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RHO archives : Topics : Safe Motherhood

Annotated Bibliography

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Antenatal care and risk assessment

Abrahams, N. et al. Health care-seeking practices of pregnant women and the role of the midwife in Cape Town, South Africa. Journal of Midwifery & Womens Health 46(4):240-247 (July-August 2001).
This qualitative study is based on 103 interviews with 32 pregnant women in a periurban area of Cape Town, South Africa. The findings indicate that womens perceptions of the quality of care greatly influence their health care-seeking practices. Women generally thought antenatal care to be beneficial, particularly to avoid being scolded by staff should they arrive in labor without prior antenatal care. The womens interactions with staff were generally poor, and women expected to be treated badly by the midwives. The womens own needs for information were not met during antenatal care. They were given little information about the status of the baby or when they might expect to deliver, and given no test results. While obstetric outcomes are good in Cape Town, this study shows the need to improve the quality of services, improve staff-patient communication, and make services more patient-oriented.

Acharya, L.B. and Cleland, J. Maternal and child health services in rural Nepal: does access or quality matter more? Health Policy and Planning 15(2):223-229 (2000).
This study evaluated the relative importance of access and quality on the utilization of preventive health services in the western and middle-western hill region of Nepal. Access was measured by travel time to the nearest health post and coverage by outreach workers. Quality was defined by physical infrastructure, number of staff, availability of drugs, and the holding of special maternal and child health clinics. The adjusted odds ratio of using some form of antenatal care were 6.6 times higher in the catchment areas of high-quality posts than in areas served by low-quality posts. Travel times to the nearest post had less effect. Regular monthly visits by outreach workers also had a significant effect on service utilization. These results suggest that investing in the quality of health posts is more important than further increases in the number, and expansion of outreach services should be a priority.

Adamu, Y.M. and Salihu, H.M. Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. Journal of Obstetrics and Gynaecology 22(6):600-603 (2002).
In Kausani, a group of villages in Kano State, Northwestern Nigeria, most women deliver at home, and few receive antenatal care. To understand the reasons for this, a trained midwife interviewed 107 pregnant women in the community using a structured questionnaire. The majority (88%) of women were not receiving antenatal care, and 96 percent had previously delivered at home. The three most common reasons given for non-use of antenatal care were: limited financial resources (46%), God’s will (17.2%), and husband’s denial (17.2%). In order to improve utilization of antenatal care services, efforts to relieve poverty, and empower women economically are needed. Any programs must take into consideration the specific socio-cultural context of the population.

Amooti-Kaguna, B and F. Nuwaha. Factors influencing choice of delivery sites in Rakai district of Uganda. Social Science & Medicine 50(2):203-213 (Jan., 2000).
Eight focus group discussions and 211 semi-structured interviews were held with women in the Rakai district of Uganda to understand the factors influencing their choice of delivery site. Forty-four percent of the women delivered at home, 32 percent at public health units, 17 percent at a traditional birth attendant's place, and 7 percent at private clinics. The factors that influenced their choice of delivery site were access to maternity services; influence from spouse, other relatives, TBAs or health workers; self-efficacy; previous experience; and the concept of normal versus abnormal pregnancy. Women had very distinct attitudes and beliefs about various delivery sites. Attendance at antenatal care actually may discourage delivery in a health unit; women who are told that their pregnancy is normal see no reason to deliver at the health unit.

Bloom, S. et al. Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning 14(1):38-48 (1999).
This review examines the relationship of antenatal care utilization with the use of safe delivery care among poor to middle income women in an urban area of Uttar Pradesh, India. A new measure for antenatal care utilization that comprised of 20 input components covering care content and visit frequency was introduced. This composite measure for antenatal care utilization was studied in a probability sample of 300 low- to middle-income women who had given birth within the last three years. After controlling for relevant socio-demographic and maternity history factors, women with a relatively high level of care (at 75th percentile of the score) had an estimated odds of using trained assistance at delivery that was almost four times higher than women with a low level of care (at the 25th percentile of the score). Similar results were obtained for women delivering in a health facility versus at home. The results showed that antenatal care utilization is an important determinant of safe delivery care, suggesting that enabling women to get better antenatal care will increase the use of safe delivery care as well. The authors conclude that methods of raising awareness about the benefits of safe delivery care should be sought, but services also need to be placed within a context acceptable to women and their families.

Carroli, G. et al. WHO systematic review of randomized controlled trials of routine antenatal care. Lancet 357:1565-1570 (May 19, 2001).
This systematic review addresses the lack of strong evidence on the effectiveness of the content, frequency, and timing of antenatal care visits on the health of mothers and babies. Seven randomized controlled trials (four in more developed countries, two in Zimbabwe, and one multi-center trial in Argentina, Cuba, Saudi Arabia, and Thailand) involving 57,418 women were identified in 53 antenatal care clinics. The interventions compared the provision of a lower number of antenatal visits (new model) with standard antenatal programs. The outcomes measured were pre-eclampsia, urinary tract infection, postpartum anemia, maternal mortality, low birth weight, and perinatal mortality. There was no clinically differential effect of a reduced number of antenatal care visits when results for pre-eclampsia, urinary tract infection, postpartum anemia, maternal mortality, and low birth weight were pooled. Rates of perinatal mortality were also similar, although there were insufficient cases for statistical significance. Some women, mostly in more developed countries, were dissatisfied with fewer visits. Proportionally, the reduction in visits is very small in more developed countries (8 visits versus 11 to 14), and more significant in less developed countries. The new model offers cost savings, especially in less developed countries. This study indicates that effective antenatal care can be provided in fewer visits than currently recommended, without any clinically important increase in the risk of adverse outcomes.

Chapman, R.R. Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk. Social Science & Medicine 57:355-374 (2003).
This qualitative study of 83 reproductive age women (currently or recently pregnant) in Central Mozambique examined women’s underutilization of clinic-based prenatal services. In Mucessua, reproductive risks are seen as consequences of social tensions and economic instability. Women fear their pregnancies will be the target of sorcery by jealous neighbors and family, so they hide their pregnancies. Instead of seeking free prenatal care at nearby health clinics, these women visit nonmedical prophets, pastors, and traditional healers who understand women’s vulnerabilities. Providing clinical prenatal services will not reduce the perceived reproductive risks for these marginalized women. Offering confidential maternity care and improving their economic security can best address their needs.

Fortney, J.A. Antenatal risk screening and scoring: a new look. International Journal of Gynecology & Obstetrics 50 (Suppl. 2):S53-S58 (1995).
This article reviews the value of various risk factors in predicting obstetric complications. Obstetric history is a far more accurate predictor of risk than demographic factors. Community characteristics (such as distance to emergency obstetric care, access to transport, availability of food, and expected work level) should also be considered as risk factors. Risk assessments must be revised throughout pregnancy as women develop new signs and symptoms. Although risk scoring can be valuable, it has two problems. First, many women categorized as high risk never develop complications but consume scarce resources such as hospital deliveries. Second, many women categorized as low risk do develop complications but are never told how to recognize or respond to them.

Gerein, N. et al. A framework for a new approach to antenatal care. International Journal of Gynecology and Obstetrics 80(2):175-182 (February 2003).
Traditional approaches to antenatal care have focused on preventing and treating pregnancy-related morbidity, and detecting women at increased risk of complications at delivery. Given the many shortcomings of this approach, a new approach is proposed to help women plan for a safe birth. From the pregnant womans first visit, providers should help her (1) plan to use a skilled birth attendant; (2) prepare a simple, clean birth kit; (3) know the signs and symptoms of complications; (4) know where to get expert care and how to get there; (5) have a transportation plan; (6) have a plan for saving money for an emergency; and (7) identify a person to accompany her in an emergency. This new approach requires communicating with women, their families, their husbands, and their communities about their roles in ensuring safe births. It requires changes in policies and programs, and its success depends on effective supervision, monitoring, and evaluation of the new approach.

Gloyd, S. et al. Antenatal syphilis screening in sub-Saharan Africa: missed opportunities for mortality reduction. Health Policy and Planning 16(1):29-34 (2001).
It is well established that active syphilis infection during pregnancy results in high rates of fetal and infant death and disability. Syphilis screening and treatment as part of antenatal care is known as a cost-effective way to reduce illness and death, and is often the national policy. However, even in countries where syphilis is widespread, there is incomplete screening of pregnant women. This study looks at data from 22 ministries of health in sub-Saharan Africa, along with published data and information from key informants. According to WHO, 73 percent of women in these countries receive antenatal care. Of these women, only 38 percent were estimated to be screened for syphilis. The obstacles to screening include high costs and service obstacles. With syphilis prevalence estimated at 8.3 percent, 1.64 million pregnant women with syphilis are undetected every year, including 1 million who receive antenatal care. The costs of antenatal syphilis screening (U.S.$0.20 per RPR test) are within the means of most developing countries. Donor agencies can help with start-up costs and ministries of health can make antenatal screening a priority to the benefit of mothers and children.

Høj, L. et al. Factors associated with maternal mortality in rural Guinea-Bissau. A longitudinal population-based study. British Journal of Obstetrics and Gynaecology 109:792-299 (July 2002).
In this longitudinal, prospective study, more than 15,000 women living in 100 clusters were visited at six-month intervals over a period of more than six years to determine risk factors for maternal death. Of the 10,931 pregnancies, 85 resulted in a maternal death. Maternal mortality increased as distance from the regional hospital increased. The risk of death was greater for a multiple pregnancy, and the risk of subsequent maternal death was greater if the fetus was stillborn. This study did not find any increase in maternal mortality associated with a class of age or parity. Screening and referral based on these factors would not reduce maternal risk. The distance to an emergency obstetric care facility is an important factor in determining the outcome of complicated deliveries.

Holtz TH et al. Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi. Tropical Medicine and International Health. 2003;9(1):77-82.
In this cluster sample survey of 391 recently pregnant women in Blantyre District, Malawi (February 2000), 98.6 percent had visited an antenatal clinic at least once, and 90.2 percent knew that intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) was recommended during pregnancy. Only 36.8 percent had received the full two-dose regimen of IPT/SP. Analysis of antenatal cards for 187 women showed no clear factor associated with failure to receive treatment. Adjusting for education, women with more than one pregnancy were more likely not to receive the recommended regimen. A substantial effort is needed to improve IPT/SP among pregnant women in this area of Malawi.

Jahn, A. et al. Obstetric care in southern Tanzania: does it reach those in need? Tropical Medicine and International Health 3(11):926-932 (1998).
The goals of this Tanzanian study were to determine: the coverage of obstetric referral-level care for high-risk pregnancies; whether specific risk factors trigger referral; and what factors predict use of referral-level care other than risk status in southern Tanzania. The researchers compared the risk profiles of pregnant women in general (1,630 women) with those seeking obstetric care at the Mtwara Hospital (415 women). The profiles of hospital patients were obtained from interviews and analyses of their antenatal cards, while population-based risk profiles were drawn from entries in antenatal care registers. Results showed that the risk-factors profile was similar for both groups of women. Only previous cesarean section and nulliparity were found to significantly predict referral-level care. No significant differences were observed for other risk factors such as previous perinatal death, height less than 150 cm, multiple gestation and breech presentation. Coverage of obstetric care at the referral level was below 50 percent for all risk factors except previous cesarean section (91.5%). The researchers concluded that antenatal care in Tanzania has only limited effect on extending obstetric care to high-risk mothers, and that the focus needs to shift from allocation of risk categories and referral advice to assisting the mother and her family to optimize their health behavior and use of services.

Langer, A. et al. Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries. MNC Womens Health 2:7 (2002). Available at:
This paper reports on a special component on a large multicenter, randomized, controlled trial evaluating a new antenatal care program featuring reduced visits (Carroli 2001). The study was conducted by WHO and collaborating organizations at 53 antenatal care clinics in Argentina, Cuba, Saudi Arabia, and Thailand. Focus group discussions and in-depth interviews were held with women and providers to assess the culture-related values in each country. The second stage included interviews using standardized questionnaires. Women in the new antenatal care model clinics were, in general, equally satisfied with their care as the women in the standard model clinics. Women in the new model were more satisfied with the time spent with the provider and with the information they received. While there was no statistically significant difference, more women in the new model clinics reported dissatisfaction with the reduced number of visits and the longer spacing between them. Providers in the new model clinics were more satisfied with the number of visits, time spent with clients, and information provided, but were less satisfied with the spacing of visits. If the new model of antenatal care visits is to be instituted on a routine basis, the safety of longer visit spacing should be reinforced. Making sure that providers are actively involved in the implementation of a new model of care will contribute to its success.

Magadi, M.A. et al. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Social Science & Medicine 51:551-561 (2000).
While antenatal care can be an important tool in diagnosing and preventing risks during pregnancy, many women in developing countries do not use these services. Using a three-level linear regression model, data from the 1993 Kenya Demographic and Health Survey were analyzed to determine the frequency and timing of use of antenatal care services. The results show that the median number of antenatal care visits is four, and the first visit occurs in the fifth month of pregnancy on average. Use of antenatal care is started later, and is less frequent for unwanted and mistimed pregnancies. Even women who appear to use antenatal care frequently are less likely to use services for a mistimed pregnancy. Long distance to the nearest antenatal care facility is an obstacle to antenatal care. The data show that women are highly consistent in their use or non-use of antenatal care services, even when services are within easy access. The reasons remain unexplained by this study, but may include personal beliefs. In-depth qualitative studies may help identify the barriers to use of antenatal care services.

Majoko, F. et al. Usefulness of risk scoring at booking for antenatal care in predicting adverse pregnancy outcome in a rural African setting. Journal of Obstetrics and Gynaecology 22(6):604-609 (2002).
This study in rural Zimbabwe evaluated the use of risk allocation made at the first antenatal care visit to identify women who will experience pregnancy complications. Of the 5,223 women in 12 rural health centers, 2,890 (55%) were classified as high risk. All high-risk women were recommended hospital delivery. Complications occurred in 924 (17.7%) women, of whom 577 (62.4%) had risk markers identified at booking. Only 20 percent of high-risk women (577 of 2,890) developed complications. The majority of women would be recommended for hospital delivery, which would overwhelm the district hospital and make use of unnecessary resources. In this study, the highest risk of complications was among women with a history of previous complications. Traditional risk factors have low sensitivity for identifying women likely to develop complications.

McDonagh, M. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning 11(1):1-15 (1996).
Differences in the definition of antenatal care make it difficult to compare studies on its effectiveness. This review concludes, however, that antenatal care has little effect on maternal mortality or morbidity in developing countries at the present time. The reason is that some problems (such as malpresentation) cannot be consistently identified, while others (such as low body weight) cannot be corrected with available resources. The irregularity of antenatal visits also limits their effectiveness. Research suggests that the most effective element of antenatal care is the distribution of iron, folate, and malaria prophylaxis to improve women's nutritional status. Antenatal care also has the potential to influence women to select a trained birth attendant.

Munjanja, S. P. et al. Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. Lancet 348:364-369 (August 1996).
The goal of this randomized controlled study was to determine whether a new program of antenatal care with fewer goal-oriented visits would result in equivalent or better pregnancy and delivery outcomes compared to the standard program. The new program consisted of fewer but more objectively oriented visits and fewer procedures per visit. Women were recruited from seven primary care clinics, which were randomly assigned to the two programs. A total of 15,532 women participated in the study: 9,394 from the four clinics that followed the new program and 6,138 from the three clinics with the standard program. Results showed that, as planned, women in the new program made fewer visits than those in the standard one (median 4 versus 6, respectively). In addition, there were significantly fewer referrals for pregnancy-induced hypertension and for severe hypertension or eclampsia during labor. The risk of preterm delivery (less than 37 weeks) was also significantly lower for women in the new program (10.1% versus 11.5%). No significant differences between the programs were found for other indices of pregnancy outcome, including antenatal referrals for other causes, labor referrals, obstetric interventions, low birthweight, and perinatal or maternal mortality and morbidity. The authors discussed the possible benefits of reducing the number of procedures carried out and visits achieved by the new program. They concluded that a simpler and reduced-visit program of antenatal care could be introduced without adverse effects on the major intermediate pregnancy outcomes.

Oboro, V.O. et al. Prevalence and risk factors for anaemia in pregnancy in Southern Nigeria. Journal of Obstetrics and Gynaecology 22(6):610-613 (2002).
Women attending antenatal care clinics at three government hospitals in Kwale, Southern Nigeria were screened for anemia from August 2000 to September 2001 (n = 779). The overall prevalence of anemia was 56.1 percent, and severe anemia was 6.7 percent. Independent risk factors for anemia and severe anemia were primigravidity (first pregnancy), late booking, and wet season. Anemia is a common problem among this population, and additional intervention for this “at-risk” group is indicated.

Piaggio, G. et al. The practice of antenatal care: comparing four study sites in different parts of the world participating in the WHO Antenatal Care Randomised Controlled Trial. Paediatric and Perinatal Epidemiology 12 (Suppl. 2):116-141 (1998).
This paper describes results from a cross-sectional baseline survey of a WHO study that evaluated a new program of antenatal care. In conducting the survey, researchers interviewed staff, performed direct observations, and reviewed a random sample of 2,913 clinical histories at 53 selected clinics: 17 in Argentina, and 12 in each of the following countries: Cuba, Saudi Arabia, and Thailand. Results revealed a high variability of antenatal care services provided in the four study countries. For example, there was a large variation across sites in the use of screening and laboratory tests and interventions that should be offered to all women. In some clinics, these services were simply not available; where services were available only a fraction of women attending the clinics received them. There was also a notable difference in the type of principal provider of antenatal care. The researchers suggested that results of the survey could guide efforts to improve antenatal care services.

Prual, A. et al. The quality of risk factor screening during antenatal consultations in Niger. Health Policy and Planning 15(1):11-16 (2000).
The goal of this study was to assess the frequency of risk factors among a sample of pregnant women receiving antenatal care in Niger and to assess the quality of the screening of those risk factors. A total of 330 pregnant women were enrolled in the study. Each woman was examined twice: the first time by a midwife, the second time by one of the authors but without knowledge of the results of the first consultation. Study results showed that 55 percent of pregnant women had at least one risk factor, and 31 percent had more than one. Ninety-one percent of the risk factors were detected at interview. The following risk factors were not systematically searched for by midwives: height (48.5%), blood pressure (43.6%), glycosuria (40.6%), vaginal bleeding (38.2%), edema (37.3%), parity (17%), age (16%), previous cesarean section (15.2%), previous stillbirth (15.2%) and previous miscarriages (14.8%). Based on the study findings, the authors conclude that the quality of screening for risk factors during antenatal consultation is poor. Antenatal care can only play a limited role. The most efficient action for decreasing maternal and neonatal mortality is the implementation of essential obstetric care at the primary or secondary level of the health system.

Swenson, I.E. et al. Factors related to the utilization of prenatal care in Vietnam. Journal of Tropical Medicine and Hygiene 96:76-85 (1993).
To determine which factors influence the use of prenatal care in Vietnam, this study analyzed data from the 1988 Vietnam Demographic ad Health Survey and the 1990 Vietnam Accessibility of Contraceptives Survey. About half the women had prenatal care for each of their pregnancies, and the provider most often was an assistant doctor or midwife. Women were more likely to receive prenatal care if they were educated, had two or fewer children, lived in an urban area, or lived in a province with a low infant mortality rate. For rural women, the availability of public transport also was important, but not the distance to a hospital or clinic.

Ujah, I.A.O. et al. How safe is motherhood in Nigeria?: The trend of maternal mortality in a tertiary health institution. East African Medical Journal 76(8):436-439 (August 1999).
A review of the records of all maternal deaths at Jos University Teaching Hospital in Nigeria between 1990 and 1994 indicated a maternal mortality ratio of 739 deaths per 100,000 deliveries. Despite the launch of the maternal and safe motherhood program in Nigeria in 1990, this study shows that maternal mortality actually increased from 450 deaths per 100,000 live births in 1990 to 1060 deaths in 1994. About one-third of the deaths during this period were to adolescents. Having more than five children, illiteracy, and non-utilization of antenatal care also were associated with an increased risk of maternal death. The main causes of death were hemorrhage (28.1%), sepsis (21.3%), and eclampsia (15.7%). Complications of induced abortion and anesthesia-related deaths each accounted for 9 percent of the deaths. The authors conclude that the maternal mortality ratio is unacceptably high, and increasing, due in part to the poor socio-economic situation in Nigeria.

Vanneste, A.M. et al. Prenatal screening in rural Bangladesh: from prediction to care. Health Policy and Planning 15(1):1-10 (2000).
The goal of this population-based cohort study was to assess whether prenatal screening can identify women at risk of severe labor or delivery complications in a rural area in Bangladesh. Antenatal risk markers, signs, and symptoms were assessed for their association with severe maternal complications including dystocia, malpresentation, hemorrhage, hypertensive disease, twin delivery, and death. The results showed that antenatal screening by trained midwives fails to adequately distinguish women who will need special care during labor and delivery from those who will not need such care. The majority of the women with dystocia or hemorrhage had no warning signs during pregnancy. Women who had an antenatal visit were four times more likely to deliver with a midwife than women who had no antenatal visit. The authors conclude that antenatal care may not be an efficient strategy for identifying those most in need for obstetric service delivery, but if promoted in concurrence with effective emergency obstetric care, and delivered in skilled hands, it may become an effective instrument to facilitate better use of emergency obstetric care services.

Villar, J. and Bergsjo, P. Scientific basis for the content of routine antenatal care: I. Philosophy, recent studies, and power to eliminate or alleviate adverse maternal outcomes. Acta Obstetricia et Gynecologica Scandinavica 76:1-14 (1997).
This literature review examines randomized controlled trials and other studies to determine which elements of antenatal care have proven health benefits. The authors conclude that there is evidence in support of: counseling women about bleeding, routine iron supplements where anemia is prevalent, hemoglobin determinations around week 30, improved detection and care of pre-eclampsia, urine culture and urinary tract infection treatment, serological screening and treatment of syphilis, screening based on obstetrical history and height to determine whether women need to deliver in a hospital, and changing the position of the fetus in breech presentations. The evidence does not support frequent routine visits for low-risk women, routine aspirin to prevent pre-eclampsia in low-risk women, and anti-hypertensive treatment of mild pre-eclampsia.

WHO, UNICEF. Antenatal Care in Developing Countries. Geneva: WHO; 2003. Available at:
While most safe motherhood programs emphasize ensuring access to emergency obstetric care and skilled care at delivery, there continues to be an important role for antenatal care. The results of this analysis of trends, levels, and differentials in antenatal care in developing countries from 1990 to 2001 indicate that antenatal care is largely a success. On average, two-thirds of pregnant women in developing countries report at least one antenatal care visit. During the 1990s, use of antenatal care increased 20 percent overall, although there has been little change in sub-Saharan Africa. Disparities in care remain between rural and urban areas, and more educated and wealthier women tend to receive more antenatal care. Women who present for one antenatal care visit are likely to come for more care. Efforts are needed to close the existing gaps in antenatal care and improve the content and quality of care.

Yuster, E.A. Rethinking the role of the risk approach and antenatal care in maternal mortality reduction. International Journal of Gynecology & Obstetrics 50 (Suppl. 2):S59-S61 (1995).
The author argues that screening for obstetric risk is not an effective way to reduce maternal mortality. Risk screening identifies many women who do not develop complications, while it misses many women who do have complications. It creates a false sense of security for women in the low risk group, whom health workers assume will have normal deliveries. Instead, antenatal care should be used to identify early obstetric complications such as high blood pressure, to educate women about obstetric danger signs, and to motivate women to seek appropriate referral care.

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Skilled attendance during pregnancy and delivery

Bell J et al. Improving skilled attendance at delivery: a preliminary report of the SAFE Strategy Development Tool. BIRTH. 2003;30(4):227-234.
This article reviews field-testing of the Skilled Attendance for Everyone (SAFE) Strategy Development Tool in five developing countries. The tool is designed to help policy makers and planners systematically gather and interpret information to develop strategies for improving skilled attendance at birth. Use of the tool can be completed in three to five months at a cost of US$12,938 to US$15,627 at the district or subdistrict level. The information generated from this tool can be used to develop evidence-based strategies suited to specific countries and contexts.

Bergström S, Goodburn E. The role of traditional birth attendants in the reduction of maternal mortality. In: De Brouwere V, Van Lerberghe W, eds. Safe Motherhood Strategies: A Review of the Evidence. Studies in Health Services Organisation and Policy. 2001;17:1-450 . Available in English, French, and Spanish on CD-ROM by request to info@jsiuk.
Traditional birth attendants (TBAs) play a significant role in offering cultural competence, consolation and psychosocial support to women during childbirth in many cultures. However, training of TBAs has had little impact on maternal mortality. The main benefits are improved referral and linkages with the formal health care system where essential obstetric care is available. Training TBAs should be given lower priority than training midwives, and developing essential obstetric care services and referral systems.

Bolam A et al. Factors affecting home delivery in Kathmandu Valley, Nepal. Health Policy and Planning. 1999;13(2):152-158.
The goal of this study was to determine the factors influencing home delivery among women who have the choice of institutional or home delivery. The delivery patterns of 357 mothers were identified in a cross-sectional survey of two communities: urban Kalimati and a peri-urban area of Kirtipur and Panga. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. Eighty one percent of the women had an institutional delivery and 19 percent delivered at home. Low maternal education level and multiparity were found to be significant risk factors for home delivery. Of the women who delivered at home, only 24 percent used a traditional birth attendant (TBA), and over 50 percent of deliveries were unplanned due to precipitate labor or lack of support. The authors conclude that, rather than poverty, poor education and multiparity increase the risk of a home delivery in the study setting. Training TBAs in this setting probably would not be cost-effective. They suggest that community-based delivery units run by midwives could reduce the incidence of unplanned home deliveries.

Buffington S et al. Life Saving Skills Manual for Midwives. 3rd ed. Washington, DC : American College of Nurse-Midwives; 1998.
The Life Saving Skills Training Program for midwives, developed and implemented by the American College of Nurse Midwives, is a competency-based training program that equips midwives with the skills to intervene in the five life-threatening complications that cause most maternal deaths: obstetric hemorrhage, obstructed labor, obstetric sepsis, hypertensive disorders of pregnancy, and complications of unsafe abortion.

Bulterys M et al. Role of traditional birth attendants in preventing perinatal transmission of HIV. British Medical Journal. 2002;324:222-225.
Given the high proportion of rural births in Africa that are assisted by traditional birth attendants, and the growing prevalence of HIV infection in many African countries, the author suggests TBAs may have a role to play in preventing perinatal transmission of HIV. New antiretroviral drugs, elective cesarean sections, and avoidance of breastfeeding have helped reduce perinatal transmission of HIV in more developed countries. TBAs are now being used to provide cost-effective malaria prevention services and to assess neonatal problems. It is proposed that TBAs could be trained to educate about HIV transmission, testing, and counseling. In some settings, if rapid HIV testing is available, TBAs could provide HIV testing, and help with prophylactic antiretroviral drugs at delivery. Issues related to illiteracy and training, confidentiality, and the use of TBAs within communities need to be studied before TBAs can be used effectively to prevent HIV transmission in rural communities.

de Bernis L et al. Skilled attendants for pregnancy, childbirth and postnatal care. British Medical Bulletin. 2003;67:39-57.
Providing skilled care at delivery makes clinical sense, is desired by women, and is both cost-effective and feasible in developing countries according to this article. While randomized controlled trials are not ethically possible, the authors provide evidence showing the benefits of skilled attendants. A skilled attendant must work in close collaboration with other obstetric care and lay providers. Health providers can advocate for skilled attendants, take part in research, and upgrade skills. Creating effective systems to deal with obstetric emergencies will benefit the entire health care system.

de Bernis L et al. Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey). British Journal of Obstetrics and Gynaecology. 2000;107(1):68-74.
This prospective population-based study followed 3,777 Senegalese women throughout pregnancy, delivery, and postpartum. It compared the levels of maternal morbidity and mortality between the urban Saint-Louis and Kaolack areas. Maternal mortality was found to be higher in the Kaolack area, where women gave birth primarily in district health centers, assisted by traditional birth attendants (874 versus 151 deaths per 100,000 live births). In Saint-Louis most women giving birth in health facilities went to the regional hospital and were assisted by midwives. Morbidity, however, was greater in Saint-Louis than in Kaolack, especially for women delivering in health facilities (9.50 versus 4.84 episodes of obstetric complications per 100 live births). Analysis of these findings showed that morbidity was associated with the training of the birth attendant, and antenatal care had no effect. The authors suggest that employing the most qualified personnel possible for monitoring labor in health facilities will have the greatest impact on maternal mortality.

Fauveau V et al. Effect on mortality of community-based maternity-care programme in rural Bangladesh. Lancet. 1991;338:1183-1186.
This article evaluates the impact of the Matlab community-based maternity care program which posted trained midwives in villages. Midwives in the program area visited 44 percent of all pregnant women at least once, were present at 13 percent of deliveries, and referred one-fifth of the women they delivered to the clinic. Women were reluctant to call on the midwives to attend births because the distance was too great and/or because they had no complications. After the program had been in place for three years, the maternal mortality ratio due to obstetric complications was far lower in the program area than in a comparison area (1.4 versus 3.8 deaths per 1,000 live births). The authors conclude that posting trained and well-equipped midwives at the village level, who have access to an effective chain of referral, can improve maternal survival.

Goldman N, Glei D. Evaluation of midwifery care: results from a survey in rural Guatemala. Social Science & Medicine. 2003;56:685-700.
In this analysis of data from the 1995 Guatemalan Survey of Family Health, training of midwives had little effect on the quality of midwife care. The study examined the extent to which women used both traditional and biomedical pregnancy care, how frequently midwives refer women to biomedical providers, the content and quality of care offered by midwives, and the effects of midwife training programs on referral and quality of care. Trained midwives were more likely than other midwives to refer clients to biomedical providers (although they did so irregularly), but most pregnant women do not see biomedical providers. The reasons for this are outside the scope of this study, but may relate to the reported poor treatment women receive at government health facilities.

Goodburn E. et al. Training traditional birth attendants in clean delivery does not prevent postpartum infection. Health Policy and Planning. 2000;15(4):394-399.
This study in rural Bangladesh found that trained TBAs are significantly more likely to practice hygienic delivery than untrained TBAs, but hygienic birth practices do not prevent postpartum infection. Data on 800 women were reviewed, including antenatal and three postpartum interviews. The cases were analyzed to assess the proportion of cases with infection and the effect of a trained TBA's presence at delivery. TBAs trained in the "three cleans" were more than twice as likely (45%) as the untrained TBAs (19%) to perform "clean" deliveries. However, there was no significant difference found in the levels of postpartum infection in the two groups. Logistic regression analysis found the TBA training and hygienic delivery had no independent effect on postpartum outcome. Pre-existing reproductive tract infection, long labor, and insertion of hands into the vagina were found to have a significant effect. More rigorous evaluation of TBA training, and its individual components, is needed to determine how they can influence postpartum infection and maternal morbidity.

Graham W et al. Can skilled attendance at delivery reduce maternal mortality in developing countries? In: De Brouwere V, Van Lerberghe W, eds. Safe Motherhood Strategies: a Review of the Evidence. Studies in Health Services Organisation and Policy. 2001;17:1-450. Available in English, French and Spanish on CD-ROM by request to info@jsiuk.
This paper explores the scientific justification for the goal of skilled attendance at all deliveries. It reviews the historical and epidemiological evidence, pointing out inconsistencies in the link between maternal mortality and skilled attendants. The article provides definitions of minimum and additional skills for skilled attendants. The authors propose that the term “skilled attendance” encompass a partnership of skilled attendants and an enabling environment of equipment, supplies, drugs, and transport for obstetric referral. An empirical model for the effect of skilled attendance on maternal health is included. However, there is a need for studies showing the true impact of different professional mixes of attendants (doctors, nurses, midwives) on maternal health. The authors also propose use of a “Partnership Ratio” - the proportion of deliveries with a midwife and the proportion with a doctor—instead of percentage of deliveries with health professionals as a more useful independent variable.

Hodnett ED et al. Continuous support for women during childbirth (Cochrane Review). In: The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd; 2004.
Results from 15 randomized controlled trials involving 12,791 women indicate that women who had continuous intrapartum support were less likely to have analgesia, operative vaginal or cesarean birth, or to report dissatisfaction with their childbirth experiences. Continuous support had greater benefits when the support person was not a member of the hospital staff, when support began early in labor, and in settings in which epidural analgesia was not routinely available. Few of these trials took place in low-resource settings, and further research could compare the cost and benefit of continuous support versus other causes of pregnancy-related morbidity.

Hoff W. Traditional health practitioners as primary health care workers. Tropical Doctor. 1997; 27(Suppl.):52-55.
This article evaluates the effectiveness of programs in Ghana, Mexico, and Bangladesh that trained TBAs and other traditional health practitioners to provide primary health care services. A qualitative analysis found that community members were satisfied with the services of trained practitioners, that pregnant women preferentially consulted trained TBAs, and that mothers in program areas were more likely to take iron pills, seek immunizations, use oral rehydration solution, practice family planning, and improve their family's diet. In Ghana, statistical records documented a reduction in still births, maternal deaths, and neonatal deaths in regions where trained TBAs worked. The programs faced two obstacles: low literacy levels among traditional practitioners and poor collaboration between traditional practitioners and hospital physicians.

Kamal IT. The traditional birth attendant: a reality and a challenge. International Journal of Gynecology & Obstetrics. 1998;63(Suppl.1):S43-S52.
Traditional birth attendants (TBAs) are a familiar part of the birthing process worldwide. They provide a much-needed service in many communities, but the quality of the care they provide often needs improvement. Many safe motherhood programs in developing countries have worked with TBAs to improve their skills and the care they provide. A review of TBA training and use in more than 70 countries over the past three decades shows there has been some success. However, once the TBA completes her training she is often left to practice with little supervision and support, and the care she provides is compromised. To make effective use of this human resource, programs need to improve TBA training curricula and better prepare the trainers; provide supervision of the TBAs post-training; ensure accessibility of emergency obstetric care; and help TBAs publicize their improved skills and receive compensation for their services. In the long term, national health plans should work to replace TBAs with a better-trained alternative which is acceptable, accessible, and affordable.

Maclean G. The challenge of preparing and enabling ‘skilled attendants’ to promote safer childbirth. Midwifery. 2003;19:163-169.
A review of historical and epidemiological evidence highlights the importance of what the author calls “The Three Es” of skilled attendance at birth: the Education of the skilled attendant, the Environment in which s/he practices, and the Effectiveness of the skilled attendant. For a skilled attendant to be effective, s/he must have the necessary skills and work in an enabling environment. The latter is crucial, and depends on political support, effective systems of communication and transport, and available equipment and supplies.

Maimbolwa M et al. Cultural childbirth practices and beliefs in Zambia. Issues and Innovations in Nursing Practice. 2003;43(3):263-274.
This study explored childbirth practices and beliefs in urban and rural Zambia. Interviews with 36 women accompanying laboring women to maternity units showed that half considered themselves to be mbusas or traditional birth assistants. These women advised laboring women on use of traditional medicines. They relied on traditional beliefs and witchcraft to explain complications. These social support women lacked understanding of causes of obstetric complications and appropriate management of labor and delivery. Their cultural knowledge, however, could be used to guide the development of safe motherhood programs, and one-third of the women were in favor of learning about childbirth care from midwives.

Minden M, Levitt MJ. The right to know: women and their traditional birth attendants. In: Murray SF, ed. Midwives and Safer Motherhood. London: Mosby; 1996.
This article reviews the debate over the proper role of TBAs. It differentiates between a crisis management perspective (which emphasizes TBA referrals to medical centers) and a community-health development perspective (which views TBAs as facilitating the natural process of childbirth and fostering women's well-being). The authors argue for a broader role for the TBA, including advising pregnant women on proper nutrition and hygiene, using preventive practices during delivery, managing certain limited complications, making referrals and acting as an agent of change and role model for other women. The article presents a broad framework for assessing trained TBAs that includes utilization and quality of their services, changes in community practices, maternal and neonatal deaths averted, and referrals made.

O'Heir JM. Midwifery education for safe motherhood. Midwifery. 1997;13:115-124.
This article reports on field tests of a series of educational modules developed for midwives by WHO. The modules cover midwifery in the community and major obstetric complications. Teachers and trainees in five countries agreed that the information was relevant, clearly presented, and easy to use. Problems were noted in the amount of time allocated to certain sessions, in the availability of cases to teach clinical skills, in arranging community visits as part of the introductory module, in using English as the language of instruction, and in the lack of reference materials for trainees to keep. Also, trainees were concerned that they would not be able to apply their new skills because of weaknesses in the health system infrastructure.

Paul B and Rumsey D. Utilization of health facilities and trained birth attendants for childbirth in rural Bangladesh: an empirical study. Social Science & Medicine. 2002;54:1755-1765.
This retrospective study analyzed factors associated with the use of modern health care among couples experiencing childbirth during 1995-1997 in 39 villages in rural Bangladesh. About 11 percent of deliveries were attended by trained personnel, and the rest were attended by traditional birth attendants (TBAs). Multivariate analysis shows that delivery complications were the most important factor determining use of modern health care resources for childbirth, followed by parental education and prenatal care. The authors conclude that training TBAs and community members to respond quickly to delivery complications, along with improving access to hospitals and trained TBAs can reduce the risks of infant and maternal morbidity and mortality in rural Bangladesh.

Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth attendants and village midwives. Journal of Obstetrics and Gynaecology. 2004;24(1):5-11.
A literature search from 1966 through February 2003 identified 15 maternal mortality intervention studies using traditional birth attendants (TBAs) and midwives. Five of the five programs using maternal mortality as an outcome measure showed a decline in maternal mortality ratios; two of three studies measuring morbidity-related indicators showed some improvement; six of seven showed improved referral rates, and three of three found high levels of knowledge retention among trained TBAs. Programs having the greatest impact used TBAs and village midwives in multisectoral activities. More research is needed, especially to establish a causal association between TBA training and maternal mortality decline.

Ronsmans C. et al. Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia. Tropical Medicine and International Health. 2001;6(10):799-810.
Training, deploying, and supervising professional midwives in villages in South Kalimantan, Indonesia, resulted in a large increase in the proportion of births attended by a skilled provider, but had little impact on providing specialized obstetric care for all women. Working with the Indonesian government, in 1994 MotherCare initiated in-service training of midwives; a supervisory system; a maternal and perinatal audit; and an information, education, and communication strategy aimed at the community. These activities increased the proportion of births attended by a skilled provider (at home or in a facility) from 37 percent to 59 percent. The program also doubled the proportion of women receiving postpartum visits (36% to 72%). Despite these improvements, the proportion of women admitted to the hospital for a cesarean section declined from 1.7 to 1.4 percent. The proportions admitted to the hospital for life-saving treatment of a complication dropped from 1.1 percent to 0.7 percent. These data indicate an increasing unmet need for obstetric care. The reasons for this most likely include lack of transportation, cultural aversion to use of health care facilities for obstetric care, and the high cost of emergency obstetric care. The government is challenged to sustain the extensive village midwifery program, and to find ways to increase access to specialized obstetrical care for those in need.

Safe Motherhood Inter-Agency Group. Skilled Care During Childbirth: A Review of the Evidence. New York: Family Care International;2003.
This review uses published and unpublished literature, country reports, and interviews with technical specialists to examine the relationship between skilled care and maternal mortality reduction.

Senah KA et al. From abandoned warehouse to life-saving facility, Pakro, Ghana. International Journal of Gynecology & Obstetrics. 1997;59(Suppl. 2):S91-S97.
Creating a village health post staffed by a midwife improved access to maternal health care in a rural area of Ghana. Other interventions included training the midwife in life saving skills, training TBAs to refer women with complications, placing new equipment in the district hospital, and educating the community and the drivers' union on the need for prompt medical attention in case of obstetric emergencies. Over a 43-month period, the midwife attended 702 antenatal clients, delivered 86 women, and made 20 referrals. The midwife was able to treat all minor and some major complications. Access remained a problem because the health post was not open 24 hours a day and some communities were located far from the post.

Sibley L and Armbruster D. Obstetric first aid in the community—partners in safe motherhood: a strategy for reducing maternal mortality. Journal of Nurse-Midwifery. 1997;42(2):117-121.
This article describes a new initiative of the American College of Nurse-Midwives (ACNM) to train community members in obstetric first aid. Obstetric first aid includes actions that prevent complications, the prompt recognition of complications, safe and effective responses to complications, and arrangements to improve access to referral facilities. ACNM has developed and is planning to field test two performance-based training programs on obstetric first aid: one is designed for TBAs, while the other is directed to women and their families.

Sibley LM, Sipe TA, Koblinsky M. Does traditional birth attendant training increase use of antenatal care? A review of the evidence. Journal of Midwifery and Women’s Health. 2004;49(4):298-305.
Narrative and meta-analytic studies of published and unpublished studies between 1970 and 2002 were reviewed to assess the relationship between traditional birth attendant (TBA) training and increased use of antenatal care. Fifteen studies from eight countries in two world regions were included. There are varying positive associations between TBA training and TBA knowledge of the value and timing of antenatal care, and on TBAs offering advice or assistance for antenatal care and compliance and use of antenatal care by their patients. There is little information on the characteristics of TBA training programs. Although no causal association can be made, results suggest that TBA training may increase antenatal care attendance rates by 38 percent. This could contribute to reductions in maternal morbidity and mortality in areas offering quality antenatal and obstetric care services. Better studies on the effect of TBA training and other factors influencing use of antenatal care are needed.

Voet W. Using Performance and Quality Improvement to Strengthen Skilled Attendance. Baltimore: JHPEIGO, Maternal and Neonatal Health Program; 2003. Available at:
This report of the Maternal and Neonatal Health Program shows how using performance and quality improvement (PQI) techniques can be used to help health facilities review and monitor skilled attendance at childbirth. It provides lessons learned in MNH programs in Burkina Faso, Guatemala, Honduras, Indonesia, and Tanzania.

WHO. Global Action for Skilled Attendants for Pregnant Women. Geneva: World Health Organization (2002). Available at:
WHO proposes an accountability framework to increase access to skilled attendants at delivery. WHO has outlined a framework that defines its own roles and responsibilities and those of other key stakeholders in this global action movement. The framework indicates what actions can be taken by people (national authorities, providers, families, etc.) at different levels, what WHO resources are available to them, and which indicators can be used to track progress.

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