How Skilled are Our “Skilled” Maternity Care Providers?

In ten years (i.e. by 2030), we should have worked hard enough to decrease the global maternal mortality ratio from 216 to below 70 deaths out of every 100,000 live births in order to meet the Sustainable Development Goal on maternal mortality. One of the indicators for measuring this goal is the proportion of births attended by skilled health personnel, commonly referred to as a skilled birth attendant (SBA). Globally, a major focus of safe motherhood interventions has been to increase the number of deliveries by skilled birth attendants. Skilled birth attendants are typically doctors, nurses, or midwives who have the competence to provide quality care to women and newborns. Skilled birth attendants must have the ability to promptly identify and manage pregnancy, delivery and postpartum complications or refer to an appropriate level of care/health facility. This is important because timely identification and management of complications is critical in decreasing maternal deaths. Most maternal deaths are due to complications such as hemorrhage, hypertensive disorders, infections, and other complications from delivery. Most of these complications can be adequately managed if a woman has timely access to a skilled health professional.

Sub-Saharan Africa has shown progress in the number of births in the region attended by a skilled birth attendant, with 59%  of births between 2012 and 2017 attended by a skilled health professional . Globally, 80% of births are attended by a skilled health professional. There remains work to be done to ensure that more women have access to skilled health professionals during pregnancy, childbirth, and postpartum.

While it is important that women have access to and actually use the services of skilled health professionals, it is equally important that providers actually have the knowledge and skill set to identify and manage women’s conditions appropriately. Poor knowledge of postpartum care and potential complications directly impacts the ability of midwives to provide quality care to patients after childbirth. An important question we must ask is “how skilled are our skilled health personnel?”

Findings from our survey of 245 midwives in Ghana revealed significant knowledge gaps among midwives related to postpartum care and postbirth warning signs, immediate newborn care, and management of complications. Most midwives gave incorrect answers on postpartum care questions related to location of fundus, postpartum examination, and care during the first 2 hours after birth. While most midwives were knowledgeable about breastfeeding and immediate hemorrhage intervention, many lacked knowledge on cord care, thermal protection, newborn resuscitation, contraindications for vacuum extraction, treating metritis, and performing a cervical repair. Our findings also revealed significant knowledge gaps on recognition of warning signs of life-threatening complications such as pulmonary embolism, cardiac events, and postpartum depression. More specifically, only 47.5%, 57.0%, and 57.0% of midwives were able to identify pain in chest, obstructed breathing, and thoughts of hurting oneself as warning signs of postpartum complications respectively.

The postpartum period is high-risk for maternal mortality. There is a need for additional training of midwives in how to care for postpartum patients and accurately identify warning signs of life‐threatening complications after childbirth. We found that more years of experience was a significant predictor of midwives’ knowledge. Thus, there must be comprehensive onboarding training programs for new midwives, as well as frequent in-service trainings on postpartum care, newborn resuscitation, and potential postpartum complications. We will not make significant progress in decreasing maternal deaths if our maternity care providers do not have the supposed knowledge, skills, and confidence to recognize and manage complications in a timely manner.

Published by

Yenupini Joyce Adams

Yenupini Joyce Adams is an Assistant Professor of the Practice and the Global Maternal Research Lead at the Eck Institute for Global Health, University of Notre Dame. Her research passion is to improve maternal health, promote safe motherhood, and decrease maternal mortality and morbidity, especially in Sub-Saharan Africa and U.S, where the burden of maternal mortality is greatest.

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