COPE® for Maternal Health Services: A Process and Tools for Improving the Quality of Maternal Health Services



To provide health care staff with a continuous quality improvement approach to maternal health services.


COPE is a process and a set of simple and practical tools for assessing and improving the quality of maternal health services. The process encourages self-assessment and joint problem solving by service staff and supervisors. It empowers staff to undertake improvement activities.

The manual contains the following tools: 1) self-assessment guides for each of the clients’ rights and providers’ needs, 2) an obstetric admission record review checklist, 3) a client interview form, and 4) client flow analysis forms for use with antenatal and postpartum clients. These tools have practical and easy-to-use data collection and analysis forms that are designed to be flexible so that the supervisors and staff can adapt them to their particular needs.

The first COPE exercise is often done with the assistance of an external facilitator, or with a supervisor within the system who has been trained in facilitating COPE. Using ten self-assessment guides based on the framework of clients’ rights and providers’ needs, the facilitator works with supervisors and staff who assess the services they provide. The self-assessment guides contain five service categories: general, antenatal care, routine labor and delivery care, emergency obstetric care, and postpartum care. The staff also interview the clients. Based upon the problems identified, the supervisors and the staff develop an action plan containing problems and causes, suggested solutions, persons responsible for taking action, and the timeframe for solving the problems. At subsequent COPE exercises, other tools may be used. For example, staff may use a client flow analysis to examine the time clients spend in the clinic and how staff use time.

Intended users:

The tool is designed to be used jointly by all levels of clinic and hospital staff, together with their supervisors and managers. This tool encourages all levels of staff to collaborate in identifying obstacles to providing high quality care and in using existing resources to overcome obstacles. It helps staff to develop a sense of ownership and to implement their recommendations for continuous quality care improvement.

Developed by:

EngenderHealth (formerly AVSC International) developed the COPE methodology for family planning services with partners in Kenya in 1989. The adaptation of COPE for Maternal Health Services began in Kenya in 1997, and over time involved contributions from the Ministries of Health in Kenya and Tanzania, the division of Health and Family Welfare in Bangladesh, and Family Care International. The tool has been field tested in Kenya, Tanzania, and Bangladesh, and this manual was published in 2001.


The tool can be used by a broad range of organizations. It has been applied in institutional settings such as district, regional and mission hospitals, and private maternity hospitals. There is some evidence that the application of this tool has had positive impact on several sites. Some sites instituted maternal and neonatal morbidity and mortality review processes where these did not previously exist. Other sites reported local solutions to a wide range of problems including infection prevention supplies and practices, access, information, privacy, and client-provider interaction.


COPE is a simple but effective tool for managers who aim to involve staff and create ownership in the quality improvement process. It encourages staff to continually assess and improve the services they provide. COPE promotes teamwork, customer focus, and cost-consciousness.

Quality improvement is an ongoing process. It requires a lot of time and commitment on the part of the institutions and site managers to involve and motivate staff to create ownership and commitment to quality improvement.

Facilitative Supervision

In addition to relying on the COPE process and tools, EngenderHealth has developed a handbook for managers to assist them in implementing quality improvement at their sites. The Facilitative Supervision Handbook is available from EngenderHealth.

Recommendations for users:

Recommended for use in sites that are committed to improving the quality of maternal health services. Women’s delay in reaching health facilities in an emergency is such a significant factor in maternal deaths, so it is recommended that improvements at the facility level be linked with community level activities to address transport and referral arrangements. Community COPE is a complementary tool to facilitate these linkages.

Reports and Publications:

Mielke, E., Bradley, J and J. Becker. “Improving Maternal and Child Health Services through COPE® ” QA Brief, Winter 2001, Vol. 9, No. 2. Provides a review of experience and tools for COPE for Maternal Health Services and COPE for Child Health Services.

In addition, there are several articles and publications about the COPE process and tools, and its applications to Family Planning and Child Health services. In all of these applications, The COPE process remains the same:

AVSC International. Working Paper no.1, COPE: A Self-Assessment Technique for Family Planning Services (April 1991). Describes the self-assessment process and earliest experiences in Kenya and Nigeria.

AVSC International. Working Paper no. 2, The Use of Self-Assessment in Improving the Quality of Family Planning Clinic Operations: The Experience with COPE in Africa (December 1992). Describes follow up evaluation of COPE in 11 African clinics.

Beattie, K, Dr. A.J. Faisel, M. Ahmed and Dr. B.A. Pati. “Introducing COPE in Asia: A Quality Management Tool for FP Services in Bangladesh” Innovations Vol.1: 16-29, 1994.

Bradley, J., J. Bruce, S. Diaz, C. Huezo, K. Mworia. "Using COPE to Improve Quality of Care: The Experience of the Family Planning Association of Kenya" Quality/Calidad/Qualité No. 9, Population Council, 1998. Describes the introduction and roll-out of COPE in FPAK clinics, results of the process, and lessons learned.

Bradley, J., S. Igras, A. Shire, M. Diallo, E. Matwale, F. Fofana, A. Camara, F. Sawe and J. Becker. “COPE® for Child Health in Kenya and Guinea: An Analysis of Service Quality”. EngenderHealth, New York. August 2002. A report of the results from the two-year evaluation

EngenderHealth. Compass. “Improving Provider Performance: Results from Guinea and Kenya. 2002, No. 1.

Lynam, P, L. McNeil Rabinovitz and M. Shobowale. “Using Self-assessment to Improve the Quality of Family Planning Clinic Services” Studies in Family Planning (1993) Vol 24,4: 252-260.

Lynam, P., T. Smith and J. Dwyer. “Client Flow Analysis: A Practical Management Technique for Outpatient Clinic Settings” International Journal for Quality in Health Care (1994) Vol. 6, No. 2: 179-186.

Mielke, E., K. Beattie. “COPE: A Process and Tools for Healthcare” QA Brief, Spring 2001, Vol. 9, No. 1. Provides a brief overview of COPE process, purpose, results and new adaptations of the materials.


English. A draft version is available in French


Erin Mielke
Quality Improvement Program Manager
440 Ninth Avenue
New York, NY 10001