Monitoring childbirth and immediate postpartum care quality: A scoping review of indicators in high-income countries

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Abstract Background: Most maternal and neonatal morbidity and mortality occur during childbirth and the immediate postnatal period. In high-income countries, where most births occur in maternity units, systematic monitoring of care quality is essential to improve safety and reduce preventable adverse outcomes. Objective: To identify maternal and neonatal indicators of quality-of-care at childbirth and immediate postnatal period in high-income countries, and to assess their level of validity. Methods: This scoping review followed PRISMA-ScR guidelines. A systematic search was conducted in April 2024 (updated March 2025) in Medline, Embase, CINAHL, and Web of Science. Eligible studies included literature from high-income countries reporting quality-of-care indicators. Indicators were extracted as reported and consolidated: those with aligned definitions were clustered into standardised indicators and subsequently grouped into broader constructs reflecting key dimensions of care. Indicators were grouped into four domains (access, structure, process, and outcome) and evaluated using a structured validity scoring system. Indicators were classified as high-validity if they included a clear definition (with specified numerator and denominator) and achieved a validity score of 3 or 4 on a 0–4 scale. Results: Eighty-four studies were included. In total, 981 individual indicators were identified; 546 were clearly defined and consolidated into 214 standardised indicators and 61 indicator constructs. Most focused on outcomes (n=253, 46.3%) and processes (n=243, 44.5%), with substantial heterogeneity in definitions. Fewer indicators addressed structure (n=47, 8.6%) and access (n=3, 0.6%). Nearly one third of all indicators demonstrated high-validity, mainly within outcome and process domains. Conclusions: This review identified a large set of quality-of-care indicators, reflecting sustained efforts to monitor care around childbirth. However, heterogeneity in definitions and variable validation limit comparability and routine use. These findings highlight the need for greater validation and standardisation of indicators, followed by the prioritisation of high-validity measures to support meaningful quality monitoring and improvement.

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