Adetoro Adegoke, Maternal and Newborn Health Unit, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, L3 5QA. Email: firstname.lastname@example.org
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.
To measure progress towards MDG5, two indicators: the maternal mortality ratio and proportion of births attended by skilled health personnel were selected. (Table 1). For skilled attendance at birth, the international community set a target of 80% by 2005, 85% by 2010 and 90% coverage by 2015. With the global human resource crisis, achieving this target is challenging but possible. However, in 2008 globally only 65.7% of all women were attended to by a skilled attendant during pregnancy, childbirth and immediately postpartum with some countries having less than 20% coverage.
Table 1. Millennium Development Goal 5 – Improving Maternal Health
5A Reduce by three –quarters, between 1990 and 2015, the maternal mortality ratio
Maternal mortality ratio Proportion of births attended by skilled health personnel
5B Achieve, by 2015, universal access to reproductive health
Contraceptive prevalence rate, adolescent birth rate, antenatal care coverage, unmet need for family planning
Over twenty years after the launch of the Safe Motherhood Initiative in Nairobi, Kenya1 motherhood in many parts of the world still remains unsafe. Globally, this neglected tragedy continues to claim many lives.2 Every year, over half a million women, and four million neonates continue to die, and the majority of these deaths have been identified as being avoidable.3 The death of a woman during pregnancy, childbirth and the puerperium remains the health statistic that shows the greatest disparity between the poor and the rich countries. While the estimated risk of a woman dying during pregnancy, childbirth and puerperium in her lifetime in Niger is 1 in 6, in Ireland the lifetime risk is 1 in 48,000.3 Improving the health of women and reducing their death during this critical period therefore remains a global priority.3
In 2000, when 149 heads of state and 189 member states adopted the United Nations Millennium Declaration in New York, USA, world leaders committed themselves to the achievement of eight ambitious Millennium Development Goals (MDGs) for accelerating development and reducing poverty including improving maternal health (MDG 5). Unlike twenty years ago when the ‘war against maternal mortality’ started, today we largely do know what works and how these unnecessary deaths can be reduced. In 1997 the Safe Motherhood Interagency Group (IAG) stated that “The single most critical intervention is to ensure that a health worker with midwifery skills is present at every birth, and transportation is available in case of emergency. A sufficient number of health workers must be trained and provided with essential supplies and equipment, especially in poor and rural communities”.4 Also in 1999, in a joint statement by the WHO, UNFPA, UNICEF and World Bank, countries were asked to ensure that all women and newborns have skilled care during pregnancy, child birth and immediately after birth.5
The global consensus therefore is that to improve maternal health and reduce maternal mortality, pregnant women should be assisted by a competent health care professional who has the required equipment, drugs, supplies and an adequate referral system in place. This strategy is referred to as ‘Skilled Birth Attendance’ and consists of two essential components - skilled health personnel and an enabling environment. The proportion of births attended by a skilled birth attendant has become a proxy indicator for maternal deaths and is used to monitor progress towards MDG 5. However, the United Nations Millennium Project in 2005 and 2006 called for the inclusion of universal access to reproductive Health as a target within MDG 5 this goal referred to as MDG5b has four core indicators: contraceptive prevalence rate, unmet need for family planning, adolescent birth rate and antenatal care attendance (Table 1).
This paper provides an overview of the strategy to ensure skilled birth attendance for all, highlighting important challenges of achieving the goal of universal access to skilled birth personnel and the key lessons learnt.
What is skilled birth attendance?
An increase in the proportion of deliveries with skilled attendance has been identified as an important approach to reduce maternal mortality and morbidity in developing countries.6 The term skilled birth attendance has been defined as the process by which a woman is provided with adequate care during labour, delivery and the early postpartum period.7 This requires skilled personnel to attend the delivery and an ‘enabling environment’, which was initially defined as including adequate supplies and equipment, transport and effective communication systems. It has also been suggested that the enabling environment should not be limited to just these factors but be seen more broadly to include the political will, policy and, sociocultural influences as well as other factors such as the education and training of skilled attendants at pre-service and in-service levels, and following that supervision and deployment.8
Three main rationales informed the decision to promote the concept of skilled attendance at birth. The first is that when major obstetric complications are identified early and are promptly and effectively managed women’s lives will be saved. This observation is crucial because as we cannot predict which woman will have complications at childbirth.9–11 Having a skilled attendant functioning within an enabling environment during the time of birth is vital as two-thirds of maternal mortality occur at this time. The second observation centres on how maternal mortality has been reduced in other countries. Historical evidence shows that countries that have been able to reduce maternal mortality have improved women’s access to skilled health professionals. Documentation of the current evidence which links availability of skilled attendance with the reduction in maternal mortality is now widely available.11–14 Thirdly, a shift to skilled attendance has been further strengthened when programmes that focused on training of Traditional Birth Attendants (TBAs) failed to show reduction in maternal mortality.15–17 It is recognised that TBAs may be more available and accessible within the community however their inability to acquire life-saving skills, lack of supportive supervision, lack of integration into the health care system and absence of emergency back-up systems have been identified as reasons for their ineffectiveness.13,16,18
The rationale for adopting skilled birth attendance as noted earlier is based on historical evidence which is commonly regarded as ‘weak’ evidence.19 For evidence to be strong (e.g. grade 1 evidence) there should be Randomised Control Trials (RCTs) which show that women who have skilled attendance at birth will have lower risk of dying during pregnancy, childbirth and puerperium than women who do not have skilled attendance. However, to group women into an experimental and control group where the control group would be denied skilled attendance at birth is considered unethical and not feasible.8 Using a quasi experimental design, in 1991, the efficacy of skilled birth attendance to reduce maternal mortality was evaluated through a maternity-care programme in a rural area in Bangladesh.20 Trained midwives were deployed to villages to attend home-deliveries, detect and manage obstetric complications, and refer when needed to a maternity clinic which could perform all the signal functions of a Basic Emergency Obstetric Care (BEOC) facility. To evaluate the effectiveness of this intervention (Skilled Birth Attendance), the Maternal Mortality Ratio (MMR) in the intervention area was compared with the MMR of a neighbouring area which had a similar baseline MMR but did not receive the intervention. Findings showed a significant decline in MMR (1.4 per 1000 live births in intervention area, 3.8 per 1000 live births in control area; P = 0.02).20 This study illustrated that maternal deaths can be reduced with the posting of midwives (skilled attendant) if they have needed skills, supervision, and back-up.21 Other recent evidence from low resource settings suggest that skilled attendance at birth may help in the reduction of maternal mortality. Available data from developing countries show a reduction in maternal mortality in countries with more access to skilled attendance (Figure 1).
The MMR shows a significant association with an increased proportion of births attended by a skilled attendant.22 (Figure 1) However, there is a need to exercise caution in the interpretation of this data as the strong correlation does not mean that increasing access to skilled attendance is the only factor resulting in reduction in maternal deaths. The possibility of other factors impacting on these indicators cannot be ruled out.22 Estimating the coverage of skilled birth attendants is also not devoid of problems as there remains in many cases still lack of clarity as to who a Skilled Birth Attendant is. Furthermore there is the problem of relying on the ability of respondents to identify the cadre of staff who attended to them at childbirth.
Who is a skilled attendant?
The Skilled attendance strategy consists of two essential and interdependent components: skilled attendant and enabling environment. The word trained attendant was used up until the early 1990s to denote health professionals and trained traditional attendants. However, in the late 1990s there was a significant shift to the word “skilled” thus bringing about the recognition that a trained person may not necessarily have acquired the needed knowledge and competence.8,21
In 1999, the first attempt at defining the term skilled attendant was made by the WHO/UNFPA/UNICEF/World Bank. In a joint statement they defined skilled birth attendant as “exclusively referring to people with midwifery skills (for example midwives, doctors and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications. They must be able to manage normal labour and delivery, recognise the onset of complications, perform interventions, start treatment and supervise the referral of mother and baby for interventions beyond their competence or not possible in the particular setting”.5‘Manage’ was added to this definition in 2000 by the Inter-Agency Group for Safe Motherhood in recognition that some skilled attendants will also have competencies to manage complications.7 However it is often argued that this definition appears to be biased towards facility deliveries as it fails to identify the place of practice and the fact that skilled professional can attend to home deliveries.22 The essential skills that can be performed at home by a skilled home birth attendant and at the institutional level do not appear to have been well defined.
A refined definition by WHO, International Confederation of Midwives (ICM) and the International Federation of Gynaecology and Obstetrics (FIGO) in 2004 defined a skilled attendant “as an accredited health professional — such as a midwife, doctor or nurse — who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”.22 In this statement, it was identified that as the skills and competencies expected of a Skilled Birth Attendant can be provided by a diverse range of health professionals (with country specific titles) this category of health professionals should be called “skilled attendant” or, “skilled birth attendant”, to avoid confusion.23
Skilled birth attendants who and how many?
Global targets for skilled attendance were established, by the United Nations ICPD+5 in 1999.23 This agreement, signed by 179 country representatives, set a goal of 40% of all births to be assisted by a skilled attendant by 2005, with 50% coverage by 2010 and 60% by 2015 among countries with very high maternal mortality. Globally, however, the United Nations called on countries to increase their efforts toward skilled attendance and set a target of 80% coverage by 2005, 85% by 2010 and 90% by 2015. New estimates in 2001 suggested that having a skilled attendant present at every delivery would reduce maternal mortality by 13—33%.8 For developing countries, ICM and FIGO in 2002 proposed a target of one skilled birth attendant for every 5,000 population which means that a skilled attendant can be expected to attend 200 births every year.23 A lower target is set for Skilled Birth Attendants in well-resourced countries with a skilled attendant expected to be attending between 30–120 deliveries per year.25 Current data on the proportion of women who deliver with a Skilled Birth Attendant show that while many richer countries have near universal coverage, just slightly over 50% of all births in developing countries take place with a skilled attendant, although this varies by region.25 (Table 2)
Table 2. Global, regional and sub-regional estimates of the proportion of births attended by a skilled health worker 2008
% births with skilled health worker
MORE DEVELOPED REGIONS
LESS DEVELOPED REGIONS
LEAST DEVELOPED COUNTRIES
Latin America & The Caribbean
Global progress towards the availability and use of skilled attendants at delivery was assessed in 2007.24 Data from Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and Reproductive Health Surveys (RHS), Pan-American Health Organisation Surveys and other surveys were analysed. This study revealed an increase in births between 1990 and 2000 attended by a skilled worker from 45% to 54% in developing countries except for South Asia and sub Saharan Africa. The WHO has used similar methodology using DHS data to calculate the proportion of births attended by skilled health workers.25 In 2008, globally an average of 65.7% of births were attended by a skilled health worker. Developed countries had over 99% coverage while East Africa had the least coverage (33.7%), with 41.2% coverage in Western Africa, and 46.9% in South Central Asia. It is now commonly agreed that a more intensive effort is needed to be able to achieve the target of 85% coverage by 201027 (Table 2).
It is important to note that in almost all surveys women themselves were asked to identify the health provider, if any, who attended their most recent deliveries.27 This assumes that women will be able to identify their provider and recall if these were skilled or unskilled. This recall by women is however plagued with difficulties. Since the skills of a ‘skilled attendant’ can not be verified during a survey, the use of such data to estimate the percentage of births assisted by skilled attendants assumes that all health professionals qualify as skilled attendants.26 Using the WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines as the competency standard, Harvey et al in 2004 assessed the competencies of 1,524 skilled attendants in Benin, Ecuador, Jamaica, Rwanda and Nicaragua. Findings revealed that skilled attendants in Benin, Ecuador, Jamaica and Rwanda could correctly answer 56% of the knowledge and only 48% of the skills questions, while skilled attendants in Nicaragua could answer 62% of the knowledge questions. This study noted that many ‘skilled birth attendants’ may not really be skilled and that health personnel identified by women during household surveys may not fit the WHO/ICM/FIGO definition of a skilled attendant.29 The two studies above also measured only the presence of a health professional 26,27 and do not reflect if an enabling environment was present (Skilled Birth Attendance). International comparison of this indicator is therefore very difficult as there are many different categories of health workers in a country who may in theory fit the definition of a ‘Skilled Birth Attendant’. As an example a registered nurse in the United Kingdom does not have core midwifery skills while a registered nurse in Nigeria based on the review of the training curriculum has the needed competence and can be categorised as a skilled birth attendant.
Training of skilled birth attendants
The education of a skilled birth attendant should be of good quality at both pre-service and in-service levels with a system for supportive supervision. The education of a skilled attendant should be based on a “competency model”.27 The ICM competency model is currently considered to be the international standard for provision of skilled, safe, professional care to childbearing women and their families. This model forms the conceptual framework upon which the core skills and abilities of a Skilled Birth Attendant is based reflecting essential knowledge, skills and behaviours expected during ante-partum, intra-partum, post-partum and neonatal care. The education of such an individual should include critical components such as practical skills, problem solving, critical thinking and skills in decision making. These components should be taught using a large degree of student centred and facilitative approaches to teaching and learning. The use of didactic lectures with little clinical practice should be discouraged.22,25,28 Before a birth attendant can be declared “skilled”, there is a set of core and essential skills outlined by ICM, FIGO and WHO that the person must achieve (Box 1).23 These core skills should form the basis for the development of training curricula for Skilled Birth Attendants’ training. It is of key importance that the curriculum should also reflect the realities of the specific community and health care system of the individual country or region and should include interpersonal communication skills.
The educational programmes for three types of health professional were assessed in Mexico to ascertain if these curricula met the international standards using the ICM competency model. These professionals included midwives, obstetric nurses and general physicians. Although both the WHO/ICM/FIGO definition and the government of Mexico identified nurses and doctors as skilled attendants, a review of their curricula showed gaps both in theory and in the supervised clinical placement and considered the curricula insufficient to prepare these professionals as skilled attendants.28 Similar findings have been documented in Nigeria and Cambodia.30–32 Although the government of the Republic of Cambodia regards the Primary Nurse-Midwives as skilled attendants, a review of the training curriculum in 2006 led to an urgent call for the revision of the content and structure of the programme and it was agreed there was a need to address the current skills deficit through the introduction of an abridgement programme for graduates of the programme and supportive supervision. In Nigeria, a recent review of the curricula of Junior Community Health Extension Workers (JCHEW) and Community Health Extension Workers (CHEW) programmes identified that these do not include the necessary skills and competence to lead to training as a skilled attendant despite the fact that this cadre is included as a ‘skilled attendant’ in Nigerian health policy documents. This contradicts WHO/ICM/FIGO statement that the “precise skills and abilities of health care providers working under various titles and reported as providing skilled care can only be clarified at the local level”23, p10. Faced with immense HR problems it is understandable that there is a tendency at individual country level to classify health personnel as ‘Skilled Birth Attendants’ even though curriculae may not fully meet the set of criteria for this. These observations from a variety of countries help identify the urgent need for a comprehensive review of training curriculums to ensure that all categories of health personnel grouped as being skilled attendants are adequately trained and truly skilled.
In addition to the content of training (curricula) more attention is needed with regard to modes of delivery of such training and the infrastructure needed for this. To facilitate learning, small class sizes have been suggested with a teacher student ratio of 1:10 and Clinical Instructor ratio of 1:5.25,31 This approach will ensure quality and allow for more hands-on experience. However it is recognised that this will currently limit the ability of countries to meet the demand for skilled birth attendants. Follow up of trainees is important to assess retention of skills and to ensure access to in-service training as well as the monitoring of the training quality.23
Innovative approaches are also required to recruit appropriate student trainee skilled attendants. In many countries, women want to be attended to by female skilled attendants and it is advisable that in such settings admission and recruitment policies should target the female trainee. However in many such cases institutions recruit and train more male than female skilled attendants. A possible reason might be lack of sufficient girls graduating from secondary school with the necessary qualifications to enter health training institution. As a short term measure remedial programmes could be organised for girls who do not have the entry requirements. In the long term education of the girl-child should be given priority in such settings.
Box 1: Skilled attendant: the required skills and abilities
All skilled attendants must have ability to:
• Communicate effectively cross-culturally in order to be able to provide holistic “women-centred” care. To provide such care skilled attendants will need to cultivate effective interpersonal communication skills and an attitude of respect for the woman’s right to be a full partner in the management of her pregnancy, childbirth and the postnatal period.
• In pregnancy care, take a detailed history by asking relevant questions, assess individual needs, give appropriate advice and guidance, calculate the expected date of delivery and perform specific screening tests as required, including voluntary counselling and testing for HIV.
• Assist pregnant women and their families in making a plan for birth (i.e. where the delivery will take place, who will be present and, in case of a complication, how timely referral will be arranged).
• Educate women (and their families and others supporting pregnant women) in self-care during pregnancy, childbirth and the postnatal period.
• Identify illnesses and conditions detrimental to health during pregnancy, perform first-line management (including performance of life-saving procedures when needed) and make arrangements for effective referral.
• Perform vaginal examination, ensuring the woman’s and her/his own safety.
• Identify the onset of labour.
• Monitor maternal and foetal well-being during labour and provide supportive care.
• Record maternal and foetal well-being on a partograph and identify maternal and foetal distress and take appropriate action, including referral where required.
• Identify delayed progress in labour and take appropriate action, including referral where appropriate.
• Manage a normal vaginal delivery.
• Manage the third stage of labour actively.
• Assess the newborn at birth and give immediate care.
• Identify any life threatening conditions in the newborn and take essential life-saving measures, including, where necessary, active resuscitation as a component of the management of birth asphyxia, and referral where appropriate.
• Identify haemorrhage and hypertension in labour, provide first-line management (including lifesaving skills in emergency obstetric care where needed) and, if required, make an effective referral.
• Provide postnatal care to women and their newborn infants and post-abortion care where necessary.
• Assist women and their newborns in initiating and establishing exclusive breastfeeding.
• Identify illnesses and conditions detrimental to the health of women and/or their newborns in the postnatal period, apply first-line management (including the performance of life-saving procedures when needed) and, if required, make arrangements for effective referral.
• Supervise non-skilled attendants, including TBAs where they exist, to ensure that the care they provide during is of sound quality
• Ensure continuous training of non-skilled attendants.
• Provide advice on postpartum family planning and birth spacing.
• Educate women (and their families) on how to prevent sexually transmitted infections including HIV.
• Collect and report relevant data and collaborate in data analysis and case audits.
• Promote an ethos of shared responsibility and partnership with individual women, their family members/supporters and the community for the care of women and newborns throughout pregnancy, childbirth and the postnatal period.
• Use vacuum extraction or forceps in vaginal deliveries.
• Perform manual vacuum aspiration for the management of incomplete abortion.
• Where access to safe surgery is not available, perform symphysiotomy for the management of obstructed labour.
• Perform Caesarean sections.
• Manage complications during pregnancy and childbirth.
• Administer blood transfusions.
Source: WHO. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. WHO 2004; 3–4.
Key challenges and lessons learnt in ensuring skilled attendance at every birth
Globally, it may be difficult to achieve the ICPD+5 target of 85% coverage with skilled attendance at birth by 2010 especially considering the current average of 65.7%. However since this global commitment it has been possible to identify the main challenges in the implementation of this strategy which if addressed will help progress towards the achievement of universal coverage for all pregnant women by 2015. These challenges are:
Human Resource problems in developing countries
Available evidence from developing countries shows that absence of sufficient numbers of health professionals is the most significant barrier to progress towards achieving the ICPD+5 target.29 Health systems, particularly in countries with a high MMR, may be weak with inadequately qualified staff, poor retention schemes, urban-rural disparity in the deployment of staff, high levels of absenteeism, and decreasing numbers of skilled workers due to HIV/AIDS and regional/international migration.29 An attempt to increase the supply of skilled Birth Attendants in some countries has led to the development of Mid-level community health workers30 while the skills of existing health workers in other countries have been upgraded.20,31 Since most community health workers only have a primary health care background, they do not possess the needed skills to deliver essential and life saving maternal and newborn care. In-service midwifery training has been undertaken for some of these health workers. The length of training has varied from 5 weeks to less than 1 year. Although this may appear a useful short term measure to increase the number of people with midwifery skills, caution should be exercised as poorly skilled staff may not be able to recognise, manage or refer complications. The implication of this would be an increase in the proportion of skilled attendance without any reduction in maternal mortality. It is important that these training interventions are properly evaluated and the effect monitored.
To ensure adequate human resources for skilled birth attendance in developing countries, Hoope-Bender et al emphasised the importance of countries taking key steps such as having a national consensus on the cadre(s) of health care providers that will be developed as skilled attendants.34 This decision should be made only after a comprehensive review of the curriculum; increasing the recruitment and production of skilled attendants; having a policy for the equitable distribution of skilled attendants and addressing issues that affect morale and motivation of skilled attendants.
Recruitment, deployment and retention of staff
The context-specific barriers to recruitment, deployment and retention of skilled personnel should be assessed and urgently addressed. One possibility is that retired skilled birth attendants (often retired at a young age) or those who have left the profession for other reasons are attracted back to work in the health service.32,33
Thailand was able to ensure equitable distribution of health workers through the use of home town placements, provision of rural training, general development of rural areas and career development incentives.34,35 These factors, including the need to expand pre-service education capacity for skilled attendants, are important for many other countries.
Supportive supervision is the process by which skilled attendants and supervisors review the quality of care provided, reinforcing effective and appropriate, evidence-based practices and offering constructive feedback.25 As important as this concept is, there appears to be a general lack of literature on supportive supervision of skilled birth attendants in developing countries. In an extensive literature search in 2000, Maclean 2003 could not identify any evidence of supportive supervision of midwifery practice in countries where MMR is high. Many skilled attendants work alone in rural areas without any support and in the few places where supervision is available it cannot be said to be supportive. For skilled attendants to function effectively there is a need to (re)focus on ensuring there is a system of adequate supportive supervision.34,36
Monitoring and Evaluating the impact of SBA
There is a global commitment to reduce maternal mortality and a heavy reliance on the proportion of births attended by a skilled attendant as the key indicator to measuring the achievement of that target. Clearly therefore, there is a need for an agreed framework to assess the impact of increasing coverage with SBA on reducing maternal mortality. However, a recent review found no standardised framework for monitoring and evaluation of the impact of skilled birth attendance. It was noted that some frameworks only monitored the “skilled attendant” and not the “enabling environment.”26,27 The two available frameworks that monitor both components of skilled attendance currently appear too weak to assess the impact of SBAs and are not universally used.37,38
An effective monitoring and evaluation framework, to inform policy makers on the progress and impact of implementing the strategy of Skilled Birth Attendance for every delivery in a variety of settings is needed.
Ensuring skilled attendance during pregnancy, childbirth and immediately after is crucial to the achievement of MDG5. Available evidence has shown that improving the recruitment, education, training and supervision of skilled attendants as well as the provision of an enabling environment are crucial steps.
Urgent global action is therefore needed to promote the availability, access and utilisation of skilled attendance. This should include a global human resource strategy, the provision of effective supportive supervision as well as the availability of a validated and standardised monitoring and evaluation framework.