https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00838-7.pdf

Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)60789-3.pdf

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)62187-3.pdf

Stillbirths: Where? When? Why? How to make the data count?

Summary Background Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100 000 livebirths globally by 2030. Methods We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. Results We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100 000 livebirths (80% UI 359–427) in 1990, to 216 (207–249) in 2015, corresponding to a relative decline of 43·9% (34·0–48·7), with 303 000 (291 000–349 000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1·8% (0·0–3·1) in the Caribbean to 5·0% (4·0–6·0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100 000 livebirths (11–14) for high-income regions to 546 (511–652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7·5%. Interpretation Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country-specific SDG targets are ambitious for most high mortality countries, countries that made a concerted effort to reduce maternal mortality between 2000 and 2010 provide inspiration and guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. Funding National University of Singapore, National Institute of Child Health and Human Development, USAID, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Global, Regional, and National Levels and Trends in Maternal Mortality Between 1990 and 2015, With Scenario-based Projections to 2030: A Systematic Analysis by the UN Maternal Mortality Estimation Inter-Agency Group

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ijgo.2009.07.013

Neonatal resuscitation in low-resource settings: What, who, and how to overcome challenges to scale up?

OBJECTIVE: Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide - the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. METHODS: The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). FINDINGS: On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour - 46%; manual removal of placenta - 52%; bimanual uterine compression - 46%; immediate newborn care - 71%; and neonatal resuscitation - 55%. CONCLUSION: There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

/pdf/are-skilled-birth-attendants-really-skilled-a-measurement-hv85omwrip.pdf

Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward

Introduction Background Each year obstetric complications kill over 500 000 women worldwide. (1,2) Skilled attendance during labour, delivery and in the early postpartum period could prevent many of these deaths, though establishing a causal link between skilled attendance and maternal survival remains problematic. (2-6) Still, the proportion of deliveries assisted by a skilled birth attendant (SBA) has become an indicator for measuring maternal mortality reduction, including the 75% reduction called for by the fifth Millennium Development Goal (MDG-5). (7,8) WHO defines an SBA as someone "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 newborns". (9) WHO uses household survey data to estimate the percentage of women delivered by an SBA in each country. (10) (An explanation of the methodology for determining the percentage of women delivered by SBAs is available at: http://www.who.int/reproductivehealth/global_monitoring/ skilled_attendant.html#methodology. WHO's most recent estimates of the proportion of women delivered by SBAs are available at: http://www.who.int/reproductivehealth/global_monitoring/ skilled_attendant_at_birth2006.pdf). Typically, these surveys ask women what type of health professional, if any, assisted at their most recent deliveries. (11-14) Most surveys report results by cadre: doctor, midwife, nurse, traditional birth attendant, relative and other. Some categorize doctors, midwives and nurses as health personnel to distinguish them from untrained attendants. Since surveys make no claim to ascertain provider skill, using survey data to estimate the proportion of SBA-assisted deliveries assumes that all health personnel qualify as SBAs. (15) (In this paper, consistent with the International Confederation of Midwives definition, the term midwife or nurse-midwife means a provider who has graduated from a certified or accredited midwifery training course in the country of practice. These programmes vary in content and duration and may or may not include medical or nursing training beyond midwifery skills. Nurse refers to a provider who has completed nursing training that is not part of a certified or accredited midwifery programme, even when midwifery functions are performed.) (15) But are skilled birth attendants really skilled? Do the health personnel enumerated by household surveys fit WHO's definition? This question was the focus of our two-phase study. In Phase I, we developed and piloted evaluation instruments, then carried out small-scale competency assessments in four countries. In Phase II, shortcomings identified in Phase I were corrected and the revised instruments used to conduct a larger-scale assessment. The results contribute to ongoing competency-improvement efforts. Methods We evaluated 166 health providers in Benin, Ecuador, Jamaica and Rwanda during Phase I. In Phase II, we tested 1358 Nicaraguan providers. In each country, our aim was to evaluate the professionals responsible for most deliveries--those most likely to appear in WHO estimates. Like WHO, we excluded traditional birth attendants. Table 1 summarizes maternal health characteristics by country. Instrument development We defined competence as possessing skills and knowledge sufficient to comply with predefined clinical standards. In a multi-country setting, this presupposes standards accepted by all providers and sites. Since no such standards exist, we measured competence against WHO's Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines, an appropriate evidence-based yardstick. (16) The three leading direct causes of maternal death are haemorrhage, preeclampsia and eclampsia, and sepsis. (17,18) We designed instruments to test competence related to prevention, diagnosis and management of these complications, plus management of uncomplicated labour and delivery. …

Are Skilled Birth Attendants Really Skilled

Quality problem or issue. Incorrect and excessive diagnosis of newborn infections in Nicaragua caused overcrowding in the neonatal intensive care units and unnecessary hospitalization. Initial assessment. A baseline study in nine hospitals found that none correctly utilized disinfectants, sterilization or hand hygiene and that diagnosis of neonatal sepsis was based primarily on clinical manifestations. Choice of solution. In 2007, the Ministry of Health (MINSA), with Unites States Agency for the International Development technical assistance, began developing guidelines and implementing quality improvement in infection prevention and control to reduce neonatal infections. In a second intervention phase, the MINSA introduced an algorithm for correct identification of maternal risk factors and standardized laboratory tests for neonatal sepsis.

Ivonne Gómez

Papers

Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward

Are Skilled Birth Attendants Really Skilled

Quality in practice: preventing and managing neonatal sepsis in Nicaragua