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The quality of skilled birth attendants in Nepal: High aspirations and ground realities.

ABSTRACT: BACKGROUND:While Nepal's maternal mortality ratio (MMR) has improved overall, the proportion of maternal deaths occurring in health facilities and attended to by skilled birth attendants (SBAs), has nearly doubled over 12 years. Although there are numerous socioeconomic, environmental and other factors at play, one possible explanation for this discrepancy between utilization of skilled maternal care services and birth outcomes lies in the quality of care being provided by SBAs. The objective of this study is to determine how competent SBAs are after training, across multiple settings and facility types in Nepal. METHODS:We used a quantitative cross-sectional analysis to evaluate a sample of 511 SBAs, all female, from 276 sub-health posts (SHP), health posts (HP), primary healthcare centers (PHC), and district and regional hospitals in the mountain, hill, and terai districts of Nepal. Any SBA actively employed by one of these health facilities was included. SBAs who had received less than three months of training were excluded. Outcomes were measured using SBAs' scores on a standardized knowledge assessment, clinical skills assessment, and monthly delivery volume, particularly as it compared with the WHO's recommendation for minimum monthly volume to maintain competence. RESULTS:SBAs on average exhibit a deficiency of both knowledge and clinical skills, failing to meet even the 80-percent standard that is required to pass training (knowledge: 75%, standard deviation 12%; clinical skills: 48%, standard deviation 15%). Moreover, SBAs are conducting very few deliveries, with only 7 percent (38/511) meeting the minimal volume recommended to maintain competence by the WHO, and a substantial fraction (70/511, 14%) performing an average of no monthly deliveries at all. CONCLUSIONS:Taken together, our findings suggest that while countries like Nepal have made important investments in SBA programs, these healthcare workers are failing to receive either effective training or sufficient practice to stay clinically competent and knowledgeable in the field. This could in part explain why institutional deliveries have generally failed to deliver better outcomes for pregnant women and their babies.

SUBMITTER: Rajbhandari R

PROVIDER: S-EPMC6448824 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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The quality of skilled birth attendants in Nepal: High aspirations and ground realities.

Rajbhandari Ruma R Rai Shovana S Hathi Sejal S Thapa Rita R Rai Indra I Shrestha Anil A

PloS one 20190404 4

<h4>Background</h4>While Nepal's maternal mortality ratio (MMR) has improved overall, the proportion of maternal deaths occurring in health facilities and attended to by skilled birth attendants (SBAs), has nearly doubled over 12 years. Although there are numerous socioeconomic, environmental and other factors at play, one possible explanation for this discrepancy between utilization of skilled maternal care services and birth outcomes lies in the quality of care being provided by SBAs. The obje ...[more]

PMID: 30947314

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Project description:BackgroundDelivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge.MethodsMidwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores.ResultsOf 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that 'Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition.ConclusionThis study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Project description:INTRODUCTION: Assistance by skilled birth attendants (SBAs) during childbirth is one of the strategies aimed at reducing maternal morbidity and mortality in low-income countries. However, the relationship between birth preparedness and decision-making on location of birth and assistance by skilled birth attendants in this context is not well studied. The aim of this study was to assess the influence of birth preparedness practices and decision-making and assistance by SBAs among women in south-western Uganda. METHODS: Community survey methods were used to identify 759 recently delivered women from 120 villages in rural Mbarara district. Interviewer-administered questionnaires were used to collect data. Logistic regression analyses were conducted to assess the relationship between birth preparedness, decision-making on location of birth and assistance by SBAs. RESULTS: 35% of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was 68%. The final decision regarding location of birth was made by the woman herself (36%), the woman with spouse (56%) and the woman with relative/friend (8%). The relationships between birth preparedness and women decision-making on location of birth in consultation with spouse/friends/relatives and choosing assistance by SBAs showed statistical significance which persisted after adjusting for possible confounders (OR 1.5, 95% CI: 1.0-2.4) and (OR 4.4, 95% CI: 3.0-6.7) respectively. Education, household assets and birth preparedness showed clear synergistic effect on the relationship between decision-maker on location of birth and assistance by SBAs. Other factors which showed statistical significant relationships with assistance by SBAs were ANC attendance, parity and residence. CONCLUSION: Women's decision-making on location of birth in consultation with spouse/friends/relatives and birth preparedness showed significant effect on choosing assistance by SBAs at birth. Education and household assets ownership showed a synergistic effect on the relationship between the decision-maker and assistance by SBAs.

Project description:BackgroundDespite improvements since 1990 to 2014, maternal mortality ratio (MMR) remains high in Ethiopia. One of the key drivers of maternal mortality in Ethiopia is the very low coverage of Skilled Birth attendance (SBA) in rural Ethiopia. This cluster randomized trial piloted an innovative approach of deploying trained community reproductive nurses (CORN) to hard to reach/unreachable rural Ethiopia to improve the coverage of SBA.MethodsWe used a three-arm cluster randomized trial to test the effect of deploying CORN in rural communities in South Ethiopia to improve SBA and other maternal health indicators. A total of 282 villages/clusters (94 from each arm) were randomly selected in the three districts of the zone for the study. The intervention was implemented in four consecutive phases that aimed at of provision of essential maternal, neonatal and child health (MNCH) services mainly focusing on SBA. The CORN were trained and deployed in health centres (arm 1) and in the community/health posts (arm2). A third arm (arm 3) consisting control villages without the intervention. A baseline and end line assessment was conducted to compare the difference in the proportion of SBA and other MNCH service uptake across the three arms Data was entered into computer, edited, cleaned, and analyzed using Epi-data statistical software. The presentation followed the Consolidated Standards of Reporting Trials (CONSORT) statement guidelines for cluster-randomized trials.DiscussionThis trial is designed to test the impact of an innovative and newly designed means of distribution for the national health extension program strategy with additional service package with no change to the target population. The focus is on effect of CORN in revitalizing the Health Extension Program (HEP) through improving SBA service uptake and other maternal health service uptake indicators. The study findings may guide national policy to strengthen and shape the already existing HEP that has certain limitations to improve maternal health indicators. The competency based training methodology could provide feedback for health science colleges to improve the national nursing or midwifery training curriculum.Trial registrationclinicaltrails.gov NCT02501252 dated on July 14, 2015.

Project description:BackgroundImproved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked?Methods and findingsWe systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care.ConclusionsThe interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist.

Project description:BackgroundTo evaluate a skilled birth attendant (SBA) training program in a neglected population on the Thai-Myanmar border, we used multiple methods to show that refugee and migrant health workers can be given effective training in their own environment to become SBAs and teachers of SBAs. The loss of SBAs through resettlement to third countries necessitated urgent training of available workers to meet local needs.Methods and findingsAll results were obtained from student records of theory grades and clinical log books. Qualitative evaluation of both the SBA and teacher programs was obtained using semi-structured interviews with supervisors and teachers. We also reviewed perinatal indicators over an eight-year period, starting prior to the first training program until after the graduation of the fourth cohort of SBAs.ResultsFour SBA training programs scheduled between 2009 and 2015 resulted in 79/88 (90%) of students successfully completing a training program of 250 theory hours and 625 supervised clinical hours. All 79 students were able to: achieve pass grades on theory examination (median 80%, range [70-89]); obtain the required clinical experience within twelve months; achieve clinical competence to provide safe care during childbirth. In 2010-2011, five experienced SBAs completed a train-the-trainer (TOT) program and went on to facilitate further training programs. Perinatal indicators within Shoklo Malaria Research Unit (SMRU), such as place of birth, maternal and newborn outcomes, showed no significant differences before and after introduction of training or following graduate deployment in the local maternity units. Confidence, competence and teamwork emerged from qualitative evaluation by senior SBAs working with and supervising students in the clinics.ConclusionsWe demonstrate that in resource-limited settings or in marginalized populations, it is possible to accelerate training of skilled birth attendants to provide safe maternity care. Education needs to be tailored to local needs to ensure evidence-based care of women and their families.

Project description:BackgroundSkilled birth attendants (SBAs) play a crucial role in reducing infant and maternal mortality. Although the ratio of skilled assistance at birth has increased in Bangladesh, factors associated with SBA use are unknown. The main goal of our study was to reveal the individual- and community-level factors associated with SBA use during childbirth in Bangladesh. We also showed the prevalence and trend of SBA use and related independent variables in Bangladesh over the past decade.MethodsThis study utilized the Bangladesh Health and Demographic Survey (BDHS) 2017-2018, a cross-sectional study. We used binary logistic regression to examine the extent of variation in SBA use attributable to the individual- and community-level variables.ResultsOverall, 53.35% of women received assistance from SBAs during childbirth. The average annual rate of increase (AARI) in the number of SBA-assisted births over the past 10 years was 8.88%. Respondents who gave birth at or above 19 years had 1.40 times (AOR = 1.40; 95% CI: 1.21-1.62) greater odds of having skilled delivery assistance than respondents aged 18 years old or less. Women and their husband's education levels were significantly associated with using skilled assistance during delivery, with odds of 1.60 (AOR = 1.60; 95% CI: 1.45-2.01) and 1.41 (AOR = 1.41; 95% CI: 1.21-1.66), respectively compared to those with education up to primary level. Women from rich families and those receiving better antenatal care (ANC) visits were more likely to have professional delivery assistance. Community-level factors also showed significance towards having professional assistance while giving birth. Women from urban communities and those who utilized more than four ANC visits and had completed secondary or higher education showed a greater tendency to use an SBA during childbirth than their counterparts.ConclusionThe use of SBAs during delivery was significantly associated with some individual- and community-level factors. To reduce maternal and child mortality, there is a need to focus on rural and uneducated people who are less likely to access these facilities. Special programs could increase awareness and help the poor community obtain the minimum facility in maternal care.

Project description:IntroductionThe "percentage of births attended by a skilled birth attendant" (SBA) is an indicator that has been adopted by several global monitoring frameworks, including the Sustainable Development Goal (SDG) agenda for regular monitoring as part of target 3.1 for reducing maternal mortality by 2030. However, accurate and consistent measurement is challenged by contextual differences between and within countries on the definition of SBA, including the education, training, competencies, and functions they are qualified to perform. This scoping review identifies and maps the health personnel considered SBA in low-to-middle-income-countries (LMIC).Methods and analysisA search was conducted inclusive to the years 2000 to 2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the World Health Organization Global Index Medicus. Original primary source research conducted in LMIC that evaluated the skilled health personnel providing interventions during labour and childbirth were considered for inclusion. All studies reported disaggregated data of SBA cadres and were disaggregated by country.ResultsThe search of electronic databases identified a total of 23,743 articles. Overall, 70 articles were included in the narrative synthesis. A total of 102 unique cadres names were identified from 36 LMIC countries. Of the cadres included, 16% represented doctors, 16% were nurses, and 15% were midwives. We found substantial heterogeneity between and within countries on the reported definition of SBA and the education, training, skills and competencies that they were able to perform.ConclusionThe uncertainty and diversity of reported qualifications and competency of SBA within and between countries requires attention in order to better ascertain strategic priorities for future health system planning, including training and education. These results can inform recommendations around improved coverage measurement and monitoring of SBA moving forward, allowing for more accurate, consistent, and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programmes.

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The quality of skilled birth attendants in Nepal: High aspirations and ground realities.

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The quality of skilled birth attendants in Nepal: High aspirations and ground realities.

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