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

  

    
Indicator    or characteristic
    
CHA    (N=1,156)
      
n (%)
    
ZamCAT    (N=22,870)
      
n (%)
    
LINCHPIN    (N=228)
      
n (%)
    
All Study    (N=24,254)
      
n (%)
  
  

    
Doctor/clinical officer 
    
70 (6.1)
    
-
    
20 (8.8)
    
90(0.37)
  
  

    
Nurse/Midwife 
    
591(51.1)
    
20,086 (87.8) 
    
176 (77.2) 
    
20,853(86.0)
  
  

    
Traditional birth attendant 
    
285(24.7)
    
2,029(8.9)
    
32(14.0) 
    
2,346(10.0)
  
  

    
Community    health worker 
    
23 (2.0)
    
-
    
0
    
22(0.1)
  
  

    
Family    member
    
4 (0.4)
    
162 (0.7%)
    
-
    
166(0.7)
  
  

    
Nobody    assisted 
    
1(0.1)
    
32 (0.1%)
    
0
    
33(0.1)
  
  

    
Other 
    
182 (15.7)
    
561 (2.5%)
    
0
    
748(3.1)
  
  

    
Total    assisted by skilled birth attendant 
    
661 (57.2)
    
20,086(87.8)
    
196(86.0)
    
20,943(86.3)
  
  

    
Total    assisted by non-skilled birth attendant
    
495(42.8)
    
2,784(12.2)
    
32(14.0)
    
3,311(13.7)
  
  

    
 
      
Proportion    of non-skilled deliveries assisted by TBA
    
285(57.6)
    
2,029(72.9)
    
32(100)
    
2,346(70.9)
  
  

    
Proportion    of non-skilled deliveries assisted by family member
    
4(0.8)
    
162(5.8)
    
0(0)
    
166(5.0)
  
  

    
Proportion    of unassisted deliveries
    
1(0.2)
    
32(1.2)
    
0(0)
    
33(1.0)
  

Table 4:  Person assisting with delivery at health facilities.

Out of the total of 3,311 unskilled deliveries, TBAs conducted 71%, family members conducted 5%, and 1% was unassisted. 25% (n=285) of the facility deliveries in the CHA study were assisted by TBAs. In the LINCHPIN and ZamCAT studies TBAs delivered 14% (n=32) and 9% (n=2,029) of the facility deliveries respectively.

Discussion

Both the LINCHPIN and CHA study results reveal low to medium [3] levels of health facility deliveries in the respective study areas, ranging from 31% to 52% respectively. This is within the Zambia national average of 48% [11]. It is also within the sub-Saharan region Figures [3]. ZamCAT data reveal high levels of facility deliveries. This is most likely due to the intense community sensitization and messages delivered to pregnant women encouraging them to deliver at health facilities. Health facility delivery has been used as a key maternal health indicator under the premise that it would facilitate and increase the number of births attended to by qualified health professionals and create conditions for safe delivery. Fretheim A. and Hviding K. [12] report that the presence of a skilled birth attendant with the necessary remedies at hand is the main argument for promoting facility-based deliveries. The authors of this paper did not find a formal definition of "facility-based deliveries", but according to them, the term implies having a permanent health facility where skilled attendance for deliveries is being provided. Despite the use of health facility deliveries as a proxy for SBA, there appears to be no clear definition in the literature of health facility delivery. The Zambia DHS for example, includes hospitals, health centres and health posts as facility deliveries irrespective of the staffing pattern at these facilities and irrespective of whether these facilities are designated delivery centers or not [11]. Our data shows that facility deliveries do not necessarily translate into 100% SBA. Part of this is due to the definition of facility deliveries. If we defined facility deliveries in the context of presence of skilled birth attendants, then facility deliveries should translate into 100% as SBAs. The fact that DHS, at least in Zambia, includes health posts as facilities is a problem if we are to promote facility deliveries in order to attain SBAs.

Overall, the proportion of unskilled deliveries of 46% observed in our data is lower than the national figure of 56% [2]. However, an examination of the individual studies reveals fairly high proportions of unskilled deliveries in the LINCHPIN and CHA studies, with 70-73% of the deliveries attended to by unskilled personnel respectively. This is not surprising, however, considering that there has been a general decline in the proportion of deliveries attended to by SBA in Zambia over the period 1992 to 2010 [2]. In the African region SBA is only 46.5%; hence unskilled delivery still stands at 55.5%. Overall, our data on unskilled deliveries is just lower than the Africa region average. Global literature shows that 34% of deliveries take place without SBAs [13]. The question is what should be done to help the large number of women currently delivering without skilled assistance? Is what Zambia calls "assisted delivery" using trained TBAs a workable interim measure? Would equipping the TBAs with greater delivery skills as well as skills to manage postpartum hemorrhage (PPH) be the interim solution? Recent evidence shows that TBAs could be trained to safely and correctly deliver misoprostol to control PPH and to correctly use blood collection delivery mat to measure PPH blood loss [14,15]. The related question is whether using TBAs to manage home deliveries better by equipping them with skills and supplying them with commodities to manage PPH would encourage home deliveries and reduce facility deliveries. We were not able to get any literature that indicates that this may be the case and it may be necessary to conduct rigorous implementation research to evaluate the effect of this approach.

Some of our data on facility deliveries reveal a fairly large number of unskilled deliveries occurring within the health facilities themselves. Data from the CHA study show that, while approximately half of the deliveries occurred at a health facility, a SBA attended less than two thirds of these (57%). This means that unskilled personnel conducted 43% or 495 deliveries within the health facilities. Even for the ZamCAT study where SBA at health facilities was 88%, in absolute terms there were 2,784 unskilled deliveries within health facilities during the study period. A large proportion of these unskilled deliveries in health facilities were conducted by TBAs, both trained and untrained. In the CHA study, 285 of the 495 unskilled deliveries within health facilities were conducted by TBAs. The ZamCAT study data revealed that 2,029 of the 2,784 unskilled deliveries (73%) within health facilities were conducted by TBAs. These data pose a number of challenges to the goal of achieving the millennium development goal number 5. First, in a country like Zambia with a critical shortage of staff for BEmONC, increasing facility deliveries may not necessarily reduce the number of unskilled birth attendance [16]. Secondly, the low proportions of facility deliveries, as shown by two of the three studies in Zambia, and considering that there are large numbers of unskilled deliveries occurring within health facility deliveries, poses great challenges to reducing maternal and neonatal mortality through SBA. Thirdly, the fact that most of the unskilled deliveries occurring in health facilities were attended to by TBAs adds to the debate on the role of TBAs in the delivery of babies and the skills TBAs should be equipped with. According to Prata et al. [17], in 2011 there were 28 countries from four major regions in which SBAs attended fewer than half of all births. And 69% of maternal deaths in those 4 regions could be attributed to the 28 countries, despite the fact that those countries only constituted 34% of the total population in those regions [18]. Prata and colleagues argue that while strengthening health systems makes excellent strategic sense, it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. 46% of the women in the CHA study, 35% in the ZamCAT study, and 61% of the women in the LINCHPIN study respectively delivered at home. This constitutes 14,374 women who delivered at home during the study period of these three studies [19]. The question is who delivered these babies and more importantly, what was the outcome of these deliveries? An even more important question is, while efforts are being made to improve health systems and attain universal access to BEmONC, what should be done to assist these women who currently deliver at home? Prata and others recommend training of community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) [20]. As stated above, equipping TBAs with more skills and resources may be an answer.

Lastly, we note that 3-4% of all deliveries were unassisted. For the CHA study, this translates to only 95 deliveries. However, for a large sample such as the one for ZamCAT, 3% of the deliveries translate into 1,000 unassisted deliveries. This scenario is not uncommon in sub-Saharan Africa, and thus requires urgent attention. For example, Fapohunda BM et al. [21] notes that not only are Nigerian women predominantly using unskilled attendants, but one in five births are delivered with No One Present (NOP).

Limitations

Although the studies on which this paper is based are fairly large and had representative samples to detect change in their original outcome measures, the sub-analysis presented here may not be representative of the Zambian population as a whole. Another limitation is the unequal sample sizes among the studies included in this paper. For example, ZamCAT with its large sample size may have skewed the results.

Conclusions and Recommendations

Results from the studies in this paper show that there is a fairly large proportion unskilled deliveries occurring within health facilities and TBAs are delivering babies both outside and within health facilities. Hence facility deliveries within the current definition in Zambia and elsewhere in Africa and globally may not translate into SBA and are therefore unlikely to lead to the desired maternal outcomes expected from skilled assistance at birth. We recommend a redefinition of facility delivery as "the proportion of births occurring in a health facility with skilled birth attendants." We also recommend a review of the role of TBAs and their training curriculum to ensure that the TBAs have stronger skills to conduct deliveries and control obstetric complications such as postpartum hemorrhage with misoprostol in addition to emphasizing the need to refer to health facilities. We make this recommendation in the light of the data that shows that in a country like Zambia, with a critical shortage of skilled health personnel for BEmONC, there are a large number of women assisted by TBAs, not just outside of health facilities but even within health facilities.

Acknowledgment

We wish to acknowledge and thank the various funding agencies that provided the resources to conduct the three studies part of whose data is presented in this paper. We thank the Clinton Health Access Initiative (CHAI) through the UK Department for International Development (DFID) for providing funds for the CHA study; the Bill and Melinda Gates Foundation for financing the ZamCAT study; and USAID for providing finances to carry out the LINCHPIN study. We also wish to thank the Ministry of Health for approving the implementation of the three studies.

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