Affette McCaw-Binns

Are skilled birth attendants really skilled? : a measurement method, some disturbing results and a potential way forward

OBJECTIVE Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. METHODS The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). FINDINGS On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%. CONCLUSION There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries.

The objective of the study described is to assess the feasibility and effectiveness of using a criterion‐based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life‐threatening obstetric complications — hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a ‘before and after’ design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re‐evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life‐threatening complications occurring over 66 hospital‐months; Review II included 342 complications over 42 hospital‐months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion‐based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life‐threatening obstetric complications.

Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries

Improving the quality of obstetric care is an urgent priority in developing countries, where maternal mortality remains high. The feasibility of criterion-based clinical audit of the assessment and management of five major obstetric complications is being studied in Ghana and Jamaica. In order to establish case definitions and clinical audit criteria, a systematic review of the literature was followed by three expert panel meetings. A modified nominal group technique was used to develop consensus among experts on a final set of case definitions and criteria. Five main obstetric complications were selected and definitions were agreed. The literature review led to the identification of 67 criteria, and the panel meetings resulted in the modification and approval of 37 of these for the next stage of audit. Criterion-based audit, which has been devised and tested primarily in industrialized countries, can be adapted and applied where resources are poorer. The selection of audit criteria for such settings requires local expert opinion to be considered in addition to research evidence, so as to ensure that the criteria are realistic in relation to conditions in the field. Practical methods for achieving this are described in the present paper.

Skilled birth attendant competence: An initial assessment in four countries, and implications for the Safe Motherhood movement

Objectives: Percentage of deliveries assisted by a skilled birth attendant (SBA) has become a proxy indicator for reducing maternal mortality in developing countries, but there is little data on SBA competence. Our objective was to evaluate the competence of health professionals who typically attend hospital and clinic‐based births in Benin, Ecuador, Jamaica, and Rwanda. Methods: We measured competence against World Health Organizations (WHO) Integrated Management of Pregnancy and Childbirth guidelines. To evaluate knowledge, we used a 49‐question multiple‐choice test covering seven clinical areas. To evaluate skill, we had participants perform five different procedures on anatomical models. The 166 participants came from facilities at all levels of care in their respective countries. Results: On average, providers answered 55.8% of the knowledge questions correctly and performed 48.2% of the skills steps correctly. Scores differed somewhat by country, provider type, and subtopic. Conclusion: A wide gap exists between current evidence‐based standards and current levels of provider competence.

Under-users of antenatal care: A comparison of non-attenders and late attenders for antenatal care, with early attenders

Demographic, behavioural, environmental, economic and obstetric history data from the Jamaican Perinatal Morbidity and Mortality Survey were examined to identify characteristics of women who do not attend for antenatal care, or present late instead of early for care, using multiple logistic regression. Non-attenders were more likely to be teenagers, unmarried, in unions of very short duration, smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They were often drawn from deprived environments (lack of sanitation, water supplies). Late attenders shared features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had previously uneventful pregnancies, including this one. Early attenders had little in common with non-attenders or late attenders. They were older, many had a secondary or tertiary education, were married and were generally middle class women. The group however included high risk multigravidae who had previous pregnancy complications or bad outcomes. Programmes aimed at reaching non-attenders must focus on the wider social and economic needs of these women and must give them a sense of their own power to effect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental way as this is often a high risk pregnancy. More fundamental changes require improved educational and employment opportunities for women as the best consumer is an educated consumer.

Effect of Aerobic Exercise (Walking) Training on Functional Status and Health-related Quality of Life in Chronic Stroke Survivors A Randomized Controlled Trial

Background and Purpose— Little is known about the effects of community-based walking programs in persons with chronic stroke. The purpose of this study was to determine the effects of aerobic (walking) training on functional status and health-related quality of life in stroke survivors. Methods— A single-blind randomized controlled trial was conducted. The intervention group (n=64) walked overground for 30 minutes, 3 times per week for 12 weeks. The control group (n=64) received massage to the affected side. Medical Outcomes Short Form, 36-Item Short Form Health Survey (SF-36), was used to assess health-related quality of life; Barthel Index and Older Americans Resource and Services scale for functional status; 6-minute walk test for endurance; and Motricity Index for lower extremity strength. Results— There was a trend toward greater improvement over time for the Physical Health Component of the SF-36 (P=0.077) and significantly greater improvement over time for distance walked in 6 minutes in favor of the walking group (P<0.001). Conclusions— Aerobic walking improves the physical health component of quality of life and endurance in persons with chronic stroke. It should form part of a comprehensive health promotion strategy. Clinical Trial Registration— Trial was not registered as enrollment commenced before 2005.

Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services.

Objective: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. Method: One intervention (St. Catherine) and two control (St Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high‐risk antenatal clinic or to hospital. Guidelines were provided to high‐risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. Results: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13–0. 27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. Conclusion: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

Maternal mortality in Jamaica: health care provision and causes of death

Details of 62 maternal deaths occurring in 1986/1987 were compared with a control population. The incidence was 11.5 per 10 000 livebirths. The major cause of maternal mortality was hypertension followed by hemorrhage and infection. There were trends with advanced maternal age and high parity. The risk of maternal death varied with hospital facilties available, being lowest in areas with access to a specialist hospital and highest in areas where there were no obstetricians available.

Translating Coverage Gains into Health Gains for All Women and Children: The Quality Care Opportunity

Wendy Graham and colleagues reflect on quality of maternal health care, the focus of Year 1 of the PLOS-MHTF Maternal Health Collection and its 18 new articles.

Excess Risk of Maternal Death from Sickle Cell Disease in Jamaica: 1998–2007

Background Decreases in direct maternal deaths in Jamaica have been negated by growing indirect deaths. With sickle cell disease (SCD) a consistent underlying cause, we describe the epidemiology of maternal deaths in this population. Methods Demographic, service delivery and cause specific mortality rates were compared among women with (n = 42) and without SCD (n = 376), and between SCD women who died in 1998–2002 and 2003–7. Results Women with SCD had fewer viable pregnancies (p: 0.02) despite greater access to high risk antenatal care (p: 0.001), and more often died in an intensive care unit (p: 0.002). In the most recent period (2003–7) SCD women achieved more pregnancies (median 2 vs. 3; p: 0.009), made more antenatal visits (mean 3.3 vs. 7.3; p: 0.01) and were more often admitted antenatally (p:<0.0001). The maternal mortality ratio for SCD decedents was 7–11 times higher than the general population, with 41% of deaths attributable to their disorder. Cause specific mortality was higher for cardiovascular complications, gestational hypertension and haemorrhage. Respiratory failure was the leading immediate cause of death. Conclusions Women with SCD experience a significant excess risk of dying in pregnancy and childbirth [MMR: (SCD) 719/100,000, (non SCD) 78/100,000]. MDG5 cannot be realised without improving care for women with SCD. Tertiary services (e.g. ventilator support) are needed at regional centres to improve outcomes in this and other high risk populations. Universal SCD screening in pregnancy in populations of African and Mediterranean descent is needed as are guidelines for managing SCD pregnancies and educating families with SCD.