Adetoro A. Adegoke

Skilled birth attendance-lessons learnt

To reduce the horrific maternal mortality figures that we have globally especially in resource poor countries, there was a global commitment to reduce maternal mortality by three‐quarters by 2015 using 1990 as a baseline. To measure the achievement of this goal, two indicators: maternal mortality ratio and proportion of births attended by skilled attendance were selected. To ensure skilled attendance at birth for all women, the international community set a target of 80% by 2005, 85% by 2010 and 90% coverage by 2015. However, in 2008 only 65.7% of all women were attended to by a skilled attendant during pregnancy, childbirth and immediately postpartum globally with some countries having less than 20% coverage. With the global human resource crisis, achieving this target is challenging but possible. This paper provides a narrative review of the literature on the skilled birth attendance strategy identifying key challenges and lessons learnt.

Skilled Birth Attendants: Who is Who? A Descriptive Study of Definitions and Roles from Nine Sub Saharan African Countries

Background Availability of a Skilled Birth Attendant (SBA) during childbirth is a key indicator for MDG5 and a strategy for reducing maternal and neonatal mortality in Africa. There is limited information on how SBAs and their functions are defined. The aim of this study was to map the cadres of health providers considered SBAs in Sub Saharan Africa (SSA); to describe which signal functions of Essential Obstetric Care (EmOC) they perform and assess whether they are legislated to perform these functions. Methods and Findings Key personnel in the Ministries of Health, teaching institutions, referral, regional and district hospitals completed structured questionnaires in nine SSA countries in 2009–2011. A total of 21 different cadres of health care providers (HCP) were reported to be SBA. Type and number of EmOC signal functions reported to be provided, varied substantially between cadres and countries. Parenteral antibiotics, uterotonic drugs and anticonvulsants were provided by most SBAs. Removal of retained products of conception and assisted vaginal delivery were the least provided signal functions. Except for the cadres of obstetricians, medical doctors and registered nurse-midwives, there was lack of clarity regarding signal functions reported to be performed and whether they were legislated to perform these. This was particularly for manual removal of placenta, removal of retained products and assisted vaginal delivery. In some countries, cadres not considered SBA performed deliveries and provided EmOC signal functions. In other settings, cadres reported to be SBA were able to but not legislated to perform key EmOC signal functions. Conclusions Comparison of cadres of HCPs reported to be SBA across countries is difficult because of lack of standardization in names, training, and functions performed. There is a need for countries to develop clear guidelines defining who is a SBA and which EmOC signal functions each cadre of HCP is expected to provide.

Methodology and tools for quality improvement in maternal and newborn health care

To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low‐income countries.

Improving essential obstetric and newborn care in resource-poor countries

Skilled birth attendance (SBA) and essential obstetric care (EOC) are key strategies for reducing maternal and newborn mortality and morbidity globally. Lack of adequately trained competent staff is a key barrier to achieving this. We assessed the effectiveness of a new package of ‘Life Saving Skills – Essential Obstetric and Newborn Care Training’ (LSS-EOC and NC) designed specifically around the UN signal functions in seven countries in sub-Saharan Africa. Among 600 healthcare providers (nurse-midwives, doctors, clinical officers and specialists), knowledge about the diagnosis and management of complications of pregnancy and childbirth as well as newborn care significantly increased (p < 0.001). There was measurable improvement in skills (p < 0.001), and participants expressed a high level of satisfaction with the training. The training package was found to meet the needs of healthcare providers, increased awareness of the need for evidence-based care and encouraged teamwork.

The impact of emergency obstetric care training in Somaliland, Somalia

To provide and evaluate in‐service training in “Life Saving Skills – Emergency Obstetric and Newborn Care” in order to improve the availability of emergency obstetric care (EmOC) in Somaliland.

Capacity building of skilled birth attendants: A review of pre-service education curricula.

OBJECTIVE to assess the level, type and content of pre-service education curricula of health workers providing maternity services against the ICM global standards for Midwifery Education and Essential competencies for midwifery practice. We reviewed the quality and relevance of pre-service education curricula of four cadres of health-care providers of maternity care in Northern Nigeria. DESIGN AND SETTING we adapted and used the ICM global standards for Midwifery Education and Essential competencies for midwifery practice to design a framework of criteria against which we assessed curricula for pre-service training. We reviewed the pre-service curricula for Nurses, Midwives, Community Health Extension Workers (CHEW) and Junior Community Health Extension Workers (JCHEW) in three states. Criteria against which the curricula were evaluated include: minimum entry requirement, the length of the programme, theory: practice ratio, curriculum model, minimum number of births conducted during training, clinical experience, competencies, maximum number of students allowable and proportion of Maternal, Newborn and Child Health components (MNCH) as part of the total curriculum. FINDINGS four pre-service education programmes were reviewed; the 3 year basic midwifery, 3 year basic nursing, 3 year Community Health Extension Worker (CHEW) and 2 year Junior Community Health Extension Worker (JCHEW) programme. Findings showed that, none of these four training curricula met all the standards. The basic midwifery curriculum most closely met the standards and competencies set out. The nursing curriculum showed a strong focus on foundations of nursing practice, theories of nursing, public health and maternal newborn and child health. This includes well-defined modules on family health which are undertaken from the first year to the third year of the programme. The CHEW and JCHEW curricula are currently inadequate with regard to training health-care workers to be skilled birth attendants. KEY CONCLUSIONS although the midwifery curriculum most closely reflects the ICM global standards for Midwifery Education and Essential competencies for midwifery practice, a revision of the competencies and content is required especially as it relates to the first year of training. There is an urgent need to modify the JCHEW and CHEW curricula by increasing the content and clinical hands-on experience of MNCH components of the curricula. Without effecting these changes, it is doubtful that graduates of the CHEW and JCHEW programmes have the requisite competencies needed to function adequately as skilled birth attendants in Health Centres, PHCs and MCHs, without direct supervision of a midwife or medical doctor with midwifery skills.

Strategies to increase facility-based skilled birth attendance in South Asia: a literature review

Global strategies to target high maternal mortality ratios are focused on providing skilled attendance at delivery as well as access to emergency obstetric care. South Asia has the lowest rates of skilled birth attendance in the world, and Nepal is lagging behind neighbouring countries. This review looks at the demand-side barriers to seeking care as well as strategies to increase facility delivery in rural South Asia. A search was made of key databases, including PubMed and the WHO, for literature relating to utilisation of facility delivery in South Asia. The main factors found to influence facility delivery in South Asia were physical and financial barriers, socioeconomic and educational status, obstetric history and awareness of danger signs, sociocultural factors and perceived quality of care. Strategies to increase facility delivery include maternity waiting homes, demand-side financing schemes, education programmes and participatory womens groups. Increasing utilisation of delivery services in South Asia requires a multisectoral approach. Key areas are increasing education for girls as well as empowering women through womens groups and community mobilisation. Removal of user fees appears to be successful but needs to be sustainable and equitable in its delivery.

Definitions and roles of a skilled birth attendant: a mapping exercise from four South-Asian countries.

To identify which cadres of healthcare providers are considered to be skilled birth attendants in South Asia, which of the signal functions of emergency obstetric care each cadre is reported to provide and whether this is included in their training and legislation.

Opportunities and challenges in implementing community based skilled birth attendance strategy in Kenya

BackgroundAvailability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the community midwifery programme in 2005. The aim of this programme was to increase women’s access to skilled care during pregnancy, childbirth and post-partum within their communities.MethodsQualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.ResultsFindings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options.ConclusionsAlthough the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers.

Utilisation of skilled birth attendance in Northern Nigeria: A cross-sectional survey

OBJECTIVE to determine the level and determinants for utilisation of Skilled Birth Attendance (SBA). METHODS a population-based survey using a structured questionnaire was conducted in Goya and Tundunya political wards of Katsina state from May to June 2012. Four hundred women aged 15-49 years who had delivered a baby within two years prior to the study were asked about birth attendance during antenatal care (ANC), childbirth and postnatal period of their most recent birth. Logistic regression analysis was performed to obtain independent predictors of skilled birth attendance (SBA). FINDINGS of the 400 women recruited for the study, 145 (36.3%) received antenatal care, 52 (13%) had their births assisted by skilled personnel and 88 (22%) received postnatal care from skilled birth attendants. Of the 52 women who had their births attended by skilled birth attendants only 29 (56%) had their births in a health facility. Maternal education, husbands occupation, presence of complication and previous place of childbirth were found to be statistically significant predictors for SBA utilisation. Barriers to SBA utilisation identified included lack of health care provider, lack of equipment and supplies and poverty. Enablers mentioned included availability of staff, husbands approval and affordable service. CONCLUSION women are more likely to utilise SBA with the availability of skilled personnel, strengthening of the health system and intervention to remove user fees for maternal health services. Joint effort should be made by government and community leaders to promote girls education and to encourage mens involvement in maternal health services.