The quality of skilled birth attendants in Nepal

17 April, 2019

'Healthcare workers are failing to receive either effective training or sufficient practice to stay clinically competent and knowledgeable in the field. This could in part explain why institutional deliveries have generally failed to deliver better outcomes for pregnant women and their babies.' This is the conclusion of a new study in PLoS One (with thanks to Maternal Health Buzz). Citation, abstract, selected extract and comment from me below.

CITATION: PLoS One. 2019 Apr 4;14(4):e0214577. doi: 10.1371/journal.pone.0214577. eCollection 2019.

The quality of skilled birth attendants in Nepal: High aspirations and ground realities.

Rajbhandari R, Rai S, Hathi S, Thapa R, Rai I, Shrestha A.

https://www.ncbi.nlm.nih.gov/pubmed/30947314

ABSTRACT

BACKGROUND: While Nepal's maternal mortality ratio (MMR) has improved overall, the proportion of maternal deaths occurring in health facilities and attended to by skilled birth attendants (SBAs), has nearly doubled over 12 years. Although there are numerous socioeconomic, environmental and other factors at play, one possible explanation for this discrepancy between utilization of skilled maternal care services and birth outcomes lies in the quality of care being provided by SBAs. The objective of this study is to determine how competent SBAs are after training, across multiple settings and facility types in Nepal.

METHODS: We used a quantitative cross-sectional analysis to evaluate a sample of 511 SBAs, all female, from 276 sub-health posts (SHP), health posts (HP), primary healthcare centers (PHC), and district and regional hospitals in the mountain, hill, and terai districts of Nepal. Any SBA actively employed by one of these health facilities was included. SBAs who had received less than three months of training were excluded. Outcomes were measured using SBAs' scores on a standardized knowledge assessment, clinical skills assessment, and monthly delivery volume, particularly as it compared with the WHO's recommendation for minimum monthly volume to maintain competence.

RESULTS: SBAs on average exhibit a deficiency of both knowledge and clinical skills, failing to meet even the 80-percent standard that is required to pass training (knowledge: 75%, standard deviation 12%; clinical skills: 48%, standard deviation 15%). Moreover, SBAs are conducting very few deliveries, with only 7 percent (38/511) meeting the minimal volume recommended to maintain competence by the WHO, and a substantial fraction (70/511, 14%) performing an average of no monthly deliveries at all.

CONCLUSIONS: Taken together, our findings suggest that while countries like Nepal have made important investments in SBA programs, these healthcare workers are failing to receive either effective training or sufficient practice to stay clinically competent and knowledgeable in the field. This could in part explain why institutional deliveries have generally failed to deliver better outcomes for pregnant women and their babies.

SELECTED EXTRACT

Merely training more SBAs will not suffice: more attention needs to be directed at their knowledge and skills and how that translates to the care that they provide for women and infants.

COMMENT (NPW): What do we know about the quality and quantity of continued professional development and in-service training opportunities for skilled birth attendants in different countries? How can this be more effectively supported?

Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org