|06. Can Skilled Attendance at Delivery Reduce Maternal Mortality in Developing Countries?|
The lack of a clear definition has been, and continues to be, the cause of much confusion over the role and thus the potential of a skilled attendant. Whilst some feel that an internationally-accepted standard is impossible, it is crucial to acknowledge the implications of the various proposed definitions. Until the mid-1990s, the word trained attendant was used by many agencies, and national statistics on coverage tended to group both professionals and non-professionals (e.g. trained TBAs) together as long as they had received some training. From 1996 onwards, however, the word skilled was employed, recognising that someone who has been trained is not necessarily skilled (Starrs 1997). Thus trained implies but does not guarantee the acquisition of knowledge and ability, whilst skilled implies the competent use of knowledge. In an effort to improve understanding, a joint WHO/UNFPA/UNICEF/ World Bank statement was issued in 1999, as indicated in Box 1.
Box 1. Defining skilled attendant: joint (WHO/UNFPA/UNICEF/World Bank statement 1999)
The term skilled attendant refers exclusively to people with midwifery skills (for example, doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage* or refer complications. Ideally, the skilled attendants live in, and are part of, the community they serve. They must be able to manage normal labour and delivery, recognise the onset of complications, perform essential interventions, start treatment, and supervise the referral of mother and baby for interventions that are beyond their competence or not possible in the particular setting.
Midwifery skills are a defined set of cognitive and practical skills that enable the individual to provide basic health care services throughout the period of the perinatal continuum and also to provide first aid for obstetric complications and emergencies, including life-saving measures when needed.
* Manage was added to this definition by the members of the Safe Motherhood Inter-Agency Group, which include WHO/UNFPA/ UNICEF/Word Bank, in recognition of the fact that skilled attendants include physicians and other medical personnel who may be able to manage complications.
Skilled attendance has only recently been defined explicitly as the process by which a woman is provided with adequate care during labour, delivery and the early postpartum period (SMIAG 2000b). This definition goes onto emphasise that the process requires a skilled attendant AND an enabling environment which includes adequate supplies, equipment and infrastructure as well as efficient and effective systems of communication and referral. The environment can, however, also be viewed more broadly to include the political and policy context in which skilled attendance must operate, the socio-cultural influences, as well more proximate factors such as pre- and in-service training, supervision and deployment and health systems financing. This constellation of factors can be conceived as the conceptual framework for skilled attendance, as illustrated in Figure 1.
Figure 1. Conceptual framework for skilled attendance at delivery
*SOURCE: Graham and Bell 2000a
Box 2. Defining minimum and additional skills required of skilled attendants*
The skilled attendant at delivery will have the minimum set of skills to:
· Take a detailed history, asking relevant questions, demonstrate cultural sensitivity, and use good interpersonal skills.
· Perform an abdominal examination identifying abnormalities and factors that place the woman at increased risk.
· Make appropriate and timely referrals for additional and emergency care, arranging for transportation and care during transport.
The skilled attendant at delivery may have the additional skills to:
· Anticipate the need for forceps delivery or vacuum extraction; perform vacuum extraction
Use managerial skills to improve service delivery
* SOURCE: SMIAG 2000b
The definitions of skilled attendance and attendants are clearly crucial to identifying the potential to impact on maternal mortality. Whilst at the simplest level, a skilled attendant is still often equated with doctors, midwives and nurses, particularly in crude coverage statistics (WHO 1997), these professionals usually have very different scopes of work and skills, particularly with regard to surgical procedures. It will be argued later in the paper, that such aggregation is unhelpful and that if professional labels are to be used, these should be differentiated. Recently attempts have been made to refine the definitions in terms of essential or core competencies required for an attendant to be designated as skilled (ICM 1999, WHO 1999). These have now been synthesised into a proposed minimum set of skills required and a set of additional or optional skills (SMIAG 2000b), as indicated in Box 2.
Review of these skill sets suggests that skilled attendant appears to equate with midwives or nurses with midwifery skills and not to include doctors, since surgical skills are omitted whilst management of normal delivery and supportive nursing care is included. Thus the minimum and additional skills in Box 2 essentially relate to the provision of Basic (BEOC) but not Comprehensive Essential Obstetric Care (CEOC) (UNICEF 1999). This however contradicts the joint (WHO/UNFPA/UNICEF/World Bank Statement 1999) referred to earlier which specifically includes doctors as skilled attendants. It may be helpful therefore to conceive of skilled attendance as encompassing a partnership of health professionals with the skills to provide care for normal and/or complicated deliveries, AND the enabling environment. This is consistent with the earlier definition of skilled attendance and is shown schematically in Figure 2. The important issue as regards the attendants is the emphasis on the word skilled since the professional title alone does not guarantee skills, and on the plural sense since women may need to be referred between different professionals, such as midwives and doctors.
Figure 2. Schematic representation of skilled attendance at delivery
Boxes 1 and 2 also highlight the three other areas of uncertainty regarding skilled attendance:
· The place of attendance: recent documents refer to skilled attendants practising at the primary or first referral level (SMIAG 2000b), implying the former refers to domiciliary care and the latter health centres. This terminology is not however consistent with earlier documents, such as the (WHO Mother-Baby Package 1994), which propose health centres as the primary tier and district hospitals as the first referral level. The extent to which skilled attendance does or does not include domiciliary care is crucial, since institutionalising all deliveries has profound resource and logistical implications for poor developing countries, as well as raising concerns over the risks of over-intervention and iatrogenicity.
· Time of attendance: the role of the skilled attendant outside the intrapartum and immediate postpartum period is unclear. One recent key document suggests that a skilled attendant serves as a proxy for a health care professional who can also provide skilled antenatal, postnatal and neonatal care (SMIAG 2000b). However, the extent to which they can impact upon early pregnancy complications, such as ectopic pregnancy or complicated induced abortion, or those occurring after the delivery, such as secondary postpartum haemorrhage, depends on the communitys acceptance and recognition of this role and thus on contact with women outside labour and delivery.
· Extent of attendance: there is ambiguity in the degree of involvement during labour and delivery required to constitute attendance. A health professional who only attends the final stages needs to be distinguished from one who is available throughout. Similarly, whether the attendant is physically present or just close-by can also be an important distinction in terms of preserving normality and detecting early warning signs.
Thus in order to identify the potential for skilled attendance to prevent the major causes of maternal death, assumptions must be made about the competency of the provider; the availability of essential drugs, equipment and supplies; the access to referral facilities; the location; and the time and duration of attendance. This assumption-based approach will now be used to consider the effectiveness of skilled attendance at two levels - the individual level, and the population level. The distinction here is crucial. At the former level, the association is considered between cases of maternal death and the type of attendant at delivery or, conversely between types of attendant at delivery and deaths among those they attend. At the population level, associations are considered in the aggregate, in other words between the maternal mortality ratio for the entire population and the proportion of deliveries in the entire population with or without skilled attendance.