Skilled Attendance at Birth

Skilled attendance at all births is considered to be the single most critical intervention for ensuring safe motherhood, because it hastens the timely delivery of emergency obstetric and newborn care when life-threatening complications arise. Skilled attendance denotes not only the presence of midwives and others with midwifery skills (MOMS) but also the enabling environment (see figure below) they need in order able to perform capably. It also implies access to a more comprehensive level of obstetric care in case of complications requiring surgery or blood transfusions.

Historical as well as contemporary evidence from many countries, most notably China, Cuba, Egypt, Jordan, Malaysia, Sri Lanka, Thailand and Tunisia, indicate that skilled midwives functioning in or very close to the community can have a drastic impact on reduction of maternal and neonatal mortality. This is why the proportion of births attended by a skilled health provider is one of the two indicators for measuring progress toward the fifth Millennium Development Goal, improving maternal health.

Complications are mostly unpredictable but treatable

Up to 15 per cent of all births are complicated by a potentially fatal condition. Although many of these complications are unpredictable, almost all are treatable. Skilled attendants are trained to recognize problems early, when the situation can still be controlled, to intervene and manage the complication, or to stabilize the condition and refer the patient to a higher level of care, if needed. Skilled attendance is also vital to protecting the health of newborns: the majority of perinatal deaths occur during labour and delivery or within the first 48 hours after delivery.

Yet in the developing world, only about 58 per cent of all deliveries are reported as attended by skilled health providers. In some countries, the figure is closer to 10-12 per cent. And in many of those cases, the woman does not have access to life-saving emergency care should something go wrong.

Who is a skilled attendant?

The term ‘skilled attendant’ refers exclusively to people with midwifery skills (for example, doctors, midwives, and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications. They must be able to recognize 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.

UNFPA has begun using the expression ‘Midwives and Others with Midwifery Skills’ (MOMS) rather than the term ‘skilled attendant’ partly because the latter lends itself to confusion with ‘skilled attendance’, which implies more than just a person. Skilled attendance refers to a professional with midwifery skills working within an enabling environment or health system capable of delivering appropriate emergency obstetric care for all women who develop complications during childbirth. In order to save lives, skilled attendants need to be linked up with a larger health care system with the facilities, supplies, transport and professionals to provide emergency obstetric care when it is needed.

The limitations of screening to identify risks

Some women may clearly be at risk for complications, such as those with obvious physical malformations or very short stature, those that are too young and immature, or those having severe health conditions. It is indeed essential to refer them to an institution before the start of the labour, in order to anticipate and manage obstetric complications. But the great majority of complications arise with little or no warning among women who have no risk factors. Every minute, 110 women in the world experience a complication in their pregnancy, and one of them will die.

Since it is difficult to predict who will develop a life-threatening complication, all pregnant women should have access to a qualified health provider for prenatal and delivery care, operating in a health centre with adequate referral services to a higher level of facility if needed.

Impoverished and rural women get less care

Over the last 20 years, all regions have shown improvement in the proportion of assisted births, from 43 per cent for the developing world as a whole in 1990 to about 58 per cent. Eastern and South-East Asia and Northern Africa have made the most headway. In sub-Saharan Africa, where nearly half of the world's maternal deaths occur, only 46 per cent of deliveries are assisted by skilled attendants. In Southern Asia, the proportion is even lower.

Enormous disparities remain within countries. Impoverished and rural women are far less likely than their urban or wealthier counterparts to receive skilled care during childbirth. In rural areas health clinics and hospitals are often spread out over vast distances and transportation systems are often rudimentary. That is one of the reasons why UNFPA supports increasing the number of community-based midwives, and strengthening district-level health systems to provide backup support.

In 2008, UNFPA partnered with the International Confederation of Midwives to address the pressing need for birth attendants in developing countries. The joint midwifery programme has expanded from 11 of the hardest-hit countries with the highest levels of maternal deaths and disability and the lowest rates of births attended by skilled workers to some 30 countried in Africa, Asia and Latin America in 2011. It has strengthened and equipped over 60 midwifery schools in more than 20 countires and set up new midwifery associations.

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