential consumables enabled immediate care to be provided to newborns. However, we noted that regular simulation training in critical emergency care for newborns at birth is needed in both maternity wards. Furthermore, the absence of a functional kangaroo mother care unit represents a missed opportunity to improve outcomes for preterm and low birth weight infants. The literature shows that implementing the kangaroo method is one of the most effective and cost-effective interventions for reducing neonatal mortality in resource-limited settings [23].

While advanced neonatal care services were generally available, gaps were identified in nutritional supplementation, neonatal transport systems for critically ill newborns, and communication with families. In addition, inadequate postnatal follow-up after discharge compromises continuity of care during a critical period for preventing avoidable neonatal deaths. It is therefore essential to strengthen referral pathways and follow-up mechanisms after discharge from the maternity ward.

Governance, infection prevention, and quality improvement: the absence of comprehensive infection prevention and control policies represents a major governance challenge. In busy maternity wards, inadequate infection prevention and control (IPC) measures significantly increase the risk of cross-transmission and adverse effects, particularly in vulnerable newborns. Similar shortcomings have been documented in other African hospitals, highlighting the need for institutionalised IPC programmes [24].

Quality improvement mechanisms varied considerably between the two maternity wards. The availability of written clinical guidelines and routine clinical audits at Dar El Hanan University Hospital reflects a more advanced quality assurance culture. In contrast, the absence of such tools at Cheiko University Hospital represents a significant barrier to continuous quality improvement, as clinical audit is the cornerstone of evidence-based practice and system learning; these results are consistent with data from the literature [21,25,26].

Although geographical accessibility to maternity services was satisfactory, poor coordination with primary health care facilities revealed gaps in referral and counter-referral systems. This lack of coordination between different levels of care is widely documented in the literature as a major obstacle to the effectiveness of maternal and neonatal care networks [14].

Respect for patient rights: the availability of patient rights charters and general respect for the rights of mothers and newborns are encouraging observations. However, the lack of specific training for healthcare professionals on these charters is likely to limit their adoption and effective application in daily practice. It is essential to integrate the principles of respectful maternity care into routine training and supervision in order to ensure rights-based care.

Strengths and limitations: among the strengths of this study are the use of a standardised WHO tool, triangulation of data sources, and the direct involvement of local health professionals, promoting internal validity and acceptability of the results. The main limitations lie in the small number of maternity wards evaluated. The partial reliance on self-reporting by healthcare professionals, as well as the lack of systematic direct observations for some clinical practices, may constitute additional limitations.

Conclusion     

This assessment highlights the urgent need for targeted improvements in infrastructure, training and policy implementation in order to bring Djibouti's maternity services into line with WHO standards, with the ultimate goal of progressing towards Sustainable Development Goal 3. Regular assessments of the quality of care in maternity wards, with follow-up and evaluation of improvement guidelines, could accelerate the reduction of preventable maternal and neonatal deaths, thereby promoting equitable and quality care for all.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Yacoub Arbahim Hassan and Rachid Bezad contributed to the training of evaluators, peer review process, and to the writing of the article; Sanae Elomranie contributed to the writing of the article. All the authors have read and approved the final version of this manuscript.

Acknowledgments     

Our warmest thanks go first to the Ministry of Health for authorizing this unprecedented peer review process. Next, to our partner who supported us throughout this evaluation project, the WHO. We would also like to express our sincere gratitude to the evaluation teams at both maternity hospitals.

Tables     

Table 1: evaluation of hospital support services in the Dar EL Hanan University Hospital Center Maternity and Cheiko University Hospital Center Maternity, 2024

Table 2: assessment of the care provided to pregnant women and newborns in the Dar EL Hanan University Hospital Center Maternity and Cheiko University Hospital Center Maternity, 2024

Table 3: assessment of policy implementations and the organization of the Dar EL Hanan University Hospital Center Maternity and Cheiko University Hospital Center Maternity, 2024

Table 4: recommendations validated to Dar EL Hanan University Hospital Center Maternity and Cheiko University Hospital Center Maternity, 2024

References