Performance indicators for maternity care in a circumpolar context: a scoping review

Figures & data

Fig. 1.  Sample search strategy.

Fig. 2.  Adapted PRISMA diagram.

Table I. Included studies

Author/organization	Year	Purpose/methods	Key findings	Target region	Indigenous focus
Centers for Disease Control (36)	2015	Online health indicators warehouse which compiles indicators from a variety of American frameworks and data sources	83 indicators listed under maternal child health (MCH); 38 indicators are measureable in the antepartum or neonatal periods; 27 indicators are measured in Alaska and/or are stratified by Indigenous status	USA/Alaska	No
Canadian Institute for Health Information (CIHI) (53)	2015	Online library of all health indicators collected by CIHI with link to the CIHI health systems performance measurement framework and report on its development	10 maternal health indicators are reported National, provincial/territorial results reported but some results are aggregated where numbers are small	Canada	No
New Zealand Ministry of Health (42)	2015	Government report on selected health indicators by Maori/non-Maori status	Report includes five maternal health indicators Indicators in this report were selected based on relevance to Maori people but were not Maori specific	New Zealand	Yes
Nordic Medio-Statistical Committee (NOMESCO) (44)	2015	Annual publication of Nordic Medio-Statistical Committee (NOMESCO) including results of health indicators and overview of regional health systems	Includes small section including 13 reproductive health indicators	Nordic regions	No
Association of Maternal & Child Health Programs (37)	2014	Government report describing the selection of MCH indicators using a life-course framework	Describes 59 life-course indicators, including 9 maternal health indicators Provides information on indicator properties	USA/Alaska	No
Australian Health Ministers’ Advisory Council (39)	2014	Government report describing the development of performance measurement framework specific to the health of Aboriginal people in Australia	Provides definitions and information on indicator properties for 13 indicators reflecting maternal health Significant stakeholder involvement in indicator and framework development	Australia	Yes
Kildea et al. (25)	2013	Retrospective observational study	Reports results of 26 key maternal health indicators Demonstrates health disparities between Aboriginal and non-Aboriginal Australians	Australia	Yes
MacKenbach (28)	2013	Cross-sectional comparison of pooled health systems performance across European countries	Reports on composite rating of overall health system performance Assessment of three maternal health indicators that are routinely reported in all European countries	Europe	No
Norum et al. (27)	2013	Retrospective observational study using data from the Medical Birth Registry of Norway (MBRN)	Compares results of 10 maternal health indicators by region (Northern Norway vs all Norway)	Northern Norway	No
Public Health Agency of Canada (31)	2013	Government report describing indicators reported as part of the Canadian Perinatal Surveillance system (CPSS)	Reports results of 26 maternal health indicators by province/territory Insufficient data to provide territorial results for all indicators	Canada	No
Steering Committee for the Review of Government Service Provision (54)	2013	Multisectoral performance report including health performance framework and indicator reporting	Includes four maternal health indicators Some results are stratified by Indigenous status	Australia	No
Daghofer et al. (33)	2013	Commissioned report for the BC Population and Public Health Program and Provincial Health Services Authority A review of health equity indicators for reporting in British Columbia, Canada	Six of the discussed indicators of health inequity pertain to maternal health Focus on immigrants, refugees and individuals transitioning into and out of the corrections system but with recognition that Aboriginal peoples, women and people in rural/remote also suffer from health inequities	British Columbia (Canada)	No
Steenkamp (26)	2012	Literature review, ethnographic study, stakeholder interviews, expert consensus to compile and evaluate in-use and new indicators	31 maternal indicators identified and classified using a framework adapted from the Aboriginal and Torres Strait Islander Health Performance Framework	Australia	Yes
First Nations Information Governance Centre (32)	2012	Report describing First Nations Regional Health Survey and cultural framework Descriptive report on survey results	8 indicators reflect maternal health Data only collected for First Nations people living on reserve or in northern First Nations communities	Canada	Yes
Irvine et al. (35)	2011	Report generated by northern Saskatchewan Health authorities on health outcomes and determinants of health	Reports includes results of 14 maternal health indicators by region Not specific to Indigenous people but 50% of residents within these health authorities live on First Nations reserves	Northern Sask. (Canada)	Yes^a
Van Wagner et al. (21)	2011	Creation of database for evaluation of Inuulitsivik midwifery service Retrospective observational study	Describes selection of 10 maternal health indicators for evaluation of Inuulitsivik midwifery service and reports results	Nunavik (Canada)	Yes^a
Euro-Peristat (43)	2010	Literature review and multiple Delphi consensus processes to select and develop pan-European maternal health indicators	Ten core and 20 recommended indicators are included Results for all indicators are presented	Europe	No
Kildea et al. (24)	2010	Review of MCH indicators currently used in Australian governmental reporting	Includes description and reporting of four maternal health indicators Calls for addition of maternal mortality ratio (MMR) to routine surveillance in Australia	Australia	Yes
Niclasen et al. (22)	2009	Review article (scientific literature and government websites) of child health indicators Selection of indicators appropriate for use in Greenland	Reports on 33 child health indicators including six relating to pregnancy or the early neonatal period Recommends a further list of child health indicators for which existing data sources are not available	Greenland	Yes^a
Public Health Agency of Canada (30)	2009	Reports on the results of the Maternity Experiences Survey, a nation-wide survey of post-partum women designed to capture their experiences with care and other patient reported outcomes	37 indicators were pertinent to the antenatal, intra-partum, post-partum or neonatal periods While the survey deliberately focused on Indigenous women, they excluded women living on First Nations reserves and other vulnerable populations	Canada	No
New Zealand Ministry of Health (41)	2007	Annual government report demographic, health and socioeconomic indicators	Three maternal health indicators are included All indicators are stratified by Indigenous status where data were available	New Zealand	No
Niclasen (23)	2007	Literature review, key stakeholder interviews, focus groups to assess value of LBW as an indicator Observational study of LBW in Greenland using national birth register data	Reviews the evidence for the use of LBW as a MCH indicator and reports risk factors for LBW according to Greenlandic national birth register	Greenland	Yes^a
Anderson et al. (38)	2006	Review article on historical and current health systems performance measurement systems for Torres Strait Islanders in Australia	Outlines performance indicators pertaining to Aboriginal people in Australia prior to 2006 Includes four maternal health indicators	Australia	Yes
Anderson et al. (16)	2006	Review article on historical and current health systems performance measurement systems for Aboriginal people in Canada Literature review, key informant interviews, consultation with leaders	Provides compendium of Aboriginal health indicators that were reported on for a subset of Aboriginal Canadians prior to 2006 Includes five maternal health indicators	Canada	Yes
Healy et al. (34)	2004	Nunavut MOH report on a set of indicators jointly agreed upon by ministries	Report includes results of two maternal health indicators	Nunavut (Canada)	Yes^a
Hansen et al. (55)	2002	Invited review of Arctic Monitoring and Assessment Program (AMAP)	Describes AMAP including 12 maternal health outcomes that are collected as part of the programme	Circumpolar	No

a Assumed to be focused on an Indigenous population based on region.

Table II. Available indicators

	Antenatal	Birth	Post-partum	Neonatal
Determinants of health	Teenage pregnancies Advanced maternal age Maternal BMI Maternal marital status Maternal education level Domestic violence Tobacco exposure during pregnancy Use of illicit drugs during pregnancy Use of alcohol during pregnancy Exposure to environmental contaminants Patient experience of stressors during pregnancy Patient knowledge and preferred sources of information regarding health practices Patient self-reported reaction to conception			Breastfeeding practices Involvement of child and family services or similar organization
Health outcomes	Urinary tract infection in pregnancy Anaemia during pregnancy Eclampsia Diabetes in pregnancy Spontaneous abortions	Stillbirths Perinatal deaths Preterm births Mean gestational age	Maternal mortality Severe maternal morbidity (composite outcome) Post-partum haemorrhage Post-partum depression	Neonatal mortality Severe neonatal morbidity (composite outcome) Congenital anomalies Small for Gestational Age (<10 percentile ) Infants
	Ectopic pregnancies			Mean newborn birth weight Low birth weight infants (LBW<2,500 g) Large for gestational age infants (>90th percentile) 5 min APGAR score <7
Effectiveness	Antenatal urine testing (culture and sensitivity) Antibiotic prescriptions for antenatal UTIs Complete blood examination in pregnancy	Women reporting shaving/enema/pushing on abdomen at time of birth Induction and augmentation of labour	Maternal readmission to hospital Post-partum contraception	NICU admission
	Folic acid supplementation HIV testing Smoking cessation counselling in pregnancy	Post-term births VBAC (after single previous C/S) Instrumental vaginal deliveries (vacuum/forceps) Caesarean sections		Neonatal readmission to hospital Uptake of male neonatal circumcision
Safety		Births without obstetric intervention Perineal trauma (3rd and 4th degree tear)	Post-partum infections
Responsiveness	Indigenous care providers Cultural competency of providers/organizations Patient reported unfair treatment based on ethnicity Discharges against medical advice	Patient reported support during labour and birth Maternal position for birth Use of analgesia in labour Mother–infant contact at birth	Presence and utilization of breast feeding support programmes Patient reported satisfaction with care
Accessibility	Frequency and timing of antenatal care Prenatal care provider Use of antenatal ultrasound Induced abortion rate	Birth attendant FHR monitoring during labour Place or setting for birth Travel to place of birth Proportion of very preterm babies born without NICU	Post-partum visits
Cost	Per capita expenditure on Aboriginal health Cost of maternity care per patient		Maternal Length of stay	Neonatal length of stay

Fig. 3.  Distribution of available indicators by domain.

Centers for Disease Control and Prevention. National Centre for Health Statistics. Health Indicators Warehouse. Available from: http://www.healthindicators.gov/ [cited 2015 Nov 4]..

 Google Scholar

CIHI Indicator library: Canadian Institute for Health Information (CIHI). 2014. Available from: http://indicatorlibrary.cihi.ca/display/HSPIL/Indicator+Library?desktop=true [cited 2015 Nov 8]..

 Google Scholar

Ministry of Health. Tatau Kahukura Maori Health Chart Book 2015 (3rd Edition). 2015; Wellington: Ministry of Health.

 Google Scholar

Nordic Medico-Statistical Committee (NOMESCO). Health statistics in the Nordic countries 2015. Copenhagen: NOMESCO; 2015.

 Google Scholar

Association of Maternal & Child Health Programs. Life course indicators online tool 2014. Available from: http://www.amchp.org/programsandtopics/data-assessment/Pages/LifeCourseIndicators.aspx [cited 2015 Nov 1]..

 Google Scholar

Australian Health Ministers’ Advisory Council. Aboriginal and Torrse Strait Islander Health Performance Framework 2014 report. 2014; Canberra: AHMAC.

 Google Scholar

Kildea S, Stapleton H, Murphy R, Kosiak M, Gibbons K. The maternal and neonatal outcomes for an urban Indigenous population compared with their non-Indigenous counterparts and a trend analysis over four triennia. BMC Pregnancy Childbirth. 2013; 13: 1.

 Google Scholar

MacKenbach JP, McKee M. A comparative analysis of health policy performance in 43 European countries. Eur J Public Health. 2013; 23: 195–201.

 Google Scholar

Norum J, Heyd A, Hjelseth B, Svee T, Mürer FA, Erlandsen R, etal. Quality of obstetric care in the sparsely populated sub-arctic area of Norway 2009–2011. BMC Pregnancy Childbirth. 2013; 13: 175.

 Google Scholar

Public Health Agency of Canada. Perinatal health indicators for Canada 2013: a report of the Canadian Perinatal Surveillance System. 2013; Ottawa: Public Health Agency of Canada.

 Google Scholar

SCRGSP (Steering Committee for the Review of Government Service Provision). Report on Government Services 2013. Volume 2: Health; Community services; Housing and homelessness. Canberra: SCRGSP; 2013.

 Google Scholar

Daghofer D. Promoting health equity – choosing appropriate indicators: literature scan. 2013; Vancouver, BC: Provincial Health Services Authority.

 Google Scholar

Steenkamp M, Rumbold AR, Kildea S, Bar-Zeev SJ, Kruske S, Dunbar T, etal. Measuring what matters in delivering services to remote-dwelling Indigenous mothers and infants in the Northern Territory, Australia. Aust J Rural Health. 2012; 20: 228–37.

 Google Scholar

First Nations Information Governance Centre (FNIGC). First Nations Regional Health Survey (RHS) 2008–10. National report on adults, youth and children living in First Nations communities. 2012; Ottawa: FNIGC.

 Google Scholar

Irvine J, Quinn B, Stockdale D. Northern Saskatchewan health indicators report 2011. 2011; La Ronge, SK: Athabasca Health Authority and Keewatin Yatthé and Mamawetan Churchill River Regional Health Authorities. La Ronge, Canada: Population Health Unit.

 Google Scholar

Van Wagner V, Osepchook C, Harney E, Crosbie C, Tulugak M. Remote midwifery in Nunavik, Québec, Canada: outcomes of perinatal care for the Inuulitsivik Health Centre, 2000–2007. Birth. 2012; 39: 230–7.

 Google Scholar

Euro-Peristat Project with SCPE and EUROCAT. European perinatal health report. Health and care of pregnant women and babies in Europe in 2010. 2013. Available from: www.europeristat.com [cited 2015 Dec 9]..

 Google Scholar

Kildea S, Kruske S, Barclay L, Tracy S. “Closing the gap”: how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural Remote Health. 2010; 10: 1383.

 Google Scholar

Niclasen B, Kohler L. National indicators of child health and well-being in Greenland. Scand J Public Health. 2009; 37: 347–56.

 Google Scholar

Public Health Agency of Canada. What mothers say: the Canadian maternity experiences survey. 2009; Ottawa: Public Health Agency of Canada.

 Google Scholar

Ministry of Health. An indication of New Zealanders’ health 2007. 2007; Wellington: Ministry of Health.

 Google Scholar

Niclasen B. Low birthweight as an indicator of child health in Greenland: knowledge and implications. Int J Circumpolar Health. 2007; 66: 18257,. doi: http://dx.doi.org/10.3402/ijch.v66i3.18257 .

 Google Scholar

Anderson M, Anderson I, Smylie J, Crengle S, Ratima M. Measuring the health of Aboriginal and Torres Strait Islander peoples: a background paper for the project “Action oriented indicators of health and health systems development for Indigenous peoples in Australia, Canada, and New Zealand. 2006. Regina, Canada: The Indigenous Peoples’ Health Research Centre (IPHRC).

 Google Scholar

Anderson M, Smylie J, Anderson I, Sinclair R, Crengle S. First Nations, Metis, and Inuit Health Indicators in Canada: a background paper for the project “Action oriented indicators of health and health systems development for Indigenous peoples in Australia, Canada, and New Zealand. 2006; Regina, Canada: The Indigenous Peoples’ Health Research Centre (IPHRC).

 Google Scholar

Healy S, Plaza D, Qayyum A, Porter L, Kablutsiak K, Sequin C. Nunavut report on comparable health indicators. 2004. Iqaluit, Canada: Department of Health and Social Services, Government of Nunavut.

 Google Scholar

Hansen JC, Reiersen LO, Wilson S. Arctic Monitoring and Assessment Programme (AMAP): strategy and results with focus on the human health assessment under the second phase of AMAP, 1998–2003. Int J Circumpolar Health. 2002; 6: 17478,. doi: http://dx.doi.org/10.3402/ijch.v61i4.17478 .

 Google Scholar