title: Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment.
abstract: BACKGROUND
  Increasing the number of women birthing with skilled birth attendants (SBAs) as one of the strategies to reduce maternal mortality and morbidity must be partnered with a minimum standard of care. This manuscript describes the quality of intrapartum care provided by SBAs in Mae La camp, a low resource, protracted refugee context on the Thai-Myanmar border.
  
  
  METHODS
  In the obstetric department of Shoklo Malaria Research Unit (SMRU) the standardized WHO Safe Motherhood Needs Assessment tool was adapted to the setting and used: to assess the facility; interview SBAs; collect data from maternal records during a one year period (August 2007 - 2008); and observe practice during labour and childbirth.
  
  
  RESULTS
  The facility assessment recorded no 'out of stock' or 'out of date' drugs and supplies, equipment was in operating order and necessary infrastructure e.g. a stand-by emergency car, was present. Syphilis testing was not available. SBA interviews established that danger signs and symptoms were recognized except for sepsis and endometritis. All SBAs acknowledged receiving theoretical and 'hands-on' training and regularly attended deliveries. Scores for the essential elements of antenatal care from maternal records were high (>90%) e.g. providing supplements, recording risk factors as well as regular and correct partogram use. Observed good clinical practice included: presence of a support person; active management of third stage; post-partum monitoring; and immediate and correct neonatal care. Observed incorrect practice included: improper controlled cord traction; inadequate hand washing; an episiotomy rate in nulliparous women 49% (34/70) and low rates 30% (6/20) of newborn monitoring in the first hours following birth. Overall observed complications during labour and birth were low with post-partum haemorrhage being the most common in which case the SBAs followed the protocol but were slow to recognize severity and take action.
  
  
  CONCLUSIONS
  In the clinic of SMRU in Mae La refugee camp, SBAs were able to comply with evidence-based guidelines but support to improve quality of care in specific areas is required. The structure of the WHO Safe Motherhood Needs Assessment allowed significant insights into the quality of intrapartum care particularly through direct observation, identifying a clear pathway for quality improvement.
authors: Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. gabbeltje@hotmail.com.
authors: Gabie
authors: G
authors: Hoogenboom
authors: Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. myo@shoklo-unit.com.
authors: May Myo
authors: MM
authors: Thwin
authors: AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands. krisvelink@hotmail.com.
authors: Kris
authors: K
authors: Velink
authors: AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands. mbaaijens@gmail.com.
authors: Marijke
authors: M
authors: Baaijens
authors: Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. jib@tropmedres.ac.
authors: Prakaykaew
authors: P
authors: Charrunwatthana
authors: Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. francois@tropmedres.ac.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. francois@tropmedres.ac.
authors: François
authors: F
authors: Nosten
authors: Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. rose@shoklo-unit.com.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. rose@shoklo-unit.com.
authors: Rose
authors: R
authors: McGready
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000592:standards; D036861:Delivery, Obstetric / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007231:Infant, Newborn; D008880:Midwifery / Q000592:standards*; D002052:Myanmar / Q000453:epidemiology; D020380:Needs Assessment / Q000706:statistics & numerical data; D018743:Perinatal Care / Q000379:methods / Q000458:organization & administration / Q000592:standards; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D011361:Professional Competence; D058996:Quality Improvement; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data; D012036:Refugees / Q000706:statistics & numerical data; D013785:Thailand / Q000453:epidemiology
references: Int J Gynaecol Obstet. 2004 Nov;87(2):203-10
references: 15491581
references: BJOG. 2009 Oct;116 Suppl 1:33-40
references: 19740170
references: Glob Public Health. 2006;1(3):205-28
references: 19153908
references: Lancet. 2006 Oct 7;368(9543):1284-99
references: 17027735
references: Midwifery. 2013 May;29(5):461-7
references: 23146139
references: Lancet Infect Dis. 2013 Oct;13(10):843-51
references: 23972825
references: J Matern Fetal Neonatal Med. 2008 Jul;21(7):483-6
references: 18570129
references: Reprod Health. 2007 Jul 06;4:5
references: 17612408
references: BMC Pregnancy Childbirth. 2014;14:176
references: 24886143
references: Int J STD AIDS. 2008 Dec;19(12):833-7
references: 19050214
references: PLoS One. 2012;7(7):e40220
references: 22808121
references: J Midwifery Womens Health. 2004 Jul-Aug;49(4 Suppl 1):14-8
references: 15236699
references: Bull World Health Organ. 2013 Nov 1;91(11):824-833I
references: 24347706
references: Int J Evid Based Healthc. 2011 Mar;9(1):25-31
references: 21332660
references: Health Policy Plan. 2004 Jan;19(1):57-66
references: 14679286
references: Cochrane Database Syst Rev. 2012;10:CD003766
references: 23076901
references: BMC Public Health. 2005;5:131
references: 16343339
references: PLoS One. 2012;7(7):e40244
references: 22815732
references: Midwifery. 2013 Oct;29(10):1151-7
references: 23932035
references: BMC Pregnancy Childbirth. 2011;11:45
references: 21679475
references: Health Policy. 2010 May;95(2-3):255-63
references: 20060193
references: Lancet. 2006 Apr 1;367(9516):1066-74
references: 16581405
references: Int J Gynaecol Obstet. 2011 Sep;114(3):211-2
references: 21745665
references: Am J Epidemiol. 2001 Sep 1;154(5):459-65
references: 11532788
references: Cochrane Database Syst Rev. 2009;(1):CD000081
references: 19160176
references: BMJ. 2013;346:f1541
references: 23538918
references: Int J Evid Based Healthc. 2012 Mar;10(1):60-7
references: 22405417
references: J Health Econ. 2008 Mar;27(2):444-59
references: 18192043
references: Int Breastfeed J. 2012 Dec 13;7(1):19
references: 23241099
references: Neurology. 2014 Aug 5;83(6):572
references: 25092928
references: Eur J Obstet Gynecol Reprod Biol. 2011 Nov;159(1):72-6
references: 21831504