Who is Assisting Women to Deliver Babies within Health Facilities? An Analysis of Deliveries in Four Provinces in Zambia

Research Article

Austin J Public Health Epidemiol. 2014;1(2): 1007.

Who is Assisting Women to Deliver Babies within Health Facilities? An Analysis of Deliveries in Four Provinces in Zambia

Biemba G1,2,3*, Yeboah-Antwi K1,2, Semrau K1,2, Hammond EE1,3 and Hamer DH1,2,3

1Center for Global Health and Development, Boston University, USA

2Department of Global Health, Boston University School of Public Health, USA

3Zambia Centre for Applied Health Research and Development, Zambia

*Corresponding author: Biemba G, Department of Global Health, Zambia Centre for Applied Health Research and Development (ZCAHRD), 121 Kudu road, Kabulonga, P.O. Box 30910, Lusaka, Zambia

Received: July 10, 2014; Accepted: Aug 05, 2014; Published: Aug 08, 2014


Skilled birth attendance (SBA) has been shown to reduce maternal mortality and improve birth outcomes. Because skilled professionals are supposed to be present in health facilities, increasing facility deliveries is expected to increase SBA. However, in a country with a critical shortage of skilled health personnel, is this always the case? We present data from three studies conducted in Zambia to understand SBA and delivery practices in health facilities.

In each of the studies, women were asked where and with whom they delivered their youngest child. We calculated the proportion of all deliveries that occurred at health facilities, and proportion of SBAs at health facilities.

Across all three studies, 62.5% of 39,419 were facility deliveries. Of 39,078 deliveries where data were available for the person assisting, SBA was 54.1%; non-SBA was 45.9%. TBAs assisted 18.5% of all deliveries, but of all non-SBAs, TBAs delivered 40.3%.

Among 24,254 health facility deliveries where data were available for person assisting, SBA was 86.3%; non-SBA was 13.7%; TBAs assisted 10% of all facility deliveries. Of all non-SBA deliveries within health facilities, 70.9% were assisted by TBAs.

Our studies revealed that unskilled personnel attended 14% of deliveries occurring within health facilities and TBAs assisted 71% of these. In a country with a critical shortage of skilled health personnel, facility deliveries may not directly translate into SBA. We recommend equipping TBAs with stronger skills to conduct deliveries and manage delivery-associated complications in addition to emphasizing the need to refer to health facilities.

Keywords: Skilled Birth Attendance; Facility delivery; Traditional Birth Attendants; TBA; Zambia

Abbreviations and Selected Definitions

BEmONC: Basic Emergency Obstetrical and Neonatal Care; CHA: Community Health Assistant; CHW: Community Health Worker; CSO: Central Statistics Office; DHS: Demographic and Health Survey; EmOC: Emergency Obstetric Care; LINCHPIN: Lufwanyama Integrated Newborn and Child Health Project in Zambia; MDG: Millennium Development Goal; MOH: Ministry of Health; SBA: Skilled Birth Attendant or Attendance; TBAs: Traditional Birth Attendants; UN: United Nations; UNDP: United Nations Development Program; UNICEF: United Nations International Children's Fund; WHO: World Health Organization; ZDHS: Zambia Demographic and Health Survey; ZamCAT: Zambia Chlorhexidine Application Trial

Traditional Birth Attendant

A person who assists the mother during childbirth and who initially acquired their skills by delivering babies themselves or through an apprenticeship to other TBAs1. Trained traditional birth attendants have received some level of biomedical training in pregnancy and childbirth care. In these studies, we considered both trained and untrained TBAs recognized by the community as such but excluded relatives.


Globally, while maternal mortality has declined by 47% since 1990, from 400 maternal deaths per 100,000 live births in 1990 to 210 in 2010, this is still far short of the Millennium Development Goal (MDG) 5 target [1]. According to the UN MDG progress report [1], meeting MDG5 will require accelerated interventions, including improved access to emergency obstetric care and assistance from skilled health personnel at delivery. In Zambia, maternal mortality declined from 649 deaths/100,000 live births in 1996 to 483deaths/100,000 live births in 2010. Despite this reduction, the chance of meeting the MDG5 target for this indicator in 2015 is unlikely. The current level of maternal mortality, with approximately one woman dying every day during pregnancy, labor and delivery, is unacceptably high. Neonatal mortality has declined from 43 deaths per 1,000 live births in 1990 to 27 deaths/1,000 in 2012 [2]. Infant mortality decreased from 107.2 deaths per 1,000 live births in 1992 to 76.2 deaths per 1,000 live births in 2010. However, like maternal mortality, these reductions are not sufficient for Zambia to attain the MDG4 target.

The proportion of deliveries attended by skilled personnel, skilled birth attendance (SBA), rose from 55% in 1990 to 66% in 2011 in developing regions. Despite this increase, about 46 million of the 135 million women who delivered live babies in 2011 did so alone or with inadequate care. In sub-Saharan Africa, a SBA attends only half of all births [1]. In Zambia, SBA has declined from 50.5% in 1992 to 44% in 2010 [2].

There is recognition that countries that have significantly reduced neonatal deaths have focused on having trained midwives at all deliveries, increased pre-natal check-ups and nutritional care, and maternity waiting homes near clinics to reduce travel distances, especially if complications arise [2]. Both health facility delivery and SBA have been associated with reductions in maternal and neonatal mortality [3]. In a recent systematic review, health facility deliveries were found to have resulted in a 29% reduction in the risk of neonatal mortality in low- and middle-income countries [4]. However, this is only so under a conducive environment with skilled staff and EmOC facilities [5]. Both where the delivery takes place and who delivers the baby are important factors in maternal and neonatal survival.

Zambia's strategy to reduce maternal mortality includes ensuring universal access to family planning, skilled attendance at birth, and basic and comprehensive emergency obstetric and neonatal care (EmONC). The MDG progress report for Zambia highlights assisted or supervised deliveries as one of the most critical interventions for ensuring safe motherhood [2]. Supervised deliveries averaged just over60%between 2008 and 2010, which is said to partially explain the reduction in maternal mortality. Supervised deliveries include births assisted by traditional birth attendants (TBAs) and the report states that several typically rural provinces did well due to their high proportion of homebirths assisted by trained TBAs. The report recognizes the role of TBAs in helping to bridge the gap until more midwives are trained.

Zambia's efforts to reduce maternal mortality are hampered by the critical shortage of skilled health personnel. According to the MOH data Zambia has 48% of the midwives and 46% of the nurses it needs [6]. And one of Zambia's strategies is to increase facility deliveries with the aim of increasing the proportion of deliveries attended to by skilled personnel. However, with the critical shortage of skilled human resource, would increasing facility deliveries necessarily increase SBA? To address this question.

This paper presents data on who assisted women to deliver babies and where the deliveries took place. The paper analyses data on who assisted with deliveries outside of the health facilities and within the health facilities. The paper also provides information on non- SBA deliveries within health facilities and who assisted with those deliveries and discusses the challenges these issues pose to improving delivery outcomes and maternal and neonatal health in general.

Materials and Methods

This paper presents and discusses data from three community-level studies in Zambia (Figure 1):