Measuring the effectiveness of maternal delivery services: A cross-sectional and qualitative study of perinatal mortality in six primary referral hospitals, Kenya

Background: The effective performance of hospitals is critical to overall health system goal achievement. Global health system performance frameworks are often used as part of global benchmarking, but not within low and middle-income countries as part of service delivery performance measurement. This study explored the utility of perinatal mortality as a measure of hospital effectiveness. Methods: : A cross sectional, mixed methods study of six primary referral hospitals, differentiated by ownership, was conducted from 10th June to 9th October 2015. Monthly summary hospital data of maternal delivery services (MDS) were abstracted to determine the perinatal mortality. Tests of associations were used to correlate bed turnover, skilled staffing, method of delivery and perinatal mortality. Additionally, 40 questionnaire interviews were held with hospital board members and the management team to assess the availability of standard operating procedures (SOP) in MDS. Qualitative data was analysed thematically. Results: : All six hospitals reported having SOP in managing MDS. The average perinatal mortality rate for all the hospitals was 24.63 per 1,000 live births. However, a perinatal death was 2.6 times more likely in public hospitals compared to private hospitals (29.8 vs 11.4 per 1,000 births respectively). The average caesarean section rate for all hospitals was 25.9%, but the odds of a caesarean section were 1.67 higher in a private hospital compared to a public hospital (P<0.001 95% CI: 1.58-1.77). Perinatal mortality was associated with bed turnover ratio (R squared 0.260, P=0.001), and skilled staff availability (R squared 0.064,P<0.001). Discussion: The high perinatal mortality reported in public hospitals may be due to high bed turnover and relatively low caesarean section rate. Input measures of performance such as reporting standards of care and staffing levels are not useful performance indicators. Perinatal mortality as a performance indicator may be an ideal measure of the effectiveness of hospitals.