Rapid assessment of selected
skilled birth attendants in eight
Latin American and Caribbean
countries
Joyce E. Thompson, Study Leader, UNFPA Technical Advisor
Alma Virginia Camacho, UNFPA LACRO, Technical Advisor
Sandra Land, UNFPA Technical Advisor
Ivelise Segovia, Midwife Observer
Martha Murdock, Family Care International, Project Technical Advisor
Background
• In spite of enabling policies, solid infrastructure, and provider
training, women and newborns in LAC continue to die in
childbirth from preventable causes:
– 9,500 childbearing women
– 190,000 babies within 28 days of birth
• MMR for LAC: 88.9 deaths per 100,000 live births (2010)
= 41% reduction since 2000
• Will not reach MDG5 target of 75% reduction by 2015
• Will not reach MDG4 target of 2/3 reduction child mortality
Why Focus on Skilled Birth Attendants (SBAs) in
Latin America and the Caribbean (LAC)?
• Need to confirm who actually attends a given birth
• ‘Trained personnel’ interpretations differ
• No effort to affirm that trained personnel are /or
remain competent to provide Mat Nb care
• Inconsistencies in reported country data: Many
countries that report high rates of trained personnel
(SBAs) attending births in health facilities also report
continuing high levels of maternal and neonatal
mortality.
Objectives of Rapid Assessment
Gather preliminary findings thru direct observation
related to providers of MN care and the observed
quality of care in 8 selected LAC countries:
1. Identify who was actually providing maternalnewborn care and attending births in selected health
facilities
2. Identify whether the person observed was providing
quality care and was competent to do so
3. Inform priorities for future coordinated country and
regional advocacy
Observation Process
• Developed methodology and standardized observation
tools
• Recruited and trained observation team (midwives and
obstetricians paired)
• Pilot tested forms seeking inter-rater reliability and
‘understandability’ in Spanish and English
• Selected 8 countries from those which volunteered
(Bolivia; Chile; Colombia; Guatemala; Guyana;
Honduras; Panama; Peru- different models of care)
• UNFPA secured national administrative approval
• Obtained prior consent from health facilities, providers
• Timeline: August – December 2011
Observation Tools
1. Demographics
o
o
Setting type, provider title & credentials
Provider Self-report of Life Saving Skills
2. Antenatal first visit
o
o
Competencies observed
Quality of care observed (repeated for each clinical area)
3. Antenatal repeat visit
o
Review of clinical record
4. Labor care
5. Birth, immediate post partum, newborn care
Measures of Quality of Care (9)
 Treat woman/family with respect at all times
 Maintain privacy & confidentiality
 Solicit questions & concerns from woman/family
 Encourage companion of choice during labor
 Provide information/counseling appropriate to needs
 Provide supportive care and pain relief during labor
 Wash hands before & after examinations/procedures
 Use clean equipment – sterile equipment on indication
 Early identification of problems with timely referrals
Measures of Provider Competence
 History taking skills with appropriate follow-up
 Key laboratory tests; e.g., syphilis, hemoglobin
 Physical assessment, including vital signs & weight
 Correctly dating pregnancy, monitoring FHR & growth
 Conducting safe delivery, airway & thermal regulation
newborn
 Recognize symptoms potential complications & take
appropriate action; e.g., syphilis, PIH, PPH, AMSTL
 Use of CLAP records and note findings correctly
 Self report of Life Saving Skills (EmONC)
Limitations of Rapid Assessment
• Not a formal study; no generalizability
• All participants, health facilities & countries
volunteered
• Only short facility-based observations –
representative of only eight LAC countries
• Only selected indicators of quality & competencies
included – not full range
• Possible lack of inter-rater reliability at times
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Outcomes of Rapid Assessment:
Objective 1: Who is providing care?
 83 different health care providers observed
 Midwives [23] & obstetricians [16] = 39 (47%)
 General MDs [19] & OB residents [6] = 25 (30%)
 Others [nurse [1], auxiliary nurses [6], students [12] = 19(23%)
 105 care encounters observed
 Antenatal care = 34
 Labor care = 34
 Birth/PP/newborn = 37
 Mean practice in setting = 6.7 years
 Mean births attended last 6 months = 93.7
 Mean time spent antenatal visit = 30.4 minutes
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Outcomes of Rapid Assessment:
Objective 1 (con’t)
• Antenatal observations (34)
– 15 by general MDs, 3 by ‘others’
– 10 by midwives, 6 by obstetricians
• Labor observations (34)
– 10 by midwives, 9 by obstetricians
– 5 by general MDs, 1 OB resident, 9 ‘others’
• Birth/PP/Newborn observations (37)
– Team approach with 13 PP women and 9 newborns
– Births by physicians, midwives, general MDs with auxiliary
nurses /students caring for newborn and PP mother
Outcomes of Rapid Assessment:
Objective 2: Quality Overview
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Greets woman/family respectfully = 100%
Respectful throughout encounter = 97%
Uses clean equipment = 85%
Solicits questions and concerns = 79%
Maintains privacy & confidentiality = 76%
Provides supportive care & pain relief = 65%
Washes hands before and after procedures = 41%
Provides information; e.g., progress in labor = 35%
Encourages support companion during labor = 15%
Objective 2: Quality Overview
Expert Opinion (% =Yes)
• Antenatal providers
– First visit = 80%
– Repeat visits = 51%
• Labor providers = 44%
• Birth/PP/Newborn providers = 41%***
With exception of first AN visit, obstetricians &
midwives rated highest (50-73%).
***Could not separate birth providers from others on
observation form
Outcomes: Objective 2
Selected Overview of Competencies
observed less than 50% in ANC
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Questioned prior contraceptive use (33%)
Discussed birth plan (38%)
Questioned prior PIH history (33%)
Asked about problems since last visit (45%)
Questioned history vaginal bleeding/PPH (33%)
Examined for edema (33%)
Ordered syphilis test (47%)
Outcomes: Objective 2
Selected Overview of Competencies
observed less than 50%
Labor/Birth
Labor care:
• Used sterile technique with ROM (50%)
• Reviewed available partograph (37%)
• Noted status of membranes (50%)
Birth care:
• Ruled out second fetus before oxytoxic given (38%)
• Clamped/cut umbilical cord stopped pulsating (15%)
Outcomes: Objective 2
Selected Competence Overview –
Postpartum/Newborn
Postpartum mother:
• Monitored fundus/bleeding q. 15” for 2 hrs (27%)
• Monitored maternal vital statistics q. 15” for 2 hrs
(27%)
Newborn care:
• Placed infant skin-to-skin (31%)
• Took newborn temperature (12%)
• Promoted exclusive breastfeeding (26%)
• Monitored NB status & VS q 15” for 2 hrs (27%)
Outcomes Objective 2 (con’t):
Self-Report of Competence
• Midwives unanimously reported they did not have the
skills of assisted delivery (forceps, vacuum extraction) or
MVA.
• One-third of midwives were skilled in manual removal
of placenta and newborn resuscitation, and 100% were
skilled in starting IVs, administering antibiotics,
oxytoxics, and MagSO4.
• Obstetricians reported administering oxytoxics at 100%,
but only 56% in starting IVs.
Objective 2: Competent
Expert Opinion (% = Competent)
• Antenatal providers
– First visit = 58% average; others (100%) and SBAs (80%) highest
– Repeat visits = 64% average with SBAs (88%), rest below 50%
• Labor providers = 47% average
– SBAs (58%)
– Gen. MD/OB residents (17%)
– Others (44%)
• Birth/PP/Newborn providers = 22% average
– SBAs (41%)
– Gen MDs (0%)
– Others (8%)
Implications of Observations:
Provider
• 23% of care was provided by ‘Other’, primarily
students, largely unsupervised
• WHO proxy of institutional birth = SBA might not
be accurate
Implications of Observations: Quality
Aspects to strengthen:
• Soliciting questions & concerns
• Providing information & counseling
• Missing elements of family-centered care
• Encouraging support persons during labor
• Promoting maternal-infant bonding
• Promoting breastfeeding
Implications of Observations:
Competencies
Strengths: Mostly routine care
Areas of improvement:
• Competencies for all providers, particularly during
PP/NB period, alarmingly low
- including identifying signs of danger and
- monitoring PP women & NB
- Hygiene (hand washing & clean equipment)
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Implications Objective 2: Competent Care
• Under-performance observed frequently in all countries,
regardless of the model of care
• Given observed inconsistent competency among all three
groups of providers, can any group be classified as skilled
personnel or SBAs?
• RE-EVALUATE HUMAN RESOURCE DEPLOYMENT PLAN: To
what extent should general MDs and auxiliary nurses be
involved in maternal-newborn care, especially births?
• SUPERVISION: To what extent do general MDs & auxiliary
nurses require supervision and/or advanced preparation
for their roles?
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Recommendations
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All countries need to use same definition of SBA for data
Provide periodic competency assessment for all providers
Partner with education institutions for updates
Update clinical guidelines based on essential
competencies & best evidence available
Carry out periodic quality of care assessments in every
facility including user satisfaction
HR development & deployment based on country needs
and competencies of personnel
Reinforce hand washing and clean equipment use
Provide direct supervision for health professional
students.
Thanks!
Martha Murdock
mmurdock@fcimail.org