Authored by: Ann-Beth Moller
When Mumtaz Mahal died on June 17, 1631, while giving birth to her 14th child, there was little remarkable about her story. At the time, women often gave birth to a dozen or more children and for every 100 to 200 births at least one mother died.
Nearly 400 years later, the risk of childbirth has declined significantly – but unevenly. The World Health Organization estimates that nearly 300,000 women die each year due to largely preventable complications related to pregnancy, childbirth, or during the postnatal period – the overwhelming majority of them in low- and middle- income countries. It is estimated that the probability that a 15-year-old girl will eventually die from a maternal cause is about 1 in 5,300 in high-income countries. But the risk is much higher – 1 in 49 – in low-income countries.
The single most important factor for preventing maternal mortality and ensuring safe childbirth is ensuring that skilled health personnel are present at every birth, which will accelerate progress toward not only reducing maternal and neonatal mortality and morbidity but also toward achieving Sustainable Development Goal 3 (SDG 3).
A skilled health professional can administer interventions to prevent and manage life-threatening complications, such as heavy bleeding, prevent infections, and make referrals to a higher level of care when needed.
SDG indicator 3.1.2 notes that the proportion of births attended by skilled health personnel is an indicator of health care utilization. It is a measure of the health system’s functioning and potential to provide adequate coverage for childbirth.
Currently the data on this indicator is mainly collected in population-based surveys. Women are asked “Who assisted with the delivery of (Name)?”. To answer this question the woman needs to provide the title of the health care provider who assisted her during the delivery.
However, that question alone is often not enough. Will the woman know or remember who supported with the birth of her child? Does she even have that information? Was the person who helped at the health facility a community health worker, a nurse, a midwife, a doctor, or an assistant midwife? There are a dizzying number of titles for individuals that provide childbirth assistance in health facilities around the world. A scoping review identified 108 different professional titles in low-and middle-income countries.
Moreover, this indicator does not provide insight into the availability or accessibility of services. Neither does it capture the quality of care received. The evidence also suggests that while countries reported relatively high levels of birth attendance by skilled health personnel, maternal and neonatal mortality rates have not proportionately decreased.
This enigma – the increasing percentage of births attended by a skilled birth attendant accompanied by stubbornly high rates of maternal mortality – has prompted researchers and health leaders around the world to better define and understand the indicator.
First, in 2018, an interagency group including WHO, UNICEF and UNFPA, the International Confederation of Midwives, the International Council of Nurses, the International Federation of Gynecology and Obstetrics, and International Pediatric Association updated and refined the definition of the widely used term and indicator “skilled birth attendant” (SBA).
The 2018 definition and associated statement outlined three critical competencies: that the individual health care provider is educated, trained, and regulated to national and international standards to be capable of:
- Providing and promoting evidence-based, human-rights-based, high quality, socio-culturally sensitive and dignified care to women and newborns
- Facilitating physiological processes during labor and delivery to ensure a clean and positive childbirth experience
- Identifying and managing or referring women and/or newborns with complications
The definition also makes clear that skilled health personnel need to be working in an enabling environment. However well qualified, if skilled health personnel are overwhelmed by too many patients, have no drugs, equipment, electricity or water, then they cannot provide quality care. The definition also states that skilled health personnel need to work as part of a team and can refer patients to higher level services as needed.
The next phase of this effort is to operationalize this definition and use Nepal, Senegal, and Zambia as case studies. The goal of this work is to develop a feasible and useful measurement of skilled health personnel based on the revised definition.
The study is being conducted as part of the Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR) work portfolio and supported by research partners in Nepal, Senegal and Zambia in collaboration with UNICEF, UNFPA, the Global Financing Facility and Exemplars in Global Health. Nepal, Senegal and Zambia were selected as case study countries as these countries have been Exemplars in reducing maternal mortality.
We know that countries are very interested in understanding the challenges related to the measurement of coverage of skilled health personnel. The outcome of this research is expected to support and enable countries to measure the coverage of birth attended by skilled health personnel in a more accurate and useful way to inform policy and programs.
Ann-Beth Moller is a Technical Officer in the Department of Sexual and Reproductive Health and Research at World Health Organization