Joyce E. Thompson, Study Leader, UNFPA Technical Advisor

1. Rapid assessment of selected skilled birth attendants in eight Latin American and Caribbean countries Joyce E. Thompson, Study Leader, UNFPA Technical Advisor Alma Virginia Camacho, UNFPA LACRO, Technical Advisor Sandra Land, UNFPA Technical Advisor Ivelise Segovia, Midwife Observer Martha Murdock, Family Care International, Project Technical Advisor

2. 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

3. 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.

4. 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 facilities 2. Identify whether the person observed was providing quality care and was competent to do so 3. Inform priorities for future coordinated country and regional advocacy

5. 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

6. Observation Tools • Demographics • Setting type, provider title & credentials • Provider Self-report of Life Saving Skills • Antenatal first visit • Competencies observed • Quality of care observed (repeated for each clinical area) • Antenatal repeat visit • Review of clinical record • Labor care • Birth, immediate post partum, newborn care

7. 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

8. 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)

9. 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

10. Outcomes of Rapid Assessment:Objective 1: Who is providing care? • 83 different health care providers observed • Midwives [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 observed • Antenatal care = 34 • Labor care = 34 • Birth/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

11. 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

12. 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%

13. 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

14. 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%)

15. 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%)

16. 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%)

17. 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.

18. 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%)

19. 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

20. Implications of Observations: Quality Aspects 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

21. 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)

22. Implications Objective 2: Competent Care • Under-performance observed frequently in all countries, regardless of the model of care • Given observed inconsistentcompetencyamong all three groups of providers, can anygroupbe 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?

23. 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 • Reinforcehand washing and clean equipment use • Provide direct supervision for health professional students.

24. Thanks! Martha Murdock mmurdock@fcimail.org