Introduction
Skilled attendance at birth is believed to prevent maternal and neonatal mortality during labour, delivery and the early postnatal period via effective care provided by trained and competent health personnel in an environment equipped with the necessary drugs and equipment.1–3 The percentage of live births attended by specified cadres of health personnel (eg, midwives) is widely used to measure skilled birth attendant (SBA) coverage and is a key proxy indicator for monitoring progress in reducing maternal mortality (see box 1). While household surveys, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), have measured delivery with medically trained personnel (doctor, nurse or midwife) since the 1980s and 1990s, SBA coverage was first tracked globally during the Millennium Development Goal (MDG) era (2000–2015), and remains an indicator on the Sustainable Development Goal (SDG) and Global Strategy for Women’s Children’s and Adolescents’ Health agenda. Yet, the discrepancy between increasing SBA coverage and lagging improvements in maternal and neonatal mortality in many low-income and middle-income countries (LMICs) has brought increasing attention to the challenge of SBA measurement and the indicator’s limitations in capturing effective, life-saving care.4–7 Amidst increasing calls to move away from measuring contact with the health system toward capturing quality of care,8 a critical review and reflection on SBA coverage measurement is needed.
Definition and calculation of the SBA coverage indicator
What is the ‘SBA’ indicator?
The ‘proportion of births attended by skilled health personnel’, commonly referred to as ‘SBAs’, is an SDG indicator (Indicator 3.1.2) and is one of the five indicators tracked by leading maternal and newborn health global initiatives.37 The SBA indicator is classed as a Tier 1 SDG indicator, in that it is considered conceptually clear, has an internationally established methodology and is reported for >50% of countries.38
How is SBA coverage calculated?
Coverage is calculated as the number of live births attended by skilled health personnel expressed as a percentage of the total number of live births in the same period.9 39 Many low and lower-middle income countries use household surveys with women’s self-reports of delivery with particular health personnel to track SBA coverage. Women may respond with multiple attendants but only the ‘most skilled’ provider from the response options selected is used to calculate SBA coverage. Survey recall periods usually vary from 2 years (MICS) to up to 5 years before the interview (DHS).32
In 2004, the WHO, along with the International Confederation of Midwives (ICM) and the International Federation of Gynaecology and Obstetrics (FIGO) defined the core skills and training required for skilled attendants.1 WHO considered the statement to be a policy document and has indicated it was not intended to serve as a basis for measurement.9 Shortages of midwifery-trained personnel led many LMICs to ‘upskill’ mid to low level health cadres to expand the range and numbers of health personnel they considered to be SBAs to address gaps in coverage.10–12 There are concerns that the length and quality of training may be insufficient,9 12 that large gaps exist between international standards and actual provider competencies and practices13 14 and that the lack of standardisation in cadre names, training and competencies make cross-country comparisons challenging.10 15 16
In the transition from the MDG to the SDG era, WHO, Unicef and United Nations Population Fund (UNFPA) undertook a process of revising the definition of SBA. The resulting 2018 joint statement expanded the 2004 statement to consider eight competencies essential for improving the quality of care received by women and newborns.2 The competency related to intrapartum care was identified as the one specifically relevant to SDG monitoring; it defined a competent maternal and newborn health (MNH) professional as someone who (1) provides and promotes evidence and human rights-based, quality, socioculturally sensitive and dignified care to women and newborns; (2) facilitates physiological processes during labour and delivery to ensure a clean and positive childbirth experience and (3) identifies and manages or refers women and/or newborns with complications.2 The care competencies include all signal functions of emergency obstetric and newborn care that could be provided by an integrated team of MNH professionals, and the 2018 joint statement noted the importance of the enabling environment to the provision of quality maternal and newborn healthcare.2 9
The 2018 joint statement also acknowledged that it was a first step towards improved measurement and called for household surveys and administrative data collection methods at the country level to be revised to support ‘meaningful measurement’ of SBA coverage.2 In parallel to the process of reviewing the definition of SBA, Unicef and WHO convened experts on several occasions between 2016 and 2018 to reflect on global tracking of SBA coverage. The aim was to improve measurement of the SBA indicator, and distinguishing which healthcare providers were ‘skilled’ for the purposes of the indicator and improving country-level reporting.2 9 To understand what this means in practice, we need to unpack what women can tell us and how the SBA indicator is currently generated via population-based surveys.17 Then, we can consider the implications of the WHO definitions (2004 and 2018 versions) on meaningful measurement of SBA coverage and effective tracking of progress in MNH. We acknowledge that country-level monitoring needs may differ from what is measured at the global level, but here we focus on the challenges and implications for global tracking of SBA coverage. In this paper, we aim to (1) systematically collate and synthesise published evidence on whether women can accurately recall the person(s) assisting with delivery, (2) describe methodological considerations and points of improvement around how SBA coverage is estimated from DHS and MICS and (3) suggest ways forward in conceptualising SBA coverage and measuring care received by women and newborns.