Skilled attendant at birth mDG 5, target 5A, Indicator 5.2 Workshop on MDG monitoring to 2015 and beyond Bangkok 9-13 July 2012 Liliana Carvajal UNICEF

MDG 5 – Improve maternal health Target 5.a – Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Indicator 5.2– Proportion of births attended by skilled health personnel

Skilled attendant at birth Background, definitions and relevance National and regional perspective Measuring the standard indicator Summary of methodological challenges

Skilled attendant at birth Background, definitions and relevance National and regional perspective Measuring the standard indicator Summary of methodological challenges

Background Every year…. 287,000 maternal deaths For each maternal death 20 women suffer injuries or disabilities related to pregnancy/childbirth Approximately 3 million neonatal deaths Greatest mortality risk for both mothers and children is during delivery and immediately after birth

Who is a skilled attendant? A skilled attendant is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and 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. Traditional birth attendants, who are not formally trained, do not meet the definition of skilled birth attendants. Source: 2004 Joint statement by WHO, ICM and FIGO, endorsed by UNFPA and the Word Bank

Why does it matter? The presence of a trained health-care worker during delivery is crucial in reducing maternal deaths. The single most critical intervention for safe motherhood is to ensure a skilled birth attendant is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A skilled health professional can administer interventions to prevent and manage life-threatening complications, such as heavy bleeding, or refer the patient to a higher level of care when needed.

Skilled attendant at birth Background, definitions and relevance National and regional perspective Measuring the standard indicator Summary of methodological challenges

Asian countries – coverage of skilled attendance at delivery around * Latest data value is for 2005, 2006

Skilled attendant at birth Proportion of births attended by skilled health personnel, around 1990 and around 2009 (Percentage) Developing regions – moderate progress from 55 per cent in 1990 to 65 per cent in 2009. Sub-Saharan Africa and Southern Asia: substantial progress but more needs to be done as the majority of maternal deaths occur in these regions. Source: MDG report 2011

Skilled attendant at birth Background, definitions and relevance National and regional perspective Measuring the standard indicator Summary of methodological challenges

Standard Indicator Skilled attendant at delivery Proportion of women age 15-49 years with a live birth in the 2 years preceding the survey who were attended during childbirth by skilled health personnel Note: Skilled provider means: Doctor Nurse Midwife (and auxiliary midwife when appropriate) Services = Blood pressure Urine sample Blood sample IPTp (if relevant)

Sources The proportion of births attended by skilled health personnel is typically calculated from data collected through national household surveys including: Multiple Indicator Cluster Surveys (MICS) Demographic Health Surveys (DHS), Reproductive Health Surveys and sometimes from data collected from administrative registrations.

Eligibility Women of reproductive age (15-49 years) Live birth in the two or five years preceding interview

Household survey – women’s questionnaire Who assisted with the delivery of your last baby? Skilled birth attendants

Household survey – women’s questionnaire Multiple categories of skilled personnel Questionnaires need to be adapted carefully at the country level Do these additional categories meet the standard to be considered skilled?

Reporting of skilled attendants Bangladesh example: Medically trained providers include - Qualified doctor, Nurse/midwife/paramedic, Family welfare assistant FWV, Community skilled birth attendant CSBA Are all these categories skilled? For global reporting, confirmation from countries is needed for extra categories

Reporting of skilled attendants Bhutan example: Skilled providers include - doctor, nurse/midwife, health assistant/basic health worker HA/BW or assistant clinical officer ACO. Are all these categories skilled? For global reporting, confirmation from countries is needed for extra categories

Skilled attendant at birth Background, definitions and relevance National and regional perspective Measuring the standard indicator Summary of methodological challenges

Summary of methodological challenges Type of health provider - birth attendant is skilled or not? Questionnaires - coding categories need to be adapted in country MDG indicators – maintain broad coding categories for comparability Direct communication with country office to ensure correct interpretation for global reporting Maintain the broad categories Doctors, nurses midwives and auxiliary midwives are skilled health personnel who have midwifery skills to manage normal deliveries and diagnose or refer obstetric complications. For SAB the specific provider needs to be specified – needs to be adapted properly within countries to ensure that the categories that are included –usually MOH capture the main service providers and are recognized by respondents. The current number of skilled attendants is critically insufficient. An estimated 700 000 midwives are needed worldwide to ensure universal coverage with maternity care, but there is currently a 50% shortfall. In addition, 47 000 doctors with obstetric skills are required, particularly in rural areas.(5) Worldwide, 4.3 million health workers are lacking.(8) Given the global shortage of health workers, existing human resources need to be employed most effectively and new health workers need to be recruited. Further, new resources must be raised to recruit, train and retain additional health workers with midwifery skills. This also means providing more incentives to work in midwifery such as satisfactory pay scales, improved status and respect within the health system and career advancement opportunities. They also need adequate equipment, supplies and medicines to help women and babies. However, training programmes for traditional birth attendants have failed to reduce maternal mortality in the past. The short trainings were not adequate to teach an otherwise unqualified person the critical thinking and decision-making skills needed to practice.

Thank you! www.childinfo.org Prepared by: Liliana Carvajal / Statistics and Monitoring Section, UNICEF/New York lcarvajal@unicef.org www.childinfo.org