The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
Introduction
In the 24 hours after childbirth, women face a heightened risk for morbidity and mortality as a consequence of postpartum complications such as hemorrhage and sepsis. An estimated 60% of maternal deaths occur in the postpartum period, and 45% of these deaths occur in the first 24 hours after delivery.
1
Although some complications are unavoidable, early identification and prompt management can reduce the chances of severe morbidity and mortality.2
, 3
, 4
This requires immediate high-quality postpartum care, including monitoring patients for signs of complications after delivery and until discharge.Despite the importance of immediate postpartum monitoring in averting morbidity and mortality, there is substantially less attention paid to this topic than to quality of care during labor and delivery. The limited available evidence suggests that women delivering in low- and middle-income countries (LMICs) receive minimal attention and care in the time between childbirth and facility discharge. A study conducted across 33 sub-Saharan African countries found that one-third of women did not receive a single health check between delivery and discharge.
5
There is also scant evidence on why postpartum monitoring is so limited or on how it can be improved.The World Health Organization (WHO)’s new postpartum care guidelines, published in March 2022 to update and expand on the 2014 guidelines, bring a renewed focus to the importance of prompt identification and management of complications in the immediate postpartum period.
6
,World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. 2022. Available at:https://www.who.int/publications/i/item/9789240045989. Accessed April 13, 2022.
7
Motivated by the high burden of postnatal maternal and newborn mortality and by the quality revolution in global health,World Health Organization. WHO recommendations on postnatal care of the mother and newborn. 2013. Available at:http://www.ncbi.nlm.nih.gov/books/NBK190086/. Accessed May 9, 2018.
8
, 9
, 10
the new guidelines emphasize the importance of high-quality postnatal care—including continuous care and monitoring during the critical first 24 hours after childbirth, followed by at least 3 postnatal care contacts during the first 6 weeks after delivery—and of ensuring a positive postnatal experience for women and their newborns. The release of these guidelines makes this an opportune time to address gaps in the quality of immediate postpartum care in LMICs.World Health Organization. Delivering quality health services: a global imperative for universal health coverage. 2018. Available at:https://apps.who.int/iris/bitstream/handle/10665/272465/9789241513906-eng.pd. Accessed XXX.
In this commentary, we highlight the importance of immediate postpartum monitoring, an often-overlooked aspect of maternal healthcare. We identify opportunities for strengthening the quality of immediate postpartum care through improvements in measurement and data availability, research into barriers to high-quality care, and innovations in service delivery design.
Clinical importance of postpartum monitoring
The first recommendation in the WHO's 2022 postnatal care guidelines states that, following childbirth, all women should have “regular assessment of vaginal bleeding, uterine tonus, fundal height, temperature, and heart rate (pulse) routinely during the first 24 hours, starting from the first hour after birth.” Although the specific recommendations on postnatal assessment have not changed—it still holds that women should be monitored 4 times during the first hour after delivery, hourly from hours 1 to 4, and every 4 hours from hours 4 to 24
11
—the new, more all-encompassing postpartum guidelines bring renewed focus to these recommendations and their clinical importance.World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 2015. Available at: https://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en/. Accessed October 24, 2022.
Evidence from maternal mortality reviews (sometimes called maternal death audits) underscores the importance of these guidelines. In a wide range of settings, these reviews have identified insufficient monitoring and delays in treatment initiation as important factors contributing to maternal mortality.
12
, 13
, 14
, 15
, 16
, 17
, 18
For example, in a review of maternal deaths over a 10-year period in France, delayed management was a leading factor contributing to deaths from postpartum hemorrhage.13
A review from the United Kingdom concluded that “in many cases in this Report, the early warning signs of impending maternal collapse went unrecognized.”19
,20
In a review in Kenya, inadequate monitoring was found to have played a role in 27% of the investigated mortality cases, and prolonged abnormal observation without action was found to have played a role in 24%.Confidential enquiry into maternal and child health (CEMACH). “Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer 2003–2005.” 2007. Available at: https://www.hqip.org.uk/resource/cmace-and-cemach-reports/. Accessed October 24, 2022.
14
Numerous studies from maternity care and other clinical domains have shown the value of vital sign measurements in predicting adverse clinical outcomes.
21
,22
For example, in medical and surgical wards, warning systems, which use clinical indicators such as vital signs and examination findings to identify patients at risk for clinical deterioration, have been shown to be effective in predicting cardiac arrest and mortality within 24 hours.21
A systematic review found that warning systems adapted for obstetrical populations (sometimes called maternal warning systems) generally have high predictive accuracy for maternal morbidity, intensive care unit admission, and mortality.22
Beyond the ability to predict outcomes, there is also a growing body of evidence that systems that improve patient monitoring can lead to better and more timely care decisions and improved patient outcomes.
4
,22
, 23
, 24
, 25
For example, evidence from general hospital wards indicates that continuous monitoring (eg, using remote monitoring technologies) can reduce critical care use, shorten hospital stays, and improve clinical outcomes relative to intermittent monitoring.23
In a pilot study in a large hospital network in the United States, an obstetrical warning system called the Maternal Early Warning Trigger tool was found to reduce severe maternal morbidity by 18%.4
It is important to note, however, that better monitoring alone does not always improve outcomes; in a large randomized trial in 8 LMICs, the introduction of a device that improved vital signs measurement in maternity wards, together with a related education intervention, did not lead to improvements in clinical outcomes.53
This finding highlights the importance of not only improving the measurement of clinical signs but also ensuring that effective systems are in place to respond to abnormal results.There have been widespread efforts to improve postpartum monitoring in high-income settings, including national implementation of obstetrical warning systems in the United Kingdom
26
and Ireland27
and numerous efforts to introduce similar systems in American hospitals.4
,28
However, this topic has received relatively little attention in LMIC settings to date despite the high burden of maternal morbidity and mortality in these settings. It is therefore critical to bring attention to postpartum monitoring in LMICs.Evidence on the quality of postpartum monitoring in low- and middle-income countries
The limited available evidence on the quality of postpartum monitoring in LMICs paints a concerning picture. Although most women remain in the health facility after delivery for at least the WHO-recommended 24 hours,
29
the care provided during this postpartum stay is minimal. Across 33 LMICs with available Demographic and Health Survey (DHS) data from 2000 to 2016, only 66% of women who delivered in health facilities reported that they received at least 1 postpartum health check during their facility stay, ranging from 27% in Eswatini to 94% in Burkina Faso.5
The rate of postpartum health checks was lowest in public health centers (61%) and highest in public hospitals (75%). An analysis of DHS data from Uganda found that among women who delivered in health facilities, the proportion who reported at least 1 postpartum health check increased from 36% in 2006 to 65% in 2016.30
However, surveys with health workers suggest that the quality of postpartum monitoring often worsened during the COVID-19 pandemic, especially in lower-resource settings; in a multicountry study, 45% of health workers in low-income countries and 11% of health workers in high-income countries reported reductions in the frequency of postpartum monitoring in health facilities.31
Although survey evidence can provide some basic insight into postpartum monitoring, evidence from clinical observation can tell us more about its content. For example, in the BetterBirth trial, a cluster-randomized trial part of a quality improvement intervention in health facilities in Uttar Pradesh, India, only 7% of women across 15 control facilities had their blood pressure taken at any time between admission to the facility and 1 hour after delivery.
32
During the same period, only 0.3% ever had their temperature taken.32
In a study in Uganda, only 5% of observed providers took mothers’ vital signs during the first hour after birth.33
In a study across 36 primary health centers in Burkina Faso, Ghana, and Tanzania, postpartum monitoring for uterine contraction and vaginal blood loss was often not performed between delivery and discharge from the health facility.34
Although it provides a limited picture, this evidence points to important gaps in postpartum monitoring. In the remainder of this article, we describe our recommendations for improvements in immediate postpartum monitoring in LMICs, summarized in the Table.TableSummary of challenges and recommendations for improving the quality of immediate postpartum monitoring
Clarke-Deelder. Immediate postpartum care in low- and middle-income countries. Am J Obstet Gynecol MFM 2023.
| Domain | Challenges | Recommendations |
|---|---|---|
| Measurement | Lack of standardized metrics for quality measurement |
|
| Over-reliance on maternal recall in quality measurement and limited observational data |
| |
| Service delivery design | Limited understanding of the reasons for low-quality care |
|
| Limited knowledge of effective interventions to improve quality |
|
Improving measurement of quality of postpartum monitoring
A first step in improving the quality of immediate postpartum monitoring is better measurement. High-quality, immediate postpartum monitoring includes not only conducting the appropriate examinations with the appropriate frequency (as set out in WHO guidance), but also using the information gathered to inform clinical decision-making, escalate care as needed, and intervene in a timely manner. Quality measures should be developed to capture all of these steps and then data should be collected to identify gaps in quality.
Currently, the quality of immediate postpartum monitoring is measured in a piecemeal and inconsistent manner; different studies report different quality measures, and they typically omit important aspects of immediate postpartum monitoring. In recent years, there have been significant improvements in the measurement of quality of care during labor and delivery, including the development of quality scales such as the Tripathi Index,
39
which provides a standardized and validated approach for measuring the quality of labor and delivery care in LMICs. There has also been progress in the measurement of disrespect and abuse during childbirth40
using standardized and validated measures. There is a need for similar progress in measuring the quality of immediate postpartum monitoring. Standardized measures should be developed that take into account (1) the content and frequency of monitoring, (2) whether systems are in place to use information from monitoring to inform decisions about when to escalate care, and (3) whether complications are managed in a timely manner. The use of standardized quality measures across settings and over time will facilitate the identification of gaps in quality, inform the design of interventions to improve quality, and enable the measurement of progress toward improved quality.In addition to a lack of standard measures, there are several major challenges with the data collection approaches that are currently used to measure the quality of immediate postpartum monitoring. First, a lot of the existing work in this area relies on maternal recall, which likely contains substantial measurement error because women may not accurately recall the care they received or may not know what constitutes a postpartum health check.
35
,36
For example, in the widely used DHS, women are asked to recall care from the past 5 years.5
,29
,30
Direct observation can provide more accurate, detailed information on quality. However, to date, direct observation studies have typically collected only limited information on postpartum care. Most delivery observation studies have ended within 1 hour of delivery,37
and postpartum care studies typically have focused on later postpartum assessments in the weeks following delivery38
; few studies have measured quality of care during the 24 hours after delivery, despite the high risk for complications during this period. Future studies should employ direct observation methods or other innovative techniques to evaluate the quality of care throughout the immediate postpartum period. Another approach may be the use of health facility records to evaluate the quality of postpartum monitoring39
; however, facility records should be used with caution in health systems with low-quality administrative data.36
Service delivery research and innovation
Next, it will be critical to understand and address the different barriers that have hindered progress to date.
Barriers to high-quality care exist at many levels, including the health system, health facility, provider, and patient. Health system barriers include challenges with resources such as blood pressure cuffs and thermometers, staffing, and provider training. However, in studies from a variety of different health domains, insufficient equipment and knowledge rarely fully explain quality gaps; indeed, substantial “know-do gaps” have been identified in maternity care and other domains in LMICs.
33
,34
,40
,41
Health facility norms and healthcare provider beliefs, behavior, and motivation likely also play a role. For example, even if maternity care providers are aware of postpartum care guidelines,33
they may not perceive postpartum monitoring as part of their job. Qualitative research with healthcare providers in India and Nigeria suggests that once a delivery has been completed, many providers feel “their work is over.”42
,43
In addition, insufficient communication between providers in labor and postnatal wards can mean that risks, which may be evident during labor and delivery, are ignored or miscommunicated when patients are transferred to the postnatal ward.44
There is evidence that over-confidence bias among healthcare providers can contribute to lower-quality care45
; understanding the potential role of overconfidence in shaping postpartum monitoring decisions may provide insights into how to improve care. Finally, patient-level challenges may include patient preferences to leave health facilities soon after delivery. The WHO recommends that all women remain in the health facility for at least 24 hours after an uncomplicated vaginal delivery; although the majority do this, many women leave much sooner.29
Insights into patient decision-making and the factors that support or hinder longer facility stays are needed to ensure that all women receive adequate postpartum monitoring.Although the new WHO guidelines address the frequency and content of postpartum monitoring, they do not provide guidance on how monitoring could be improved or how to ensure that information collected during patient monitoring is used to inform decisions about when to escalate care.
6
Addressing quality gaps will require innovative thinking, including the adaptation of existing approaches and the development of new systems and tools. This is an important area for future research. In some contexts, there may need to be increases in staffing or reallocation of staff to monitoring roles. There may also be a need for investment in monitoring devices including accurate and affordable automated blood pressure monitors.World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. 2022. Available at:https://www.who.int/publications/i/item/9789240045989. Accessed April 13, 2022.
46
,47
World Health Organization. WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff. 2020. Available at:https://apps.who.int/iris/handle/10665/331749. Accessed October 24, 2022.
More complex interventions may also be needed. One promising way forward is the design and implementation of maternal warning systems for different contexts, building on experiences to date in settings such as Ethiopia, Malawi, Nigeria, Pakistan, and Zimbabwe.
48
, 49
, 50
, 51
, 52
For example, a pilot study of a maternal warning system in a referral hospital in Zimbabwe suggested that wider implementation of these interventions may be a feasible and effective way to improve patient outcomes.48
Warning systems provide a structured protocol for monitoring and for using information from monitoring to inform decision-making about care.28
Although there are a variety of different approaches used, including both single-parameter and multiparameter warning measures, these systems typically rely on metrics that are easy to collect in low-resource settings.22
,53
Existing work has highlighted a number of factors that are critical to the success of warning systems, including local validation of the predictive accuracy of the warning system, clear processes for escalating care, facility norms that reward providers when they call for support as needed, and buy-in from senior clinicians and facility leadership.28
,50
,51
These findings should be considered in efforts to innovatively and adaptively develop warning systems for implementation in different settings.Beyond warning systems, further innovations could be informed by evidence on closing the know-do gap from a variety of clinical domains. For example, multifaceted approaches that combine health worker training with supervision or group problem-solving activities have been effective in improving adherence to pediatric care guidelines
54
; similar interventions could be adapted to improve communication around patient risks and decision-making around escalation of care in maternity wards. Healthcare providers at facilities in rural areas are likely to face particular challenges because of their often limited experience with emergency or complex cases. Novel training or coaching interventions may be needed in these settings. There is evidence that different types of facilities may be better at motivating providers to provide high-quality care and therefore reduce know-do gaps: for example, research from India suggests that quality is higher in public hospitals and private clinics than in small public clinics,55
and research from Tanzania suggests that providers perform better in facilities with decentralized authority (eg, where decisions about hiring and firing providers are made more locally).56
Changes in facility organization and norms may be needed to promote a culture in which providers actively assess patients for the risk of postpartum complications instead of responding after complications have already progressed to severe.42
Principles from human-centered design could be applied to increase the salience of postpartum monitoring among providers.57
Interventions should be informed by an understanding of how providers think, communicate, and make decisions about postpartum care.58
Conclusion
To reduce morbidity and mortality from postpartum complications in LMICs, there is a vital need for researchers, policy makers, and practitioners to bring increased focus to immediate postpartum monitoring. We need to better understand the current state of immediate postpartum monitoring, examine reasons for limited postpartum monitoring, and develop and test interventions to improve it.
References
- The postpartum period: the key to maternal mortality.Int J Gynaecol Obstet. 1996; 54: 1-10
- The role of delays in severe maternal morbidity and mortality: expanding the conceptual framework.Reprod Health Matters. 2012; 20: 155-163
- A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems.Int J Gynaecol Obstet. 2021; 154: 393-399
- Use of Maternal Early Warning Trigger tool reduces maternal morbidity.Am J Obstet Gynecol. 2016; 214 (e1–6): 527
- Provision of postpartum care to women giving birth in health facilities in sub-Saharan Africa: a cross-sectional study using demographic and health survey data from 33 countries.PLoS Med. 2019; 16e1002943
World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. 2022. Available at:https://www.who.int/publications/i/item/9789240045989. Accessed April 13, 2022.
World Health Organization. WHO recommendations on postnatal care of the mother and newborn. 2013. Available at:http://www.ncbi.nlm.nih.gov/books/NBK190086/. Accessed May 9, 2018.
- Time for a quality revolution in global health.Lancet Glob Health. 2016; 4: e594-e596
- Crossing the global quality chasm: improving health care worldwide.2018 (Available at:) (Accessed October 24, 2022)
World Health Organization. Delivering quality health services: a global imperative for universal health coverage. 2018. Available at:https://apps.who.int/iris/bitstream/handle/10665/272465/9789241513906-eng.pd. Accessed XXX.
World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 2015. Available at: https://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en/. Accessed October 24, 2022.
- Centre for Maternal and Child Enquiries. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-8: a review.Br J Anaesth. 2011; 107: 127-132
- French National Experts Committee on Maternal Mortality. Ten years of confidential inquiries Into maternal deaths in France, 1998-2007.Obstet Gynecol. 2013; 122: 752-760
- Saving Mothers’ Lives: Confidential Inquiry into Maternal Deaths in Kenya.2017 (Available at:) (Accessed March 5, 2020)
- Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care.Reprod Health. 2016; 13: 47
- Facility-based maternal death review in three districts in the Central Region of Malawi: an analysis of causes and characteristics of maternal deaths.Womens Health Issues. 2009; 19: 14-20
- How to improve the quality of care for women with postpartum haemorrhage at Onandjokwe Hospital, Namibia: quality improvement study.BMC Pregnancy Childbirth. 2019; 19: 489
- Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review.BMC Pregnancy Childbirth. 2014; 14: 280
- Maternal early warning systems.Obstet Gynecol Clin North Am. 2015; 42: 289-298
Confidential enquiry into maternal and child health (CEMACH). “Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer 2003–2005.” 2007. Available at: https://www.hqip.org.uk/resource/cmace-and-cemach-reports/. Accessed October 24, 2022.
- Early warning system scores for clinical deterioration in hospitalized patients: a systematic review.Ann Am Thorac Soc. 2014; 11: 1454-1465
- Early warning systems in obstetrics: a systematic literature review.PLoS One Patman S. 2019; 14 (ed)e0217864
- The impact of continuous versus intermittent vital signs monitoring in hospitals: a systematic review and narrative synthesis.Int J Nurs Stud. 2018; 84: 19-27
- Lower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system.Resuscitation. 2014; 85: 424-430
- Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital.J Community Hosp Intern Med Perspect. 2015; 5: 26716
- Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study.BMJ Qual Saf. 2014; 23: 26-34
- Maternal bacteremia and the Irish maternity early warning system.Int J Gynaecol Obstet. 2015; 129: 142-145
- The maternal early warning criteria: a proposal from the national partnership for maternal safety.J Obstet Gynecol Neonatal Nurs. 2014; 43: 771-779
- Length of stay after childbirth in 92 countries and associated factors in 30 low- and middle-income countries: compilation of reported data and a cross-sectional analysis from nationally representative surveys.PLoS Med. 2016; 13e1001972
- Immediate postnatal care following childbirth in Ugandan health facilities: an analysis of demographic and health surveys between 2001 and 2016.BMJ Glob Health. 2021; 6e004230
- Separated during the first hours”—postnatal care for women and newborns during the COVID-19 pandemic: a mixed-methods cross-sectional study from a global online survey of maternal and newborn healthcare providers.PLoS Glob Public Health. 2022; 2e0000214
- Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India.N Engl J Med. 2017; 377: 2313-2324
- Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities.Trop Med Int Health. 2021; 26: 535-545
- Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study.Trop Med Int Health. 2016; 21: 70-83
- Can surveys of women accurately track indicators of maternal and newborn care? A validity and reliability study in Kenya.J Glob Health. 2016; 6020502
- Assessment of the validity of the measurement of newborn and maternal health-care coverage in hospitals (EN-BIRTH): an observational study.Lancet Glob Health. 2021; 9: e267-e279
- Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools.Lancet Glob Health. 2019; 7: e624-e632
- Can reproductive health voucher programs improve quality of postnatal care? A quasi-experimental evaluation of Kenya's safe motherhood voucher scheme.PLoS One. 2015; 10e0122828
- An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care?.J Glob Health. 2018; 8010409
- The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India.JAMA Pediatr. 2015; 169: 349-357
- Quality of primary care in low-income countries: facts and economics.Annu Rev Econ. 2014; 6: 525-553
- Categorizing and assessing comprehensive drivers of provider behavior for optimizing quality of health care.PLoS One. 2019; 14e0214922
- Once the delivery is done, they have finished”: a qualitative study of perspectives on postnatal care referrals by traditional birth attendants in Ebonyi state, Nigeria.BMC Pregnancy Childbirth. 2017; 17: 429
- Gaps in continuity of care: patients’ perceptions of the quality of care during labor ward handover in Mulago Hospital.Uganda. BMC Health Serv Res. 2015; 15: 190
- A review of the application and contribution of discrete choice experiments to inform human resources policy interventions.Hum Resour Health. 2009; 7: 62
- Innovations in vital signs measurement for the detection of hypertension and shock in pregnancy.Reprod Health. 2018; 15: 92
World Health Organization. WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff. 2020. Available at:https://apps.who.int/iris/handle/10665/331749. Accessed October 24, 2022.
- Implementation of a modified obstetric early warning system to improve the quality of obstetric care in Zimbabwe.Int J Gynaecol Obstet. 2017; 136: 175-179
- Maternal early warning scores (MEWS): development of a Nigerian national maternal early warning scores (MEWS) version.International Journal of Innovative Research in Medical Science. 2020; (Available at:) (Accessed April 13, 2022)
- Introduction of a modified obstetric early warning system -(-MOEWS-)- at an Ethiopian referral hospital: a feasibility assessment.BMJ Open Qual. 2019; 8e000503
- Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study.PLoS One. 2013; 8: e59830
- Implementation of warning tool to improve maternal newborn health outcomes in a developing country.J Pak Med Assoc. 2017; 67: 111-115
- Development and validation of an obstetric early warning system model for use in low resource settings.BMC Pregnancy Childbirth. 2020; 20: 531
- Improving health worker performance: an ongoing challenge for meeting the sustainable development goals.BMJ. 2018; 362: k2813
- Money for nothing: the dire straits of medical practice in Delhi, India.J Dev Econ. 2007; 83: 1-36
- Getting doctors to do their best: the roles of ability and motivation in health care quality.J Human Resources. 2007; XLII: 682-700
- Patient safety begins with proper planning: a quantitative method to improve hospital design.Qual Saf Health Care. 2010; 19: 462-465
- Why don't physicians follow clinical practice guidelines? A framework for improvement.JAMA. 1999; 282: 1458-1465
Article info
Publication history
Published online: October 06, 2022
Accepted:
October 3,
2022
Received in revised form:
September 16,
2022
Received:
April 29,
2022
Footnotes
T.B., J.L.C., and M.M. contributed equally.
The authors report no conflict of interest.
All authors received support from the Bill & Melinda Gates Foundation under grant number OPP1176156. The funder had no role in the preparation of this manuscript or the decision to publish.
Identification
Copyright
© 2022 Published by Elsevier Inc.
User license
Creative Commons Attribution (CC BY 4.0) | How you can reuse 
Elsevier's open access license policy
Creative Commons Attribution (CC BY 4.0)
Permitted
- Read, print & download
- Redistribute or republish the final article
- Text & data mine
- Translate the article
- Reuse portions or extracts from the article in other works
- Sell or re-use for commercial purposes
Elsevier's open access license policy
