A Concept Note

 

 

1. Background

 

1.1 Situation of maternal health in South and West Asia

 

South Asia presents a paradoxical picture in level of maternal mortality. On one hand, it has the dubious distinction of having countries with some of the highest levels of maternal mortality in the world and on the other it has a country like Sri Lanka with a low level of maternal mortality. Afghanistan with the second highest maternal mortality ratio in the world is part of West Asia. The top five causes of death are the same (in varying proportions) in all the countries and they are haemorrhage, sepsis, eclampsia, obstructed labour and unsafe abortions. It is well known that for every woman who dies, another thirty suffer injuries, infection and disabilities during pregnancy and childbirth. In the region, obstetric fistula and uterine prolapse are increasingly being recognised as important reproductive health problems.

 

While maternal mortality is influenced by social, cultural, economic and political factors affecting women seeking care, there is also epidemiological evidence that shows that most of the deaths could be prevented if women received skilled care at critical moments during pregnancy and childbirth. This is evident from the comparison of percentage of deliveries attended by skilled attendants, Sri Lanka reporting above 90% while the other countries in the South Asia region and Afghanistan reporting less than 40%. Also the interpretation of skilled attendants data varies with different countries and surveys and the actual level of births that received skilled care as per definition (see box) is much lower. 

 

1.2 Skilled attendant and skilled care

 

Skilled care during childbirth is almost universally accepted as one of the key indicators for assessing progress towards maternal mortality reduction. Proportion of births assisted by skilled birth attendants is one of the ICPD +5 indicators and also one of the Millennium Development indicators. Although this is a process indicator, it is used due to its strong links with maternal outcome.

 

 

The term skilled attendant refers exclusively to people with midwifery skills (for example, doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer complications. They must be able to manage normal labour and delivery, recognise the onset of complications, perform essential interventions, start treatment and supervise the referral of mother and baby for interventions that are beyond their competence or not possible in the particular setting.”

   Joint WHO/UNFPA/UNICEF/World Bank Statement 1999

 

Skilled attendance /skilled care is the process by which a woman is provided with adequate care during labour, delivery and early post-partum period (SMIAG 2000b). The process requires a skilled attendant and an enabling environment, which includes adequate supplies, equipment and infrastructure as well as efficient and effective systems of communication and referral.

 

 

It is clear from the above definitions that “ to be skilled”, life saving skills are a must. Skilled attendants by themselves cannot be effective in reducing incidence of maternal deaths, morbidity or disability unless an enabling environment that facilitates and support their work as described above is available at domiciliary; health centre or hospital level; hence the focus is on ‘skilled attendance.’

 

1.3 Conceptual and operational issues related to the use of the indicator ‘proportion of deliveries assisted by skilled birth attendants’ in South and West Asia

 

Besides conceptual and operational issues, there are also measurement issues related to the use of the indicator.

 

The problems with the use of the indicator discussed below are not just limited to South and West Asia.

 

Conceptual issues

 

As mentioned earlier there are definitional problems- the way the term ‘skilled attendant’ is defined in different countries and the setting in which the delivery takes place (home or institution). Traditionally, doctors, midwives and nurses are considered skilled. However, they may not possess life saving skills. Access to these ‘so-called’ skilled categories is a major problem in the countries in South and West Asia (except Sri Lanka and Iran). Many of the countries in the region are making an earnest effort to improve access to skilled care, but with poor understanding of the definition of skilled care. For example, some of the countries in the region define skilled birth attendant as some one who has received six months – one year training in conducting normal delivery and possibly in recognising problems, but not possessing skills in dealing with the life threatening complications. Clearly this group of birth attendants cannot affect maternal mortality and morbidity unless timely access to care for complications is assured.  The danger of including this category as skilled birth attendant is evident.

 

The regulatory and policy frameworks that support the skilled birth attendant to carry out life saving interventions in which they are proficient are non-existent in many of the countries. For example, nurses cannot carry out life saving skills, as the current regulatory mechanisms do not allow. Such barriers block the increase in number of skilled birth attendants.

 

Operational issues

 

The indicator does not capture the supportive enabling environment issues that affect the provision of skilled care such as the availability of supplies, equipment and infrastructure. are other major barriers to providing skilled care. 

 

In South Asia, the social, cultural, economic and political factors affecting women’s access and utilization of care are also major barriers. These crucial factors are also not captured by the indicator.

 

2. Proposal for a workshop on skilled birth attendants

 

2.1 UNFPA’s strategic response to improve maternal health

 

UNFPA focuses on three major programme strategies to prevent maternal mortality and morbidity. These strategies are most effective when implemented as a package. The strategies are:

·        Family planning

·        Skilled attendance at birth

·        Emergency obstetric care

 

The shortage and poor distribution of professionally trained and skilled attendant at birth is a major problem in most of the countries. UNFPA is seeking to address this problem of shortage and distribution of skilled attendance at birth by promoting more training of professionals and by seeking innovative ways to retain them in the regions in greatest need[1].

 

The association between low level of skilled attendance at birth in most countries of South and West Asia and the continuing high level of maternal mortality is evident from the previous section. One of the major problems is the availability of professionally trained and skilled birth attendants. UNFPA Country Technical Services Team for South and West Asia proposes to hold a workshop to develop strategies to increase the availability of skilled birth attendants in collaboration with UNFPA Country Offices, Governments and Nursing/Midwifery Councils of countries in the region. The workshop will address conceptual and operational issues related to skilled attendance at birth.

 

The objectives of the workshop

 

  1. Develop a common understanding of the definition of the skilled birth attendant.
  2. Develop a strategy to increase the access to skilled birth attendants through training of existing potential cadres or new cadres, changes in regulations and policies and human resource development policies. The strategy will focus on domiciliary as wells as primary care levels.
  3. Develop plans to strengthen the partnership between unskilled birth attendants (example; auxiliaries, community workers) and skilled birth attendants to further increase the access to skilled care.
  4. Identify health systems interventions to improve the access of the skilled birth attendants to supplies and equipment and transportation and referral facilities.

Objectives 2,3 and 4 are country specific.

 

Expected output

Country specific strategies to increase the availability of skilled birth attendants and the enabling environment to provide skilled care

 

Proposed duration of workshop

 

Three days

 

Proposed dates and venue

 

Early April

 

UNFPA CO, Pakistan has agreed to host the workshop in Islamabad.

 

Proposed participants

 

The following group of participants are expected from each of the countries in the region:

 

UNFPA CO focal point for RH

Government focal point for Maternal Health

Senior officer from Nursing/Midwifery council

One obstetrician with community orientation (not mandatory and only if the country office feels that they will play a critical role)

 

Partners

 

TSD, WHO/Geneva and SEARO, UNICEF ROSA

 

Pre-workshop exercise

 

Each of the UNFPA COs will be requested to work closely with the relevant official in the Government and Nursing/Midwifery Council (and selected obstetrician/s) for the following activities (may be through a one day working session):

 

  1. Classify the existing categories of health providers trained in providing care during pregnancy, labour, delivery and post-partum in each country according to the following groups:
    1. who match the definition of skilled birth attendant
    2. who have the potential to become skilled birth attendants and
    3. who do not fit in either of the categories

2. Identify the level and location (urban/rural) of facility where the above groups are posted and the additional responsibilities (other than care during delivery) to define the future workload

 

Post-workshop activities:

CST through country offices to follow up action plans developed, possibly hold a follow up workshop.

 


 

[1] UNFPA: Maternal Mortality Update 2002. A Focus on Emergency Obstetric Care.