Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward.
OBJECTIVE
Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement.


METHODS
The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II).


RESULTS
On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%.


CONCLUSIONS
There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.
Quality Assurance Project, University Research Co LLC, Bethesda, MD 20814, USA. sharvey@urc-chs.com
Steven A
SA
Harvey
Yudy Carla Wong
YC
Blandón
Affette
A
McCaw-Binns
Ivette
I
Sandino
Luis
L
Urbina
César
C
Rodríguez
Ivonne
I
Gómez
Patricio
P
Ayabaca
Sabou
S
Djibrina
D002983:Clinical Competence; D003906:Developing Countries; D005260:Female; D006801:Humans; D008427:Maternal Health Services / Q000592:standards*; D008428:Maternal Mortality; D008880:Midwifery / Q000592:standards*; D011247:Pregnancy; D011248:Pregnancy Complications