Assessing quality of childbirth care provided by skilled health personnel in Exemplar countries.

The world has made progress in increasing the number of births attended by skilled health personnel (SHP), but maternal and neonatal mortality have not declined proportionately. This may indicate that quality of care has not risen at the same rate as SHP coverage. Several 'Exemplar' countries have been previously recognized for outstanding progress in improving maternal and newborn health, and offer a unique opportunity to understand coverage and quality of care provided by SHP. Here we describe quality of care and how it compares with SHP coverage in three Exemplar countries-Nepal, Senegal and Zambia. We developed a conceptual framework, compiled primary and secondary data, and employed latent variable analysis. We combined quality estimates with coverage estimates to quantify the effective coverage of SHP. Results show that effective SHP coverage ranges between 12% and 43% across subnational regions, compared with crude SHP coverage ranging from 30% to 100%, indicating that mothers and newborns are receiving less lifesaving care than coverage statistics portray. The detection of this quality gap in Exemplar settings, which represent some of the highest-performing health systems among low- and middle-income countries, emphasizes the criticality of quality care to reduce maternal and neonatal mortality worldwide.