Increasing Skilled Birth Attendance

The largest threat of maternal mortality occurs during labor, birth and the 24 hours following birth. Many of the interventions known to save the lives of women and their newborns depend upon the presence of a skilled birth attendant (SBA). This health professional must be accredited—such as a midwife, doctor or nurse—and have been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, as well as the identification, management and referral of complications in women and newborns. The need to increase women’s access to SBAs is highlighted by the fact that MDG 5 (to improve maternal health by decreasing the maternal mortality ratio by 75% by 2015) includes as an indicator the proportion of births attended by skilled health personnel.

Key Activities
MCHIP works to improve quality of care through competency-based training, supportive supervision, quality of care surveys, an ongoing goal-oriented performance improvement approach, and development of user-friendly resources, including the Pre-service Education Toolkit. Support to field programs provided by MCHIP technical staff has included training courses for SBAs as well as programmatic development. MCHIP technical staff have also provided input to the World Health Organization’s Making Pregnancy Safer Division regarding the revision of guidelines for provision of Postpartum and Postnatal Care (PPC/PNC). It is anticipated that these guidelines will address the care of women in facilities by skilled providers and will thus be valuable for this group. However, PPC/PNC guidelines would also be of value for those who care for women who give birth outside of facilities, the majority without skilled providers. Therefore, MCHIP is undertaking the development of harmonized guidelines for PPC/PNC to assist both skilled providers in facilities as well as community-based providers who visit mothers and newborns in their homes to provide key evidence-based interventions.

Respectful Maternity Care (RMC) and prevention of abuse and disrespect is another key focus in SBA activities. MCHIP works to strengthen the provision of RMC as a central aspect of quality improvement in gender equity and service delivery. Program efforts address the multiple contributing and enabling factors that influence respectful and dignified care, including: working conditions for providers; community engagement; social accountability; rights based approaches; and values clarification.

MCHIP technical staff are members of the White Ribbon Alliance Advisory Council and were involved in developing the RMC Charter, a human rights based document that delineates international declarations and conventions which affirm women’s rights to RMC as well as other advocacy materials. And as part of its Latin America and Caribbean activities, MCHIP provided technical leadership for the development of the Caribbean Regional Midwifery Association (CMRA) in order for the small Caribbean island nations to have a regional voice for midwifery and to participate in the International Confederation of Midwives. Specifically, MCHIP is working with CRMA to promote and use distance-access continuing education modules for both pre-service and in-service instruction.

The Pre-service Education Toolkit, launched in 2011, provides health care professionals information to develop policies, design programs, and make decisions related to pre-service education based on evidence. The Roadmap provides guidance for implementation, and resources and tools are packaged for easier use at country programming level in one online location. The multi-organizational technical advisory group identifies important materials that are updated using a continuous publishing process. As other toolkits with high relevance to pre-service education are developed (such as for postpartum hemorrhage and pre-eclampsia/eclampsia), they are linked to the toolkit, contributing to knowledge management efforts.

MCHIP also recently launched an RMC toolkit in the same model. It provides evidence-based content for use by clinicians, trainers, educators and supervisors as well as by policy makers interested in promoting RMC. In addition to the toolkit, technical staff specifically and purposefully include RMC content in trainings, courses and when providing field support to pre-service and in-service programs.

In the area of SBA, a key result of support to field programs occurred in Ghana, where MCHIP partnered with the Ministry of Health to develop two operations manuals—one for midwifery preceptorship, and one for simulation labs. Trainings on Basic Emergency Obstetric and Newborn Care and effective teaching skills were conducted across all midwifery schools and a follow-up training using a low dose/high frequency mobile mentoring was piloted. Technical staff has also conducted trainings in Helping Babies Breathe (neonatal resuscitation) and Helping Mothers Survive (PPH), two courses designed to bring critical skills to frontline SBAs.