Reducing neonatal mortality through skilled birth attendance


This blog was originally published In The Lancet Global Health Blog

Maternal and neonatal survival have been in the headlines again this week as the Institute for Health Metrics and Evaluation and WHO released new figures and Save the Children published its annual State of the World’s Mothers report. May 5 was International Day of the Midwife: what can skilled birth attendance do for maternal and neonatal health and how can it be scaled up? Recent figures from WHO indicate that the proportion of under-5 deaths that occur in the first month of life increased from 37% in 1990 to 44% in 2012, resulting in 2.9 million neonatal deaths annually. One of the strategies to reduce neonatal mortality is promoting the provision of essential newborn care by skilled birth attendants (SBAs). However, with an estimated 46 million women who are likely to deliver alone or without adequate care, one wonders whether promotion of skilled birth attendance is being prioritised enough to bring about the much desired reduction in global neonatal mortality.

In a systematic review estimating the effect of various childbirth care packages on neonatal mortality due to childbirth-related events in term babies, Lee and colleagues reported that skilled birth care could reduce neonatal mortality by 25%. The review also reported the potential in the provision of comprehensive emergency obstetric care and basic emergency obstetric care to reduce these deaths by 85% and 40%, respectively.

However, many developing countries struggle to provide basic care for women and their babies. In a cross-sectional survey of 378 health facilities in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh, and India, Ameh and colleagues reported that only 23.1% of the health facilities aiming to provide comprehensive emergency obstetric care were able to offer the nine required signal functions and only 2.3% of health facilities expected to provide basic emergency obstetric care provided all seven signal functions. The picture is not different in many other sub-Saharan African and Asian countries. The global shortage of health-care providers certainly does not help the situation.

In addition, there is evidence of a “skills gap” for many SBAs in countries where most of the neonatal mortality occurs. In a study that mapped out cadres of health-care providers considered to be SBAs in nine sub-Saharan African countries, Adegoke and colleagues found that a total of 21 different cadres of health-care provider were reported to be an SBA. Most of these cadres lacked the skills to provide the signal functions of emergency obstetric care and early newborn care. Utz and colleagues also reported similar findings when they did a similar study in four countries in southeast Asia.

Task shifting is one of the strategies recommended by WHO to improve availability of emergency obstetric care and newborn care services. Lower-level and middle-level health-care providers such as community health workers are trained to perform specific tasks that may otherwise be performed by higher-level staff that take longer and cost more to train.

In the continuum of care, because newborn care is closely related to maternal care, training of lower-level health-care providers also provides the additional benefit of addressing challenges related to both demand for and supply of maternal care.

It is on this premise that the Making it Happen programme, which is being delivered by the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine, UK, is helping health-care providers in developing countries to increase their knowledge and develop skills in the provision of basic and comprehensive emergency obstetric care and early newborn care.

A short competency-based "skills and drills" training package for health-care providers in resource-poor countries was developed in 2006 by the centre in collaboration with the Royal College of Obstetricians and Gynaecologists and the Department of Making Pregnancy Safer at WHO. The package focuses on the signal functions of emergency obstetric care and early newborn care. With the support of UK Department for International Development, the programme has been rolled out in 12 sub-Saharan African and Asian countries.

In a before-and-after study involving 222 health-care providers in Somaliland who were trained in the Making it Happen programme, participants were evaluated on change in knowledge, skills, behaviour, and functionality of their facilities during and immediately after training, and at 3 and 6 months post-training. There was improvement in 50% of knowledge and 100% of skills modules assessed. Availability of signal functions for basic and comprehensive emergency obstetric care in participating facilities improved from 43% and 56%, respectively, to 100%.

For the long-term success of interventions, it is crucial that they follow the guiding principles of the forthcoming WHO Every Newborn Action Plan. In line with these principles, the Making it Happen programme ensures ownership of the intervention by training some of the higher-level health-care providers as trainers so that, with the aid of training equipment that is also supplied to the participating countries, they can continue to build skills within their countries even after the programme. Additionally, the monitoring, evaluation, and feedback mechanisms that have been built within the programme enables the Centre for Maternal and Newborn Health and other stakeholders to continuously refine and innovate for even better delivery and impact.

Finally, with current evidence suggesting that training of health-care providers is effective in increasing availability and quality of maternal and newborn care services, this strategy should be placed higher on the newborn health stakeholders’ list of priorities, and continued improvement of skilled birth attendance in developing countries should be supported.

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