Clinical Indicators Proposed to Measure the Quality of Obstetric Care During Childbirth: A Systematic Review of Published and Unpublished Literature Open Access

Arnold, Shaye Beverly (2013)

Permanent URL:


Increasingly comprehensive maternal morbidity and mortality data in the United States has revealed stagnating or worsening rates of poor maternal outcomes during childbirth, including stark disparities based on maternal race and ethnicity. This prompts a call to action to improve obstetric care across the nation and review clinical indicators that have been proposed to measure the quality of care during childbirth. This systematic review of the literature examines both published and unpublished literature from both domestic and international sources to compile a comprehensive list of proposed clinical quality indicators for obstetric care. The indicators are then categorized by clinical area, and descriptive characteristics of indicators are presented. A total of 93 unique clinical indicators are identified, covering a range of clinical areas including induction and augmentation of labor, elective delivery, vaginal birth, vaginal birth after cesarean, perineal care, cesarean section, and maternal morbidity and mortality. A discussion of the indicators centers on the advantages and disadvantages of specific indicator characteristics, as well as the variations in indicator characteristics based on the indicator source (published versus unpublished literature, United States versus international). The paper concludes with implications and recommendations for clinicians and policymakers, and outlines opportunities for further research.

Table of Contents

Table of Contents

Introductory Pages.....i

  • Distribution Agreement.....i
  • Thesis Committee Approval Form.....ii
  • Abstract Title Page.....iii
  • Abstract.....iv
  • Thesis Title Page.....v

Chapter 1: Introduction.....1

  • Rationale.....1
  • Problem Statement.....1
  • Purpose Statement.....5
  • Significance Statement.....5
  • Definition of Terms.....6

Chapter 2: Methods.....7

  • Overview.....7
  • Procedures.....8
  • Search Outcomes.....11

Chapter 3: Results.....12

  • Overview.....12
  • Labor Induction, Augmentation, and Elective Delivery.....13
  • Vaginal Birth and Vaginal Birth After Cesarean.....24
  • Perineal Management and Outcome.....25
  • Cesarean Delivery.....26
  • Maternal Morbidity and Mortality.....28
  • Miscellaneous Measures.....29
  • Composite Measures.....29

Chapter 4: Discussion, Implications, and Recommendations....31

  • Statement of Principle Findings.....31
  • Strengths and Weaknesses of the Study.....35
  • Unanswered Questions and Future Research.....36
  • Implications and Recommendations for Clinicians and Policymakers.....38



  • Table A1. List of organization websites searched for potential inclusion in review.....48
  • Table A2. Description of organizations included in final review.....50

Tables and Figures

  • Table 1. Components of the database search strategy for potentially appropriate articles included in the systematic review.....9
  • Figure 1. Flow diagram depicting the process of literature review.....10
  • Table 2. Characteristics of identified obstetric quality of care indicators.....13
  • Table 3. Indicators identified in the published literature.....15
  • Table 4. Indicators identified in the unpublished literature.....17

About this Master's Thesis

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Partnering Agencies
Last modified

Primary PDF

Supplemental Files