Skilled birth attendance

A skilled birth attendant ‘is an accredited health professional-such as a midwife, doctor or nurse-who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborn babies’ .

Skilled birth attendants need to be trained to have the required competencies and should be provided with an ‘enabling environment’ that includes drugs, supplies, appropriate policies and a functional referral system . SBA is only available when a skilled birth attendant as well as the ‘enabling environment’ are in place.

Globally, 72% of births are now attended by a skilled birth attendant. This, however, varies according to income group (46% in low-income groups and 99% in high-income groups) and by geographical area (48% in the African region, 67% in Southeast Asia and 99% in Europe) .

There is a critical shortage of health-care providers in Africa; the World Health Organization (WHO) reported that 36 of the 57 countries facing chronic human resource shortages in the health sector are in SSA and that only 2.6 and 12.0/10,000 of physicians and nursing/midwifery personnel, respectively, are in Africa compared to 33.1 physicians and 80.5 nurses/midwives per 10,000 people in the European region. This shortage of skilled birth attendants is even more severe in rural compared to urban areas .

Approaches used to improve coverage of SBA include increasing the number of SBAs trained (pre-service) and increasing the skills and knowledge of existing cadres of staff to be able to provide SBA and emergency obstetric and early NC including via task shifting . In addition, research has shown that a large variety of cadres of health-care providers are expected to provide SBA in SSA and Asia. However, not all are trained to the required standard and/or supported and legislated to carry out all tasks required of a SBA according to the international definition .

Emergency obstetric care

An estimated 15% of pregnant women will develop a complication during pregnancy, childbirth or the puerperium, which will require EmOC . The collective minimum set of medical interventions (or bundle of care) required to prevent or manage the main obstetric complications (haemorrhage, pre-eclampsia or eclampsia, sepsis, complications of obstructed labour or abortion) is known as emergency obstetric care (EmOC). These were first described and internationally agreed upon in 1997, and they consist of key interventions (or signal functions) that must be available at health-care facilities designated to provide either comprehensive (nine signal functions) or basic (seven signal functions) EmOC ( Table 1 ). An additional signal function was introduced in 2009 for performing basic neonatal resuscitation with a bag and mask (emergency obstetric care and early newborn care, EmONC ). A new indicator to assess progress was also introduced at this time, ‘intra-partum and very early neonatal death rate’.

More recently, new signal functions to measure the ability of health facilities to provide routine care and emergency obstetric and newborn care have been described, one general and three for obstetric and newborn care. These are as follows: (a) general requirements for health-care facilities such as 24/7 service availability, sufficient numbers of SBAs, functional referral systems and infrastructure; (b) routine care for all mothers and babies; (c) basic EmONC for mothers and babies with complications; and (d) comprehensive EmONC to include blood transfusion and caesarean section at the secondary level .

The availability of EmONC with a minimum acceptable level of five health-care facilities per 500,000 people (one of which should be a comprehensive EmONC health-care facility) providing all EmONC signal functions in the 3 months preceding the assessment is one of the eight indicators for monitoring the availability and utilization of EmOC . The other indicators are presented in Table 2 .

A number of surveys have shown that the majority of health-care facilities in low- and middle-income settings, although designated to provide either basic or comprehensive EmONC, may be unable to do so . In many cases, structures are in place, and equipment and consumables were noted to be available, but the staff reported that they lacked competency and skills and were therefore unable to provide all the signal functions of EmONC and essential NC . In other instances, the lack of knowledge and skills to provide EmONC is compounded by non-utilization of simple but proven health technologies and equipment .

How is in-service EmONC training best delivered?

In-service EmONC training programmes should utilize evidence-based learning methods including a ‘skills-and-drills’ approach; have sufficient content to improve the health-care providers’ competency in evidence-based, effective and woman- and baby-friendly care; and be of short duration and as close to the working environment as possible .

Simulation-based medical education (SBME) with deliberate practice has been shown to be superior to traditional clinical and didactic education. Deliberate practice embodies strong and consistent educational interventions grounded in information processing and behavioural theories of skill acquisition and maintenance .

There is some evidence that short competency-based EmONC training programmes based on adult learning methodology are more effective in improving professional practice than longer didactic-based training. Several short in-service training programmes with ‘skills-and-drills’ components have been developed for well-resourced settings, and they have in some cases been modified for implementation in lower-resource settings .

One of the earliest EmONC in-service training packages was developed by the American College of Nurse-Midwives (ACNM), and it was designed to be primarily competency based (emphasis on acquiring skills through repetition in hands-on practice) . The duration of the training ranged from 10 days to 4 weeks depending on the cadre of the health-care provider being trained. More recently, shorter competency-based and multidisciplinary courses, usually 1–5 days in duration, have been developed. In addition to the generic Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine (CMNH-LSTM) EmONC 3-5 package developed in 2006, these include the following: the Advanced Life Support in Obstetrics course (ALSO – 1990), Managing Obstetric Emergencies and Trauma (MOET – 1998), Advances in Labour and Risk Management (ALARM – 2003), Essential Surgical Skills with Emphasis on Emergency Maternal and Newborn Health (ESS-EMNH – 2007), Essential Steps in Managing Obstetric Emergencies (ESMOE – 2008) (adapted from CMNH-LSTM EmONC package), Practical Obstetric Multi-Professional Training (PROMPT – 2009), PRONTO (2009), Essential Newborn Care Course (ENCC – 2010), Helping Babies Breathe (HBB – 2011) and Helping Mothers Survive Bleeding after Childbirth (HMS-BAC – 2013).

EmONC in-service training such as ALARM, ALSO, MOET and PROMPT are mandatory for health-care providers working in well-resourced countries, all delivered off-site except for PROMPT . PROMPT has the additional advantage of training multidisciplinary maternity care teams together within their local setting. Such courses are usually tailored around the predominant causes of maternal deaths in those settings, which may be different from those in low- and middle-income countries (LMICs) . The quality of pre-service training, clinical practice and patient caseload in these settings will also vary from that in LMICs. Some of these training programmes have had varying degrees of adaptation for delivery in LMICs (MOET, ALSO and PROMPT) , but they have not been fully evaluated at all levels based on the adapted Kirkpatrick framework.

EmONC training courses designed specifically for a low-resource country setting include the CMNH-LSTM EmONC training course , ESMOE , PRONTO , ESS-EMNH , the Pacific Emergency Obstetric Course (PEOC), HBB and HMS-BAC. However, only few of these training packages have content that covers all the emergency obstetric and newborn care signal functions.

Evaluation of the effectiveness of EmONC training

It is important to determine the effectiveness of in-service EmONC training so as to make continuous improvements to the training programme, provide evidence to sustain the intervention and ensure limited resources are well spent.

In-service training programmes are often delivered as one component of a larger maternal health intervention programme. Therefore, it may be difficult to specifically attribute a change in outcomes to EmONC training per se even if comprehensive monitoring and evaluation of the whole programme is carried out. Where EmONC training programmes have been evaluated, this has been mainly to assess health-care provider competency before and/or after training. Very few studies have evaluated the effect on change in practice and/or health outcomes . In addition, many of the available reports and studies evaluating training programmes in low- and middle-income settings have poor study designs and generally make limited use of qualitative methodology.

Although it can be argued that regular in-service training is required to ensure that maternity care providers remain confident and competent in providing EmONC and that therefore demonstrating a change in knowledge and skills is important, evidence is also required to convince policymakers regarding what the best EmONC training approach is. Policymakers are likely to be influenced by evaluation conducted within ‘real-life’ settings using information generated within the health system. Key evidence required to facilitate change in policy includes information regarding the acceptance of the training by health-care providers and affirmation that they consider the training as useful; demonstrable improvement in knowledge, skills, confidence and practice; and finally improvement in maternal and newborn health outcomes.

New approaches to the evaluation of effectiveness of implementation programmes in real-life settings include operational research (or implementation research) .

Operational research provides the opportunity to ask questions about the effectiveness of programmes or health systems. Operational research has been described as the use of systematic research techniques for programme decision-making to achieve a specific outcome . Operational research provides policymakers as well as managers with evidence that they can use to improve programme operations. Operational research is often less expensive compared to prospective or controlled trials, it is less threatening to local staff who readily appreciate its relevance to the health system and it often relies on routinely collected data.

A framework for evaluating EmONC training

Evaluation is the ‘determination of the effectiveness of a training programme’ . The most commonly used EmONC training evaluation framework found in the literature is that developed by Kirkpatrick . Kirkpatrick suggests that training evaluation itself should be considered the last of ten steps that are required for successful implementation of training programmes ( Box 1 ).

• Level 1 – Reaction : The first level determines how well participants like the programme. It can be a measure of the acceptability of the training programme. A positive reaction to training is indicative of interest and enthusiasm, both being prerequisites to maximum learning.

• Level 2 – Learning : Trainees may accept a training programme, but this may not be translated into improvement in their knowledge and skills. Evaluation at Level 2 is to determine what knowledge and skills were learned as a result of the training.

• Level 3 – Behaviour : An improvement in knowledge and skills immediately after training does not guarantee a change in behaviour after attending training. Evaluation at Level 3 is to determine what job changes resulted from the training.

• Level 4 – Results : Job changes following training may not lead to quantifiable or ‘tangible’ results. These results depend on the objectives of the training programme and the expectations of the stakeholders (who commission the training or are administratively responsible for the staff being trained). These stakeholders consider evaluation at Level 4 the most important. Kirkpatrick stated that evaluation at Level 4 is to determine the tangible costs of the training in terms of reduced cost, improved quality, improved customer satisfaction, improved quantity and productivity, etc.

How is in-service EmONC training best delivered?

In-service EmONC training programmes should utilize evidence-based learning methods including a ‘skills-and-drills’ approach; have sufficient content to improve the health-care providers’ competency in evidence-based, effective and woman- and baby-friendly care; and be of short duration and as close to the working environment as possible .

Simulation-based medical education (SBME) with deliberate practice has been shown to be superior to traditional clinical and didactic education. Deliberate practice embodies strong and consistent educational interventions grounded in information processing and behavioural theories of skill acquisition and maintenance .

There is some evidence that short competency-based EmONC training programmes based on adult learning methodology are more effective in improving professional practice than longer didactic-based training. Several short in-service training programmes with ‘skills-and-drills’ components have been developed for well-resourced settings, and they have in some cases been modified for implementation in lower-resource settings .

One of the earliest EmONC in-service training packages was developed by the American College of Nurse-Midwives (ACNM), and it was designed to be primarily competency based (emphasis on acquiring skills through repetition in hands-on practice) . The duration of the training ranged from 10 days to 4 weeks depending on the cadre of the health-care provider being trained. More recently, shorter competency-based and multidisciplinary courses, usually 1–5 days in duration, have been developed. In addition to the generic Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine (CMNH-LSTM) EmONC 3-5 package developed in 2006, these include the following: the Advanced Life Support in Obstetrics course (ALSO – 1990), Managing Obstetric Emergencies and Trauma (MOET – 1998), Advances in Labour and Risk Management (ALARM – 2003), Essential Surgical Skills with Emphasis on Emergency Maternal and Newborn Health (ESS-EMNH – 2007), Essential Steps in Managing Obstetric Emergencies (ESMOE – 2008) (adapted from CMNH-LSTM EmONC package), Practical Obstetric Multi-Professional Training (PROMPT – 2009), PRONTO (2009), Essential Newborn Care Course (ENCC – 2010), Helping Babies Breathe (HBB – 2011) and Helping Mothers Survive Bleeding after Childbirth (HMS-BAC – 2013).

EmONC in-service training such as ALARM, ALSO, MOET and PROMPT are mandatory for health-care providers working in well-resourced countries, all delivered off-site except for PROMPT . PROMPT has the additional advantage of training multidisciplinary maternity care teams together within their local setting. Such courses are usually tailored around the predominant causes of maternal deaths in those settings, which may be different from those in low- and middle-income countries (LMICs) . The quality of pre-service training, clinical practice and patient caseload in these settings will also vary from that in LMICs. Some of these training programmes have had varying degrees of adaptation for delivery in LMICs (MOET, ALSO and PROMPT) , but they have not been fully evaluated at all levels based on the adapted Kirkpatrick framework.

EmONC training courses designed specifically for a low-resource country setting include the CMNH-LSTM EmONC training course , ESMOE , PRONTO , ESS-EMNH , the Pacific Emergency Obstetric Course (PEOC), HBB and HMS-BAC. However, only few of these training packages have content that covers all the emergency obstetric and newborn care signal functions.

Evaluation of the effectiveness of EmONC training

It is important to determine the effectiveness of in-service EmONC training so as to make continuous improvements to the training programme, provide evidence to sustain the intervention and ensure limited resources are well spent.

In-service training programmes are often delivered as one component of a larger maternal health intervention programme. Therefore, it may be difficult to specifically attribute a change in outcomes to EmONC training per se even if comprehensive monitoring and evaluation of the whole programme is carried out. Where EmONC training programmes have been evaluated, this has been mainly to assess health-care provider competency before and/or after training. Very few studies have evaluated the effect on change in practice and/or health outcomes . In addition, many of the available reports and studies evaluating training programmes in low- and middle-income settings have poor study designs and generally make limited use of qualitative methodology.

Although it can be argued that regular in-service training is required to ensure that maternity care providers remain confident and competent in providing EmONC and that therefore demonstrating a change in knowledge and skills is important, evidence is also required to convince policymakers regarding what the best EmONC training approach is. Policymakers are likely to be influenced by evaluation conducted within ‘real-life’ settings using information generated within the health system. Key evidence required to facilitate change in policy includes information regarding the acceptance of the training by health-care providers and affirmation that they consider the training as useful; demonstrable improvement in knowledge, skills, confidence and practice; and finally improvement in maternal and newborn health outcomes.

New approaches to the evaluation of effectiveness of implementation programmes in real-life settings include operational research (or implementation research) .

Operational research provides the opportunity to ask questions about the effectiveness of programmes or health systems. Operational research has been described as the use of systematic research techniques for programme decision-making to achieve a specific outcome . Operational research provides policymakers as well as managers with evidence that they can use to improve programme operations. Operational research is often less expensive compared to prospective or controlled trials, it is less threatening to local staff who readily appreciate its relevance to the health system and it often relies on routinely collected data.

A framework for evaluating EmONC training

Evaluation is the ‘determination of the effectiveness of a training programme’ . The most commonly used EmONC training evaluation framework found in the literature is that developed by Kirkpatrick . Kirkpatrick suggests that training evaluation itself should be considered the last of ten steps that are required for successful implementation of training programmes ( Box 1 ).

• Level 1 – Reaction : The first level determines how well participants like the programme. It can be a measure of the acceptability of the training programme. A positive reaction to training is indicative of interest and enthusiasm, both being prerequisites to maximum learning.

• Level 2 – Learning : Trainees may accept a training programme, but this may not be translated into improvement in their knowledge and skills. Evaluation at Level 2 is to determine what knowledge and skills were learned as a result of the training.

• Level 3 – Behaviour : An improvement in knowledge and skills immediately after training does not guarantee a change in behaviour after attending training. Evaluation at Level 3 is to determine what job changes resulted from the training.

• Level 4 – Results : Job changes following training may not lead to quantifiable or ‘tangible’ results. These results depend on the objectives of the training programme and the expectations of the stakeholders (who commission the training or are administratively responsible for the staff being trained). These stakeholders consider evaluation at Level 4 the most important. Kirkpatrick stated that evaluation at Level 4 is to determine the tangible costs of the training in terms of reduced cost, improved quality, improved customer satisfaction, improved quantity and productivity, etc.

Box 1

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