Skilled attendants at Every birth:Essential requirements for the delivery of basic emergency obstetric care

The United Nations' Sustainable Development Goals represent a renewed call to action to sustain the gains achieved by the Millenium Development Goals (MDGs). Fulfilment of the 3rd SDG, will require that several low-income countries strengthen their health systems, and enable skilled attendants to provide good quality obstetric care. The main goal of this project was to identify the broad range of factors that influence the delivery of obstetric care by skilled birth attendants in low-income countries. Methods 1. A systematic review of the factors that influence the delivery of obstetric care by skilled birth attendants in low- and middle-income countries (WP1) 2. Analysis of the policy to scale up skilled birth attendance in Uganda (WP2). 3. A qualitative study of health worker and maternal perspectives and experiences of obstetric care in two districts of Uganda (WP3). 4. Comparison of the Uganda case study with other regions and global initiatives (WP4). Results WP1: Thirty-one qualitative studies were included in this review. Fifteen studies were conducted in Africa, eleven in Asia and seven in Latin America. Data were extracted and analysed using a framework thematic synthesis approach. Key findings: Staff shortages were linked to increased workload that compromises the quality of care. Limited physical infrastructure, unreliable water and electricity supply, non-functional equipment and stock-outs of supplies contribute to poor quality care. On the other hand, health workers were motivated by pride in their work, public recognition, positive appraisal by their supervisors and teamwork. WP2: Twenty-two policy documents on maternal health in Uganda, African region and globally were retrieved from an internet-based search and analysed. Between June and August 2014, we conducted interviews with 18 policy makers selected from the Ugandan Ministry of Health, Professional organisations, the Parliament, International agencies, Non- governmental organisations, Private not for profit providers and District Health Officers . Key Findings: There was concerted effort to increase access to skilled attendance at birth eg through increased skills training in midwifery, scholarships and bonding, introduction of the comprehensive nurse midwife cadre, expansion of physical Infrastructure, improvement of medicines and supplies distribution. Despite this effort, there was slow increase in skilled birth attendance and the 5th MDG target was not attained. Several bottlenecks were experienced eg. Health worker recruitment and deployment was slow. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood bank infrastructure, and several health facilities were not fully functional. WP3: Between June and August 2014, we conducted twenty nine interviews with health facility providers of obstetric care at eleven health facilities in Mpigi and Rukungiri districts. Four focus group discussions were held with mothers that had recently delivered. Key findings: Health workers and mothers identified the availability of human, material, financial resources and the interaction between health workers and mothers, among key determinants of the quality of maternity care available at lower level health facilities in Uganda. Some mothers experience discrimination and disrespectful behaviour by some health workers, and develop strategies to navigate the power at play. Improving the quality of maternity care at health centres will require increased resources and orientation of the service to provide woman-centred care. WP4: Four case studies of nationwide interventions to attract, recruit and retain health workers were retrieved. Findings from the Malawi Emergency Human resources program, Nigeria Midwives Service Scheme, Indonesia Village Midwife Program, Zambia Health Worker retention scheme and Uganda?s comprehensive nurse midwife programs were synthesised to document lessons learned. Key Findings: Interventions to attract and retain health workers are multifaceted, and include training, financial and non-financial incentives, professional support and bonding. Several programs appeared to achieve a short to medium term increase in the health workforce and health service delivery. Poor quality of training, supervision and mentoring, retaining health workers in rural areas, bureaucracy during implementation were some of the challenges. Dependence on donor funding, changes in the socioeconomic and political context influence the long-term sustainability of these programs. Expected Outcomes: The evidence generated from this project will be useful to global and national policy makers for the development of implementation strategies to strengthen health systems, and improve the quality of care for mothers and their babies.

The United Nations Global Strategy for Women and Child health 2010 is a renewed call to action to scale up and prioritise a package of high-impact interventions, such as skilled care during childbirth, and strengthen health systems. With three years left before the 2015 target date set by the UN in the millennium development goals, several countries will need to scale up skilled attendance at birth in order to attain the target set at 90% coverage of births by skilled attendants. The overall goal of this project is to build on the existing body of knowledge about factors within the health system and policy environment that influence the provision of basic emergency obstetric care by skilled birth attendants in low income countries. Methods: We utilise a mixed methods approach beginning with a qualitative review of the evidence. Findings from the qualitative review will guide the development of a case study to be conducted in Uganda. Uganda is selected to represent a low income country where skilled bir th attendance is low and with health system challenges. Objectives:1.To identify the broad range of factors which promote or prevent the delivery of basic emergency obstetric care by skilled birth attendants in low and middle income countries. 2.To stu dy the influence of the policy environment on recruitment, deployment, regulation and retention of skilled birth attendants in Uganda 3.To explore in depth the barriers and facilitators at the micro level that influence provision of basic emergency obste tric care at the primary levels of the health system 4. To compare the findings from the Uganda case study with other regions and global initiatives. Expected Results: The evidence generated from this project will be useful to global and national policy makers for the development of policy options and implementation strategies needed to strengthen health systems, and improve the quality of care for mothers and children in low income countries.