Rapid assessment of selected skilled birth attendants in eight Latin American and Caribbean

countries

Joyce E. Thompson, Study Leader, UNFPA Technical AdvisorAlma Virginia Camacho, UNFPA LACRO, Technical Advisor

Sandra Land, UNFPA Technical AdvisorIvelise Segovia, Midwife Observer

Martha Murdock, Family Care International, Project Technical Advisor

Background• In spite of enabling policies, solid infrastructure, and provider

training, women and newborns in LAC continue to die in childbirth from preventable causes:– 9,500 childbearing women– 190,000 babies within 28 days of birth

• MMR for LAC: 88.9 deaths per 100,000 live births (2010) = 41% reduction since 2000

• Will not reach MDG5 target of 75% reduction by 2015• Will not reach MDG4 target of 2/3 reduction child mortality

Why Focus on Skilled Birth Attendants (SBAs) in Latin America and the Caribbean (LAC)?

• Need to confirm who actually attends a given birth• ‘Trained personnel’ interpretations differ • No effort to affirm that trained personnel are /or

remain competent to provide Mat Nb care• Inconsistencies in reported country data: Many

countries that report high rates of trained personnel (SBAs) attending births in health facilities also report continuing high levels of maternal and neonatal mortality.

Objectives of Rapid Assessment

Gather preliminary findings thru direct observation related to providers of MN care and the observed quality of care in 8 selected LAC countries:1. Identify who was actually providing maternal-newborn care and attending births in selected health facilities2. Identify whether the person observed was providing quality care and was competent to do so3. Inform priorities for future coordinated country and regional advocacy

Observation Process • Developed methodology and standardized observation

tools• Recruited and trained observation team (midwives and

obstetricians paired) • Pilot tested forms seeking inter-rater reliability and

‘understandability’ in Spanish and English• Selected 8 countries from those which volunteered

(Bolivia; Chile; Colombia; Guatemala; Guyana; Honduras; Panama; Peru- different models of care)

• UNFPA secured national administrative approval • Obtained prior consent from health facilities, providers• Timeline: August – December 2011

Observation Tools

1. Demographics o Setting type, provider title & credentialso Provider Self-report of Life Saving Skills

2. Antenatal first visito Competencies observedo Quality of care observed (repeated for each clinical area)

3. Antenatal repeat visito Review of clinical record

4. Labor care5. Birth, immediate post partum, newborn care

Measures of Quality of Care (9) Treat woman/family with respect at all times Maintain privacy & confidentiality Solicit questions & concerns from woman/family Encourage companion of choice during labor Provide information/counseling appropriate to needs Provide supportive care and pain relief during labor Wash hands before & after examinations/procedures Use clean equipment – sterile equipment on indication Early identification of problems with timely referrals

Measures of Provider Competence

History taking skills with appropriate follow-up Key laboratory tests; e.g., syphilis, hemoglobin Physical assessment, including vital signs & weight Correctly dating pregnancy, monitoring FHR & growth Conducting safe delivery, airway & thermal regulation

newborn Recognize symptoms potential complications & take

appropriate action; e.g., syphilis, PIH, PPH, AMSTL Use of CLAP records and note findings correctly Self report of Life Saving Skills (EmONC)

Limitations of Rapid Assessment

• Not a formal study; no generalizability• All participants, health facilities & countries

volunteered• Only short facility-based observations –

representative of only eight LAC countries• Only selected indicators of quality & competencies

included – not full range• Possible lack of inter-rater reliability at times

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Outcomes of Rapid Assessment:Objective 1: Who is providing care?

83 different health care providers observedMidwives [23] & obstetricians [16] = 39 (47%)General MDs [19] & OB residents [6] = 25 (30%)Others [nurse [1], auxiliary nurses [6], students [12] = 19(23%)

105 care encounters observedAntenatal care = 34 Labor care = 34Birth/PP/newborn = 37

Mean practice in setting = 6.7 years Mean births attended last 6 months = 93.7 Mean time spent antenatal visit = 30.4 minutes

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Outcomes of Rapid Assessment:Objective 1 (con’t)

• Antenatal observations (34)– 15 by general MDs, 3 by ‘others’– 10 by midwives, 6 by obstetricians

• Labor observations (34)– 10 by midwives, 9 by obstetricians– 5 by general MDs, 1 OB resident, 9 ‘others’

• Birth/PP/Newborn observations (37)– Team approach with 13 PP women and 9 newborns– Births by physicians, midwives, general MDs with auxiliary

nurses /students caring for newborn and PP mother

Outcomes of Rapid Assessment:Objective 2: Quality Overview

• Greets woman/family respectfully = 100%• Respectful throughout encounter = 97%• Uses clean equipment = 85%• Solicits questions and concerns = 79%• Maintains privacy & confidentiality = 76%• Provides supportive care & pain relief = 65%• Washes hands before and after procedures = 41%• Provides information; e.g., progress in labor = 35%• Encourages support companion during labor = 15%

Objective 2: Quality OverviewExpert Opinion (% =Yes)

• Antenatal providers – First visit = 80% – Repeat visits = 51%

• Labor providers = 44%• Birth/PP/Newborn providers = 41%***

With exception of first AN visit, obstetricians & midwives rated highest (50-73%).

***Could not separate birth providers from others on observation form

Outcomes: Objective 2Selected Overview of Competencies

observed less than 50% in ANC

• Questioned prior contraceptive use (33%)• Discussed birth plan (38%)• Questioned prior PIH history (33%)• Asked about problems since last visit (45%)• Questioned history vaginal bleeding/PPH (33%)• Examined for edema (33%)• Ordered syphilis test (47%)

Outcomes: Objective 2Selected Overview of Competencies

observed less than 50%Labor/Birth

Labor care:• Used sterile technique with ROM (50%)• Reviewed available partograph (37%)• Noted status of membranes (50%)Birth care:• Ruled out second fetus before oxytoxic given (38%)• Clamped/cut umbilical cord stopped pulsating (15%)

Outcomes: Objective 2Selected Competence Overview –

Postpartum/Newborn

Postpartum mother:• Monitored fundus/bleeding q. 15” for 2 hrs (27%)• Monitored maternal vital statistics q. 15” for 2 hrs

(27%)Newborn care:• Placed infant skin-to-skin (31%)• Took newborn temperature (12%)• Promoted exclusive breastfeeding (26%)• Monitored NB status & VS q 15” for 2 hrs (27%)

Outcomes Objective 2 (con’t): Self-Report of Competence

• Midwives unanimously reported they did not have the skills of assisted delivery (forceps, vacuum extraction) or MVA.

• One-third of midwives were skilled in manual removal of placenta and newborn resuscitation, and 100% were skilled in starting IVs, administering antibiotics, oxytoxics, and MagSO4.

• Obstetricians reported administering oxytoxics at 100%, but only 56% in starting IVs.

Objective 2: CompetentExpert Opinion (% = Competent)

• Antenatal providers– First visit = 58% average; others (100%) and SBAs (80%) highest– Repeat visits = 64% average with SBAs (88%), rest below 50%

• Labor providers = 47% average – SBAs (58%)– Gen. MD/OB residents (17%)– Others (44%)

• Birth/PP/Newborn providers = 22% average– SBAs (41%)– Gen MDs (0%)– Others (8%)

Implications of Observations: Provider

• 23% of care was provided by ‘Other’, primarily students, largely unsupervised

• WHO proxy of institutional birth = SBA might not be accurate

Implications of Observations: QualityAspects to strengthen:• Soliciting questions & concerns • Providing information & counseling• Missing elements of family-centered care• Encouraging support persons during labor• Promoting maternal-infant bonding• Promoting breastfeeding

Implications of Observations: Competencies

Strengths: Mostly routine care

Areas of improvement:• Competencies for all providers, particularly during

PP/NB period, alarmingly low - including identifying signs of danger and - monitoring PP women & NB- Hygiene (hand washing & clean equipment)

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Implications Objective 2: Competent Care

• Under-performance observed frequently in all countries, regardless of the model of care

• Given observed inconsistent competency among all three groups of providers, can any group be classified as skilled personnel or SBAs?

• RE-EVALUATE HUMAN RESOURCE DEPLOYMENT PLAN: To what extent should general MDs and auxiliary nurses be involved in maternal-newborn care, especially births?

• SUPERVISION: To what extent do general MDs & auxiliary nurses require supervision and/or advanced preparation for their roles?

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Recommendations• All countries need to use same definition of SBA for data• Provide periodic competency assessment for all providers• Partner with education institutions for updates• Update clinical guidelines based on essential

competencies & best evidence available• Carry out periodic quality of care assessments in every

facility including user satisfaction• HR development & deployment based on country needs

and competencies of personnel• Reinforce hand washing and clean equipment use• Provide direct supervision for health professional

students.

Thanks!

Martha Murdockmmurdock@fcimail.org