1. Skilled Birth Attendants, Traditional Birth Attendants & Intrapartum Care Karen Hays, CNM, DNP-c GH 544 January 6, 2011

2. Clinical Activities: Maternal-Newborn Care

3. “A skilled attendant at childbirth is the most effective intervention…” But what is skilled? photo of WHO Safe Motherhood book WHO 1999.

4. Skilled Birth Attendant (SBA) W.H.O. Definition An accredited health professional (e.g., a midwife, physician, or nurse) who has been educated & trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, & in the identification, management, and referral of complications in women & newborns.

5. An Accredited Health Professional… Accredited – does that mean licensed? board certified? registered? graduate of basic training program? What about upkeep of that credential? 3 photos of different types of skilled attendants: Cambodian nurse/midwife in birth center Rich-country obstetrician Trained traditional midwives in Guatemala

6. …educated & trained to proficiency in the skills… ‘Educated’ & ‘Trained’ – either within their primary MD, MW, RN program or as an extra training after graduation ‘Proficiency’ – to pass the tests in the context of the training; rarely any follow-up in real life work setting ‘The Skills’ – see next slide

7. SBA Skill Set Prenatal Care Intrapartum Care Newborn Care Postnatal Care SBA skill set is standardized based on the country & the SBA’s scope of practice as defined by licensure/registration/tradition/hierarchy

8. Intrapartum Care Infection prevention, patient rapport Uncomplicated labor, birth, & postpartum Normal newborn care (breastfeeding & the Warm Chain) Complication prevention & management –obstructed labor – partograph, vacuum extraction* –pre-eclampsia / eclampsia –postpartum hemorrhage – AMTSL, bimanual compression, manual vacuum aspiration* –neonatal resuscitation –sepsis (mom & baby) –post-abortion care – manual vacuum aspiration* *not always included

9. Rationale for the SBA Skill Set - Moms

10. Rationale for the SBA Skill Set - Babies Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/newborncare.html and based on Lawn, JE et al. ‘4 Million Neonatal Deaths: When? where? why?’ The Lancet, vol. 365, no. 9462, 2005, pp. 891–900.http://www.childinfo.org/newborncare.html

11. Skill Set – Infection Prevention photos of handwashing, gloving, cleaning instruments, etc

12. Skill Set - Patient Rapport Mother-Friendly Childbirth Initiative Lonely women, delivering all over the world…. photos of women laboring alone and looking forlorn

13. SBA Skill Set: Uncomplicated Labor Photos of women and their attendants during labor, in homes & facilities, from several different countries and resource-levels.

14. SBA Skill Set: Uncomplicated Delivery Photos of normal births, at home & in facilities, with different types of attendants in different countries with different resource levels.

15. SBA Skill Set: Uncomplicated Postpartum Photos of placental delivery and moms with their babies soon after birth.

16. SBA Skill Set: Normal Newborn Care Photos of babies being cared for in many different countries

17. SBA Skill Set: Complication Prev & Tx Photos of BPs being taken, women in trouble, book of PPH management, etc.

18. Two Trendy Prevention Strategies 1. The Partograph Graph to be used during Active Labor & 2 nd Stage Charts –vital signs –contraction pattern –cervical dilation –fetal descent –medications given Purpose – to minimize delays in recognizing prolonged labor 2. Active Management of the Third Stage of Labor (AMTSL) Protocol for delivery of the placenta Includes –Use of a uterotonic medication –Controlled cord traction –Abdominal uterine massage after placenta out Purpose – to reduce risk of postpartum hemorrhage (PPH)

20. AMTSL Oxytocin injection is preferred, but misoprostol tablets are okay in places where injection skills & equipment management is not feasible. Early cord clamping is not required for AMTSL. To the right – photo of AMTSL poster from India

21. SBA Skill Set: What’s Missing? Hint: 2 lifesaving medical procedures

22. SBA Skill Set: What’s Missing? Blood Transfusion & Cesarean Section Photo of a C-section and of a woman getting a transfusion

23. Basic vs. Comprehensive Emergency Obstetric Care (EmOC) Basic EmOC for some health centers & all hospitals (SBA+ level care) –antibiotics, oxytocics, anti-convulsants, anti- hypertensives, manual removal of placenta, manual vacuum aspiration Comprehensive EmOC for hospitals with surgical capacity (personnel, O.R., anesthesia) –basic EmOC capabilities –blood transfusions –Cesarean section

24. Why can’t SBAs and EmOC save more lives? Reproductive Health Response in Conflict Consortium ©2005

25. The 3 Delays Model Delay in recognition of a problem Delay in transport to referral facility Delay in proper treatment at the facility Photos of transportation difficulties and a crowded female hospital ward

26. Will the SBA reduce mortality in this setting? Photo of a midwife in a dreadful facility

27. Other reasons for under-utilization of SBAs & EmOC Women fear poor treatment due to political, socio- economic, ethnic, religious, language, etc. problems Facility reputation for poor quality services, long waiting times, exclusion of family, male health care workers Cost Women unable to travel due to security, poor travel conditions, no vehicle, or cultural restrictions Concerns about privacy, social stigma Status of Women – unable to obtain permission from husband, mother-in-law, patriarch Prefer local traditional healers – TBAs, shamans, etc. Fatalism, attribute illness & death to supernatural forces

28. Will the SBA & EmOC reduce mortality for this woman? Photo of an emaciated young mother with 2 small babies in a horrible refugee camp

29. Is a Traditional Birth Attendant (TBA) a Skilled Birth Attendant (SBA)? TBAs are influential in their communities & need to be respected & included in MCH activities, even if non-literate TBAs have a different, overlapping, & complementary skill sets Photos of TBAs from 4 different countries.

30. Integration of TBAs into the Slooow ‘Modernization’ of MCH Services Recognition & Support Education – the 3 cleans (hands, surface for birth, cord cutting) Incorporate into facility services, e.g. Doula role Organize gatherings where TBAs can share knowledge & support Recognize ‘Big Picture’ issues before judging or trying to replace them Photos of TBAs learning hand washing, being doulas in hospital, having a TBA meeting

31. It’s all so worth it! Photo of happy mom with brand new baby on her chest.

32. Websites http://www.internationalmidwives.org http://www.who.int/reproductive- health/global_monitoring/skilled_atten dant.html http://www.paho.org http://www.midwives.org http://www.hesperian.org/index.htm