The Quality of Skilled Birth Attendants in Nepal: High Aspirations - - PowerPoint PPT Presentation

The Quality of Skilled Birth Attendants in Nepal: High Aspirations and Ground Realities

Ruma Rajbhandari MD MPH Division of Global Health Equity, Brigham and Women's Hospital / Harvard Medical School Academy Health 6-27-2017

Introduction

• “a skilled birth attendant (SBA) is a midwife, physician, obstetrician, nurse or other health care

professional who provides essential and emergency health care services to women and their newborns during pregnancy, childbirth and the postpartum period”

• SBAs widely seen as key to reducing maternal and newborn mortality in low income settings
• Many countries have invested substantial resources on training
• Nepal training program: 2-3 months, over 7000 SBAs trained since 2006 when the National SBA

Policy was enacted

• Institutional deliveries with SBAs have not resulted in substantially better outcomes for women

and their babies (e.g. India’s Janani Suraksha Yojana--Powell-Jackson, JPE 2015)

Introduction

• Discrepancy between access to and outcomes of care, suggests a critical gap in

quality of care provided by SBAs

• We thus examined the level of knowledge and skill retention for SBAs after they

finish training as well as how often they use their skills at their clinical sites

• What proportion met the World Health Organization (WHO) guidelines for

minimum volume needed to retain competency?

Methods

• Nationally representative sample of 511 skilled birth attendants (SBA) in Nepal

as well as the characteristics of the location in which they work.

• Data collected by the NGO, Nick Simons Institute, with the collaboration of the

Nepal Government’s National Health Training Center between 2013-2016

• Follow up and Enhancement Program (FEP)—innovative program actually

following up and mentoring SBAs post training

• Government health facilities (sub-health posts, health posts, primary health

centers and district hospitals)

• Any SBA actively employed by one of these health facilities was included
• SBAs with less than 3 months of training excluded

Methods: Variables studied

• Demographic variables of SBA: age, position (Staff nurse versus auxiliary nurse

midwife), recruitment (temporary versus permanent position)

• Experience of SBA: Months of total nursing experience, months of total SBA

experience

• Training site: NGO supported site versus not
• Facility/Enabling environment: facility type (hospital versus lower level),

composite score of 17 indicators needed for basic emergency obstetric care, district type (mountain, hill, terai)

Methods: Main Outcomes

• Knowledge score (%) on 20 question test
• Clinical skills score (%): demonstration on mannequins and case-based testing
• n various aspects of normal and complicated deliveries (e.g. Partograph,

Normal delivery, Vacuum delivery, Newborn resuscitation, Eclampsia management, Referral, Shock management, Post-partum hemorrhage management)

• Total numbers of deliveries: Includes normal delivery, vacuum delivery,

shoulder dystocia and breech delivery

Count (%) of SBAs Aggregate n=511 (100%) Lower-level facilities* n=383 (75%) Hospitals n=128 (25%) Age mean [SD] Age categories: <29 30-39 40-49 >=50 33 [9] 214 (42%) 181 (35%) 85 (17%) 31 (6%) 33 [9] 161 (42%) 130 (34%) 73 (19%) 19 (5%) 33 [9] 53 (41%) 51 (40%) 12 (9%) 12 (9%) Position: Staff Nurse Auxiliary Nurse Midwife 46 (9%) 465 (91%) 9 (2%) 374 (98%) 37 (29%) 91 (71%) Recruitment: Permanent Temporary 261 (51%) 249 (49%) 185 (48%) 197 (52%) 76 (59%) 52 (41%) Total Nursing Experience, months [SD] 117 [93] 115 [89] 124 [105]

Table 1. Descriptive statistics of skilled birth attendants (SBAs) by facility type

Total SBA Experience, months [SD] 35 [26] Training Site: NGO-supported site Other 83 (16%) 428 (84%) District: Mountains Hills Terai 69 (14%) 158 (31%) 284 (56%) Table 1 (cont). Descriptive statistics of skilled birth attendants (SBAs) by facility type Count (%) of SBAs Aggregate n=511 (100%) Lower-level facilities* n=383 (75%) Hospitals n=128 (25%) 34 [25] 36 [31] 56 (15%) 327 (85%) 27 (21%) 101 (79%) 54 (14%) 127 (33%) 202 (53%) 15 (12%) 31 (24%) 82 (64%)

Poor infrastructure and underutilization

Inpatient ward Delivery bed Operating room Store room

Bajhang District Hospital, Far-Western Development Region, Nepal

Delivery bed Inpatient ward

Table 2. Key enabling environment index scores (%) by facility type Aggregate n=492 Lower-level facilities n=364

§

Hospitals n=128 Total Score, % [SD] 83 [10] 81 [10] 89 [7] General Requirements Electricity Water Toilet 458 (93%) 384 (78%) 113 (23%) 331 (91%) 273 (75%) 80 (22%) 128 (100%) 113 (88%) 35 (27%)

§§§Note that the “n” is smaller here due to missing data regarding environmental factors for some lower level health facilities.

Table 2 (cont). Key enabling environment index scores (%) by facility type Aggregate n=492 Lower-level facilities n=364

§

Hospitals n=128 Routine Delivery Care Partograph Fetoscope Baby weighing machine Blood pressure instrument Soap Gloves Autoclave Standard delivery set 428 (87%) 492 (100%) 487 (99%) 477 (97%) 477 (97%) 487 (99%) 453 (92%) 133 (27%) 302 (83%) 364 (100%) 360 (99%) 360 (99%) 357 (98%) 364 (99%) 328 (90%) 87 (24%) 125 (98%) 128 (100%) 128 (100%) 120 (94%) 122 (95%) 128 (100%) 127 (99%) 49 (38%)

Table 2 (cont). Key enabling environment index scores (%) by facility type Aggregate n=492 Lower-level facilities n=364

§

Hospitals n=128 Basic EmONC* Oxytocin Vacuum delivery set Tear repair set MgSO4* Newborn resuscitation set I.V. set 487 (99%) 246 (50%) 403 (82%) 458 (93%) 458 (93%) 467 (95%) 360 (99%) 124 (35%) 288 (79%) 331 (91%) 328 (90%) 349 (96%) 128 (100%) 120 (94%) 115 (90%) 128 (100%) 128 (100%) 119 (93%)

SBA Testing

PAPER-BASED KNOWLEDGE TEST AND CLINICAL SKILLS ON MANNEQUINS

Aggregate n=511 Lower-level facilities* n=383 Hospitals n=128 Knowledge Score, total [SD] 75 [12] 74 [12] 78 [11] Clinical Skills Score, total [SD] Partograph Normal delivery Vacuum delivery Newborn resuscitation Eclampsia management Referral Shock management Post-partum hemorrhage management 48 [1] 42 [28] 55 [19] 26 [28] 52 [25] 51 [24] 35 [24] 35 [21] 84 [17] 46 [15] 40 [27] 55 [19] 22 [27] 51 [25] 50 [24] 36 [24] 33 [20] 83 [17] 51 [16] 48 [28] 56 [22] 39 [29] 53 [25] 54 [24] 32 [23] 40 [22] 87 [15]

Low levels of knowledge and clinical skills in SBAs

Volume of deliveries

VOLUME AS A QUALITY MEASURE

Low rates of deliveries by trained SBAs

• 14% of the SBAs had

conducted 0 deliveries in the last 3 months

• 42% were conducting less

than 4 deliveries per month

• Only 7% were conducting >15

deliveries per month (WHO recommendation to maintain competence)

70 (14%) 214 (42%) 189 (37%)

38 (7%)

Breakdown of SBAs by Monthly Deliveries Performed

< 4 4 to 15 > 15 deliveries/month

Low rates of complications managed by SBAs over a three month period

SBA Training at an NGO-supported training site predicts higher numbers of deliveries conducted Total deliveries (Adjusted) β (95% CI) p value Training at NGO-supported Site 5.99 (3.06 to 8.92) <0.0001 Facility Type (hospital) 5.06 (2.18 to 7.95) 0.001 District: Mountains Hills Terai ref 1.60 (-1.92 to 5.12) 5.19 (1.95 to 8.44) 0.372 0.002

Additional variables included in the model which were not significant were age, position (ANM versus staff nurse), recruitment status (temporary versus permanent), total months of nursing and total months of SBA experience, knowledge score, clinical skills score, expected deliveries at health facility based on reproductive age women in the cachement population

Presence of an enabling environment and temporary recruitment status of SBAs predicts higher numbers of deliveries

Lower-level facilities Hospitals β (95% CI) p value β (95% CI) p value Age Range 0-29 30-39 40-49 50+ ref

• 0.57 (-1.83 to 0.68)
• 1.39 (-3.39 to 0.61)
• 3.60 (-6.76 to -0.43)

0.367 0.173 0.026 ref 3.94 (-6.76 to 14.63) 19.14 (-0.71 to 39.00) 12.01 (-20.28 to 44.30) 0.467 0.059 0.463 Recruitment (temporary) 1.95 (0.69 to 3.22) 0.003 1.04 (-7.80 to 9.88) 0.816 Training at NGO-supported Site

• 1.28 (-2.74 to 0.18)

0.086 17.77 (8.09 to 27.45) <0.0001 Presence of Key Enabling Indicators 0.46 (0.12 to 0.80) 0.007 0.89 (-2.64 to 4.43) 0.618 District: Mountains Hills Terai ref 1.37 (-0.26 to 2.99) 2.90 (1.34 to 4.47) 0.099 <0.0001 ref 3.97 (-9.25 to 17.19) 11.57 (-0.09 to 23.22) 0.553 0.052

Additional variables included in the model which were not significant were position (ANM versus staff nurse), total months of nursing and total months of SBA experience, knowledge score, clinical skills score, expected deliveries per SBA based on reproductive age women in the cachement population

Conclusion

• Trained SBAs performed poorly in terms of knowledge and clinical skills
• Fewer than 1 in 10 SBAs are delivering enough babies to meet the WHO criteria for minimal

competence (15 deliveries per month)

• 14% of the SBAs had conducted 0 deliveries in the last month
• Predictors of higher numbers of monthly deliveries included:
• status as a temporary SBA
• training at an NGO supported training site
• higher enabling environment score for the health facility at which the SBA was posted
• While countries like Nepal have made important investments in SBA programs, these healthcare

workers are failing to receive effective enough training or sufficient practice to stay clinically competent and knowledgeable in the field

• This could in part explain why institutional deliveries have generally failed to deliver better outcomes for

pregnant women and their babies.

Implications for Policy or Practice

• Regular post-training follow-up is critical
• High proportion of SBAs conducting zero average monthly deliveries challenges the value of

quota-drive targets for SBA training

• Vast majority of SBAs oversaw normal deliveries, with fewer than 15 percent managing

complicated deliveries, particularly at lower level facilities--?bypassing of lower level facilities

• Vacuum delivery sets collecting dust at lower level facilities
• Temporary contract nurses more productive in terms of delivery volume than permanent

nurses in the government systems--?increase recruitment of such temporary nurses

• An enabling work environment is important: SBAs need the basic structural tools to carry out

the work that the have been trained to do

Thank you

• Nick Simons Institute (Follow-up and Enhancement Program Team)
• Shovana Rai
• Rita Thapa
• All others involved with FEP development, refinement, data collection
• Dr. Anil Shrestha
• Sejal Hathi, Stanford University
• Ashish Jha MD, Harvard Chan School of Public Health

Total Delivery (Unadjusted) Total delivery (Adjusted) b (95% CI) p value b (95% CI) p value Age Range 0-29 30-39 40-49 50+ ref

• 0.07 (-2.36 to 2.21)

1.25 (-1.65 to 4.15)

• 1.85 (-6.19 to 2.50)

0.951 0.399 0.404 ref 0.56 (-2.15 to 3.27) 3.29 (-1.15 to 7.73)

• 2.69 (-9.69 to 4.30)

0.684 0.146 0.449 Position (ANM)

• 2.67 (-6.16 to 0.81)

0.133 1.39 (-2.80 to 5.59) 0.515 Recruitment (temporary) 0.54 (-1.46 to 2.55) 0.595 1.40 (-1.23 to 4.03) 0.296 Total Months of Nursing Experience

• 0.001 (-0.01 to 0.01)

0.821

• .005 (-0.03 to 0.02)

0.664 Total months of SBA Experience 0.02 (-0.02 to 0.06) 0.309 0.03 (-0.02 to 0.07) 0.256 Total Knowledge Score (%) 0.09 (0.01 to 0.17) 0.035 0.04 (-0.06 to 0.15) 0.392 Total Clinical Skills Score (%) 0.06 (-0.01 to 0.12) 0.093

• 0.02 (-0.10 to 0.06)

0.636 Training at NSI Site 4.84 (2.16 to 7.52) <0.0001 5.99 (3.06 to 8.92) <0.0001 Presence of Key Enabling Indicators 1.17 (0.57 to 1.77) <0.0001 0.41 (-0.34 to 1.16) 0.281 Facility Type (hospital) 6.08 (3.83 to 8.32) <0.0001 5.06 (2.18 to 7.95) 0.001 District: Mountains Hills Terai ref 0.85 (-2.36 to 4.06) 4.86 (1.88 to 7.85) 0.602 0.001 ref 1.60 (-1.92 to 5.12) 5.19 (1.95 to 8.44) 0.372 0.002 Expected deliveries per SBA 0.08 (0.03 to 0.12) <0.001 0.03 (0.01-0.08) 0.124

Table 7. Multivariate regression analysis of predictors of total delivery, by facility type