Community-based skilled birth attendants in Bangladesh: attending deliveries at home

Abstract

Only 15% of births in Bangladesh in 2007 were delivered at health facilities, but the increase over previous years has been significant, and treatment-seeking from a medically trained provider for obstetric complications has also increased. A programme to create a cadre of skilled birth attendants for home births was launched by the Government of Bangladesh in 2004. The training, for community-based health and family planning fieldworkers, covers 74 essential midwifery skills and danger signs for referral. Training of trainers and supervisors for the fieldworkers was also initiated. By the end of 2008 an estimated 4,000 out of a proposed 13,500 skilled birth attendants and 50 of 4,000 proposed supervisors had been trained and were working in 56 districts. There needs to be a full evaluation of the programme and whether it has reduced maternal deaths. Bangladesh now needs to decide how long to invest in this programme and/or whether to train a new cadre of fully qualified midwives, as proposed by the Nursing Council. We believe this programme can only be an interim measure, not a long-term solution, as more women decide to seek institutional delivery and professional midwifery care. For the moment, though, task-shifting seems to have yielded beneficial results and important insights into human resources planning for safe motherhood in Bangladesh.

Résumé

Au Bangladesh, en 2007, 15% seulement des naissances avaient eu lieu dans un établissement de santé, mais la hausse par rapport aux précédentes années était sensible et le recours aux services d'un prestataire formé médicalement pour les complications obstétricales avait aussi augmenté. En 2004, le Gouvernement a lancé un programme de création d'un groupe d'accoucheuses qualifiés pour les naissances à domicile. La formation des agents de santé et de planification familiale communautaires couvre 74 compétences obstétricales essentielles et les signes de danger exigeant le transfert de la patiente. La formation des formateurs et des superviseurs des agents de terrain a aussi été lancée. Fin 2008, environ 4000 des 13 500 accoucheuses qualifiés envisagés et 50 des 4000 superviseurs prévus avaient été formés et travaillaient dans 56 districts. Il faut mener une évaluation complète du programme et déterminer s'il a diminué les décès maternels. Le Bangladesh doit maintenant décider pendant combien de temps investir dans ce programme et/ou s'il souhaite former un nouveau groupe de sages-femmes pleinement qualifiées, ainsi que l'a proposé le Conseil des infirmières. Nous pensons que ce programme ne peut être qu'une mesure provisoire et non une solution à long terme, à mesure que davantage de femmes opteront pour un accouchement institutionnel et des soins de sages-femmes professionnelles. Pour le moment, néanmoins, la délégation des tâches semble avoir produit des résultats positifs et des connaissances précieuses sur la planification des ressources humaines pour une maternité à moindre risque au Bangladesh.

Resumen

En 2007, sólo el 15% de los partos en Bangladesh ocurrieron en establecimientos de salud. En comparación con años anteriores, este porcentaje ha aumentado considerablemente, al igual que la búsqueda de tratamiento de complicaciones obstétricas brindado por un profesional médico capacitado. En 2004, el Gobierno de Bangladesh lanzó un programa para crear una categoría de asistentes de partos calificados que ayudaran con los partos domiciliares. La capacitación de trabajadores comunitarios de la salud y de planificación familiar, abarca 74 habilidades esenciales de partería y los signos de alarma para dar referencias. También se inició la capacitación de capacitadores y supervisores de los trabajadores de campo. A finales de 2008, aproximadamente 4,000 de los 13,500 asistentes de partos calificados y 50 de los 4,000 supervisores propuestos habían recibido capacitación y estaban trabajando en 56 distritos. Es necesario realizar una evaluación completa del programa y determinar si éste ha logrado disminuir la tasa de muertes maternas. Bangladesh debe decidir por cuánto tiempo continuar invirtiendo en este programa y/o si capacitar a un nuevo grupo de parteras profesionales plenamente cualificadas, como propone el Consejo de Enfermería. Estimamos que este programa es sólo una medida provisional, no una solución de largo plazo, ya que cada vez más aumenta el número de mujeres que deciden buscar atención institucional y cuidados de partería profesionales. No obstante, por ahora la reasignación de tareas parece haber dado buenos resultados e importantes datos sobre los recursos humanos en la planificación de la maternidad sin riesgos en Bangladesh.

Key Words:

• mid-level providers
• skilled birth attendants
• community-based programmes
• maternal mortality
• Bangladesh

In Bangladesh maternal mortality rates are among the highest in the developing world. According to the Bangladesh Maternal Health Services and Maternal Mortality Survey 2001, the maternal mortality ratio in Bangladesh was estimated at 320–400 per 100,000 live births.¹ This means an estimated 12,000 women's deaths annually from pregnancy-related causes. Since the 2001 survey, there have been reports of a gradual decline in maternal deaths (the next national survey is due in 2009). For example, the MDG mid-term Bangladesh Progress Report 2007 states that “there has been adequate success in reducing maternal mortality from 574 deaths per 100,000 live births in 1991 to 290 in 2006, against the target of 298 in 2006.”²

In an agrarian economy like Bangladesh, with low literacy, poverty, low status of women and high traditional values, many pregnant women have difficulties coming to deliver at a clinic or hospital. However, according to the 2007 Bangladesh Demographic and Health Survey (DHS), although only 15% of births were delivered at health facilities in that year, the increase over previous years has been significant. The proportion of deliveries at facilities was reported at 4% in the 1993–94 Bangladesh DHS and 9% in the 2004 Bangladesh DHS. In addition, treatment-seeking from a medically trained provider for obstetric complications increased from 29% to 42% in the three years up to the 2007 DHS,³ indicating enhanced demand from women. Nevertheless, 85% of women are still delivering at home.

Faveau et al reported in 1991 that maternal survival can be improved by posting midwives at the community level with close monitoring and supervision.⁴ The need to create a cadre of providers skilled in safe delivery at home births was recognised by the Ministry of Health and Family Welfare, Government of Bangladesh, based on the findings of a Needs Assessment Study done by WHO in 2001.⁵ There was a reluctance to revisit the traditional birth attendants programme, especially after the WHO report that training traditional birth attendants alone did not help in decreasing maternal deaths.⁶ Instead, the government took the initiative in 2003 to retrain community-based female fieldworkers (family welfare assistants and female health assistants) in midwifery skills and identifying danger signs for referral. This cadre, who are already known at village level and accountable to their government supervisors, have been providing family planning methods, such as oral contraceptives and condoms, and advising on sanitation and preventive health measures. The government made a commitment to train 13,500 skilled birth attendants by 2010 and to increasing the rate of deliveries assisted by these attendants from 13% to 50% by 2010, as per the Bangladesh National Maternal Health Strategy 2001.⁷

This rural woman gave birth assisted by an untrained TBA. The placenta was not delivered. It took three hours by boat and riksja for her to reach the sub-district health complex, which had no blood supply, and then three hours by taxi to the regional hospital. By then, she had lost 2.5 litres of blood and was in a critical condition. Bangladesh, 2002

The training programme

WHO, UNFPA and the Obstetric and Gynecological Society of Bangladesh assisted the government to design the training programme. The selection of trainees is done through a review of candidates' profiles and an interview, in which they are screened on the basis of criteria that include their willingness to stay and serve the community with midwifery services. The training programme was designed through a consultative process with professionals from different training institutions, such as the Azimpur Maternal and Child Health Training Institute and Institute of Child and Maternal Health at Matuail, the Bangladesh Nursing Council, the Obstetrics and Gynecological Society of Bangladesh, UNFPA and WHO. The six-month course is intensive and competency-based, and stresses both clinical and community practice.

Seventy-four essential skills were included in the curriculum from among the skills recommended by the Safe Motherhood Inter-Agency Group 2001. The curriculum provides theoretical and practical knowledge for counselling and essential obstetric skills in antenatal care, childbirth and post-partum care for the woman and her newborn, including identifying complications requiring referral. The trainees are also taught to motivate women, their households and neighbours to use their services through regular courtyard meetings, where they explain the need for skilled attendance and care for pregnant women. The trainees are examined and certified as skilled birth attendants by the Bangladesh Nursing Council. Only those centres having at least 100 deliveries a month are considered for providing this training. These centres must also have good organisational arrangements, including administrative and financial controls, adequate classrooms, training aids and a dormitory. An appropriate ratio of trainers to trainees must also be present. Two-thirds of the trainers must be clinical trainers and have passed the Training of Trainer's course.

To reinforce the skills of the attendants, a three-month additional course on management of bleeding in pregnancy, childbirth and post-partum, and dealing with unexpected problems and difficult deliveries, medical disorders and other factors contributing to complications, including infections in mother and newborn, was approved by the Nursing Council in 2007.⁸ Community-based skilled birth attendants who have spent at least nine months in the community after training are eligible for the additional course. To date, 205 skilled birth attendants have attended it.⁹

The training of trainers' programme is a two-week course run at the Maternal and Child Health Training Institute at Azimpur and the Institute of Child and Maternal Health at Matuail, where batches of 15 trainers from the districts are trained. These trainers are from the district hospitals, the Maternal and Child Welfare Centres and from the administration of family planning and health departments. The training is conducted by master trainers who are senior professors of medical colleges or nursing faculty.

Technical supervision is of critical importance if the skilled attendants are to achieve and maintain quality of care. Training of female paramedics (family welfare visitors) as technical supervisors was initiated in 2008 at the National Institute of Population and Research Training. These paramedics have already received 18 months of pre-service training on primary health care, maternal health, pregnancy, delivery, newborn care, family planning services and counselling, and an additional six months in-service training on midwifery for which a curriculum has been developed by the Directorate General of Family Planning under the Ministry of Health and Family Welfare. They get an additional two weeks' training in supervisory techniques. They are the logical supervisors as the fieldworkers also receive technical supervision from these paramedics for community-based family planning services.¹⁰

The pilot programme

The pilot programme for the community-based skilled birth attendants was initiated in 2003. Ninety fieldworkers were selected from six districts for training. Prior to this the curriculum was prepared and master and national trainers were trained. The entire training programme was supervised by both government officials, WHO and the Obstetrics and Gynaecological Society of Bangladesh. The first batch of pilot trainees received their certificates the same year and reported back to their places of duty to perform their work as community-based skilled birth attendants. The pilot programme was evaluated in 2004, assessing the training programme as well as the performance of the trained women. Nine master trainers,15 district trainers and 86 community-based skilled birth attendants were interviewed and the performance of 12 of the trained attendants was observed at their duty stations.

The evaluation of the pilot programme focused on performance, both in terms of coverage of services (number and proportion of women covered) and quality (efficiency and effectiveness) of services rendered, the latter measured in terms of women's satisfaction. In addition, selected performance indicators were analysed, comparing the trained skilled birth attendants with other cadres, including doctors, paramedics and traditional birth attendants giving pregnancy and delivery care and services in selected communities. The evaluation revealed that the 86 trained community-based skilled birth attendants were attending 29% of home deliveries, performed 52% of antenatal check-ups recorded and 44% of post-natal check-ups recorded. Some 91% of 288 women in the area covered who used the services provided were fully or fairly satisfied. The women were village women from different income groups, with a family income ranging from Taka 1,000–25,000 per month (equivalent to US$17–417). Of the 49% of women surveyed who wanted another child, 60% said they preferred to have their next deliveries with a community-based skilled birth attendant.¹¹

Progress to date

After the positive evaluation, the government decided to scale up the programme nationwide. Gradual escalation has been carried out, adding an average of 10 districts per year. During the years 2006–2008, reports received from 1,739 community-based skilled birth attendants showed that they had delivered over 65,000 babies and referred 21,000 women needing medical care.¹² These attendants had not been conducting deliveries prior to their training; the women had previously been delivered either by traditional birth attendants or relatives.²

After the first batch of pilot trainees had received their certificates, no formal graduation ceremony was held for the new trainees in the scaled-up programme. So a special certification ceremony was held on 28 November 2007 in Dhaka, where 2,500 community-based skilled birth attendants received their certificates from senior government officials.

By the end of 2008 there were an estimated 4,000 community-based skilled birth attendants who had been trained since the inception of the programme, which had by then been expanded to 56 of the 64 total districts. Annually, around 1,000 women receive resident competency-based training. Yet the country needs at least two community-based skilled birth attendants per union (lowest level of public service delivery centres, catering for a population of 20,000) as per the National Maternal Health Strategy 2001, or a total of 13,500 community-based skilled birth attendants, by 2010.⁹ This means there are still another 9,500 to train in 2009–2010, which is hardly possible, not least because of the strict criteria for selection of the training centres.

Some 50 family welfare visitors are now trained in supervisory techniques, out of 4,000 currently working in the country. Since there should be one of this cadre per union, training of the remaining 3,950 women is required. Many of these paramedics are on the verge of retirement and replacements need to be recruited. Furthermore, the supervisory training has been slow to take off due administrative bottlenecks. Both problems need attention.

The issue of reporting to the national Management Information System is being addressed by a pilot intervention in one district, with the support of the Japan International Cooperation Agency, which aims to enhance the quality of monitoring and documentation of the services.¹³

Next steps

There needs to be a full evaluation of the intervention. Lessons learnt and best practices need to be documented. A primary question is whether or not the increasing number of referrals to Upazilla (sub-district) health complexes, maternal-child welfare centres and district hospitals has reduce the ratio of maternal deaths and morbidity. The effect of the additional workload on the trained community-based fieldworkers also needs to be monitored, to ensure that the fieldworkers are not being overburdened and that there is no detrimental effect on the provision and supervision of family planning services. A quantitative and qualitative review can answer these questions, and was being planned at this writing.

Many challenges still remain as Bangladesh moves on to provide more skilled attendance at home and institutional delivery. Though no defined policy has yet been formulated, a recent position paper, Proposed Strategic Directions, by the Directorate of Nursing,¹⁴ has been published, which discusses whether to create a full midwifery cadre and explores the different options open to Bangladesh to achieve a reduction in maternal mortality. In the interim, women need skilled assistance for safe delivery and neonatal care, which the community-based skilled birth attendants are providing. As more skilled attendants are trained, an increasing number of mothers will get these services, and the referral load will also increase. Basic emergency obstetric care must be available at the union level and comprehensive emergency obstetric care at the Upazilla level. These service delivery points need to be strengthened, to be ready for the increased load – as well as transportation links improved in this riverine and flood-prone country.

Non-governmental agencies like the Bangladesh Rural Advancement Committee and the International Centre for Diarrhoeal Disease and Research, Bangladesh, have placed requests to the Director General of Health Services, Ministry of Health and Family Welfare and UNFPA to carry out training and research. Research is essential to explore which models work and in what situations.

In the MDG Mid-term Bangladesh Progress Report 2007,² the Government acknowledges that Bangladesh faces serious challenges in achieving MDG 5 and other targets. One of the reasons cited is weak governance in the delivery of basic health care services, including maternity care, and that the poor are not benefiting from the development process. Research has also shown that shifting care from home to institution level might lead to increased inequities in access. Therefore government maternity care policy has stressed bringing care to the community.¹⁵ The re-training and utilisation of fieldworkers as skilled birth attendants is a reflection of the government's concern about the urgency of this situation. No cadre of midwives (as against nurse–midwives) exists in Bangladesh today. The growing number of home deliveries now being attended by community-based skilled birth attendants highlights the fact that Bangladeshi women are still happy to deliver at home. However, Bangladesh now needs to decide how long to invest in this programme and/or whether to train a new cadre of fully qualified midwives, as proposed by the Nursing Council.¹⁶

We believe that the cadre of community-based skilled birth attendants may not be the best solution to the problem of safe maternity care for the country in the long term and should only be an interim measure. We see it as a transitional model, which will be forced to change as more women decide to seek institutional delivery and professional midwifery care. For the moment, though, task-shifting seems to have yielded beneficial results as well as important insights into human resources planning for safe motherhood in Bangladesh.