Provision of Care

Key and emerging evidence

This page includes a curated list of select resources presenting key evidence on quality of care during labor and birth, the impact of poor quality MNH care, the effectiveness of strategies to improve quality of care, and a report on progress – with additional resources to be added on an ongoing basis.

Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries, The Lancet, 2016

This study analyzed 2016 data from 137 countries on deaths amenable to health care in LMICs and estimated the proportion of these deaths that are due to poor quality of care versus non-utilization of care.   

Key finding

  • Poor quality of care was estimated to account for over half (55%) of deaths amenable to health care across 61 common conditions, including 61% of neonatal deaths and half of deaths from maternal causes

Quality care during labor and birth: a multi-country analysis of health system bottlenecks and potential solutions, BMC Pregnancy & Childbirth, 2015

This article describes the findings of an analysis in 12 countries in Africa and Asia to synthesize and grade health system “bottlenecks”, or factors that hinder the scale up, of maternal-newborn intervention packages. Health financing and health workforce were critical bottlenecks for skilled birth attendance. Health service delivery bottlenecks were the most critical for both basic and comprehensive emergency obstetric care. Health financing was a critical bottleneck for comprehensive emergency obstetric care. Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, solutions included improving quality of care and establishing public private partnerships. 

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity are worldwide, The Lancet, 2018

This systematic review categorizes evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care as recommended, recommended only for clinical indications, and not recommended. It also presents prevalence data from middle-income countries for specific clinical practices, which demonstrate “too little too late” (care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help) and increasing “too much too soon” (unnecessary use of non-evidence-based interventions, as well as use of interventions that can be lifesaving when used appropriately, but harmful when applied routinely or overused).  

Key messages

  • Adherence to evidence-based guidelines could help health-care providers to avoid “too little too late” and “too much too soon.”
  • “Too little too late” is found everywhere there are disparities in socio-demographic variables, including, wealth, age, and migrant status.
  • “Too much too soon” is rapidly increasing everywhere, particularly as more women use facilities for childbirth. Increasing rates of potentially harmful practices, especially in the private sector, reflect weak regulatory capacity as well as little adherence to evidence-based guidelines.
  • Caesarean section illustrates both “too little too late” and “too much too soon” with disparate rates between and within countries, and higher rates in private practice and higher wealth quintiles. Rates are highest in middle-income countries and rising in most low-income countries.
  • Quality clinical practice guidelines need to be developed that reflect consensus among guideline developers, using similar language, similar strengths of recommendation, and agreement on direction of recommendations.
  • Strategies for enhanced implementation and adherence to guidelines need multisectoral input and rigorous implementation science.
  • A global approach that supports effective and sustained implementation of respectful, evidence-based care for routine antenatal, intrapartum, and postnatal care is urgently needed.

Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study, Plos Medicine, 2019

The authors of this paper systematically quantify the potential gain of addressing quality of care globally using country-level data about antenatal, childbirth, and postnatal care interventions. They created models to project health outcomes if quality of care was addressed in a representative sample of 81 low- and middle-income countries (LMICs). Findings indicated that if health systems could effectively deliver a subset of evidence-based interventions to women and newborns who are already seeking care, there would be an estimated 28% decrease in maternal deaths, 28% decrease in neonatal deaths, and 22% fewer stillbirths compared to no change or improvement in quality of care.  Interventions provided at or around the time of childbirth were most critical (64% of the estimated impact overall). This suggests that efforts to close the quality gap would still produce substantial benefits at current levels of access or utilization. 

The Lancet Series “Optimising ceasarean section use”, The Lancet, 2018

Caesarean section (CS) use has increased over the past 30 years (over the 10–15% of births considered optimal) without significant maternal or perinatal benefits. This three-part Lancet Series reviews the global epidemiology and disparities in CS use, as well as the health effects for women and children, and lays out interventions and actions to reduce unnecessary CSs.  

Key messages

  • CS use is increasing in all regions. In most countries, CS use has reached a frequency well above what is expected on the basis of obstetric indications.  
  • Inadequate access to CS is still a problem in most low-income and several middle-income countries. The low use of CS implies that women and babies are at much higher risks of dying. 
  • Optimizing CS use is needed. We need to better understand demand and supply factors that drive the overuse of CS and put more effort into ensuring universal access to CS. 
  • CS confers an increased risk of maternal mortality and severe acute morbidity and a higher risk for adverse outcomes in subsequent pregnancy compared with vaginal birth. Multiple CSs are associated with a higher risk of maternal morbidity and mortality. 
  • Infants born by CS have different hormonal, physical, bacterial, and medical exposures and are exposed to more short-term risks compared with those born vaginally. 
  • Approaches that prioritize positive human relationships, promote respectful and collaborative multidisciplinary teamwork, and address clinicians’ beliefs and attitudes and women’s fear of labor pain and of poor quality of care might reduce CS use.  
  • Multifaceted strategies are needed to reduce CS use and to increase physiological birth for healthy women and babies; these strategies must be tested, and tailored to local determinants. 

The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicounty, facility based, observational study, The Lancet Global Health, 2020

This study describes the care received by neonates up to 2 hours after birth in Ghana, Guinea, and Nigeria. Data from this facility-based, observational study were collected on 15 neonatal care practices across 9 facilities, as part of WHO’s wider multi-country study on how women are treated during childbirth. Between 2016 to 2018, data was collected about neonatal care practices for 1,627 woman-neonate dyads.

Key findings

  • 91.8% of neonates received delayed cord clamping
  • At 64.4%, practices such as skin-to-skin contact were less commonly done
  • 51.9% of mothers and neonates were separated during the first 2 hour after birth (more common for mothers who were single than those who were married or cohabiting)
  • Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices.
  • Neonates with a low birthweight were more likely to not begin breastfeeding on demand than full weight neonates

Quality of Care Network report: Evolution, Implementation and Progress 2017-2020, WHO, 2021

This report reviews progress in 10 countries participating in the Network for improving quality of care for maternal, newborn, and child health. It also includes a set of related briefs: a summary brief, a knowledge brief on leadership, a knowledge brief on action, and a knowledge brief on learning and accountability. Based on learning in the first three years of the Network, the report outlines critical levers of change for improving quality of maternal newborn and child health care at scale (categorized under the four strategic objectives of the Network):  


  • It takes a whole health system to improve quality of care 
  • Government leadership and long-term commitment is a prerequisite for success 
  • Quality of care requires dedicated and sustained investment and partnership 


  • Health system contexts impact the pace of quality of care development, adaptation and implementation 
  • Building quality improvement capabilities is necessary for sustaining quality of care provision 


  • Designing, implementing, and monitoring a comprehensive and adaptable quality of care program at the district or sub-national levels is critical 
  • Documenting and sharing lessons from quality of care initiatives can help build more effective programs and it requires trust 
  • A facilitated network offers a valid platform for rapid learning and accelerated progress


  • Engaging communities and stakeholders in designing and implementing quality of care for MNH programs paves the way to progress and ensures accountability for quality of care 
  • Investing early and intentionally in the development and strengthening of data systems for quality of care is essential 
  • Demonstrating impact of quality improvement activities takes time

Effectiveness of Strategies to Improve Health-care Practices in Low- and Middle-Income Countries: A systematic review, The Lancet, 2018

Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs).  This review by Rowe and colleagues found substantial variation in the impact of strategies to improve health-care provider practice although some approaches were more consistently effective than others.

Key findings

  • Training or supervision alone typically had moderate effects (10·3–15·9 percentage points), whereas combining training and supervision had somewhat larger effects (18·0–18·8 percentage points).
  • Group problem solving alone (e.g. quality improvement) showed larger improvements on provider performance (28·0–37·5 percentage points).