CLINICAL ARTICLE Multifaceted intervention to implement indicators of quality of care for severe pre-eclampsia/eclampsia Pattarawalai Talungchit a , Tippawan Liabsuetrakul b, ⁎, Gunilla Lindmark c a Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand b Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand c International Maternal and Child Health, Uppsala University, Uppsala, Sweden abstract article info Article history: Received 13 April 2013 Received in revised form 6 August 2013 Accepted 24 October 2013 Keywords: Acceptability Adherence Eclampsia Indicator Multifaceted intervention Priority Severe pre-eclampsia Objective: To assess the acceptability of implementing indicators of quality of care for severe pre-eclampsia/ eclampsia to health providers, and to evaluate the effect of a multifaceted intervention on adherence to these indicators. Methods: A multifaceted approach was used to implement indicators of quality of care for severe pre-eclampsia/eclampsia that were relevant to both district and referral hospitals. Healthcare providers at 9 hos- pitals in Southern Thailand rated the acceptability and priority of each indicator. In addition, medical records were reviewed before and after the intervention. Results: More than 90% of the indicators were considered to be acceptable by the 145 health providers who participated in the study. After the intervention, adherence to most indicators was significantly increased. However, adherence after the intervention was lower than 80% for one-third of the indicators at district hospitals, compared with less than 10% of the indicators at referral hospitals. Common barriers to indicator implementation were lack of resources and skills, difficulty in making early and ac- curate diagnoses, and management. Conclusion: The indicators for the quality of care for severe pre-eclampsia/ eclampsia were acceptable. Adherence to the indicators increased through a multifaceted intervention; however, the adherence varied considerably depending on the hospital referral level. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Severe pre-eclampsia/eclampsia is a common obstetric condition leading to maternal mortality and severe morbidity worldwide, includ- ing in the Southeast Asian region [1]. Evidence-based guidelines for best practice have been established and implemented [2,3], but substandard care for this condition has been documented even in high-income coun- tries [4,5]. Most adverse pregnancy outcomes associated with severe pre-eclampsia/eclampsia can be prevented by prompt diagnosis and management. Therefore, the quality of care has a crucial role in reducing the rates of maternal mortality and severe morbidity associated with severe pre-eclampsia/eclampsia. Although various recommendations and guidelines have been established, the utilization of recommendations based on guidelines in clinical practice remains a challenge. A multifaceted approach is an effective strategy to change the behavior of healthcare providers in obstetrics and to improve adherence to standard practices [6]. However, no data are available on the effects of such an intervention on the quality of care in severe pre-eclampsia/eclampsia, as determined by assessing the implementation of indicators in differ- ent healthcare facility settings [7]. Clinical indicators are important tools in evaluating and monitoring the quality of care and guiding the process of quality improvement [8]. In addition to adequate relevant standards [9], such indicators need to be acceptable to healthcare providers and there should be no barriers preventing their implementation [10,11]. The present study aimed to assess the acceptability of quality-of-care indicators for severe pre- eclampsia/eclampsia to health providers and to evaluate the effective- ness of a multifaceted intervention to implement these indicators in clinical practice. 2. Materials and methods A quasi-experimental study was conducted in Songkhla province, Southern Thailand. Songkhla province was chosen for the study setting because maternity and delivery services are provided by various types of hospital, including district, provincial, regional, and university hospi- tals. In total, 6 district hospitals and 3 referral hospitals (1 provincial, 1 regional, and 1 university hospital) participated in the study. At the referral hospitals, maternity care was mainly provided by obstetricians. At the district hospitals, most doctors were general practitioners, with the exception of 2 district hospitals, where an obstetrician was posted. The medical records of women with severe pre-eclampsia/eclampsia admitted to a participating hospital between October 1, 2008, and International Journal of Gynecology and Obstetrics 124 (2014) 106–111 ⁎ Corresponding author at: Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, 15 Karnjanavanit Road, Songkhla 90110, Thailand. Tel.: +66 74 451165; fax: +66 74 429754. E-mail address: ltippawa@hotmail.com (T. Liabsuetrakul). 0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.08.005 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo