What factors influence the delivery of care by skilled birth attendants in low- and middle-income countries?

Review aim

The aim of this Cochrane synthesis of qualitative evidence was to identify factors that influence the provision of care by skilled birth attendants. To answer this question, we searched for and analysed qualitative studies of skilled birth attendants’ views, experiences, and behaviour.

This synthesis complements another Cochrane Review assessing the effect of strategies to promote women’s use of healthcare facilities when giving birth.

Key messages

Many factors influence the care that skilled birth attendants provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork, trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to these factors.

What did we study in the synthesis?

In low- and middle-income countries, many mothers still die during childbirth. Women are encouraged to give birth in health facilities rather than at home so they can receive care from skilled birth attendants. A skilled birth attendant is a health worker such as a midwife, doctor, or nurse who is trained to manage a normal pregnancy and childbirth, and refer the mother and newborn when complications arise.

By exploring skilled birth attendants’ views, experiences, and behaviour, this synthesis aimed to identify factors that can influence their ability to provide quality care.

Main findings

We included 31 studies conducted in Africa, Asia, and Latin America. Participants were skilled birth attendants including doctors, midwives, nurses, auxiliary nurses and their managers.

Our synthesis pointed to several factors that affected skilled birth attendants’ provision of quality care. The following factors are based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they sometimes had insufficient training during their education or after they had begun work. Where facilities lacked staff, skilled birth attendants’ workloads could increase, it could become difficult to provide supervision, and mothers could receive poorer care. In addition, skilled birth attendants did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues could lead to stress and affect skilled birth attendants' family life. Some skilled birth attendants felt that managers lacked capacity and skills, and they felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages included problems with hiring and assigning health workers to health facilities; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of their work; these included good-quality housing, allowances for extra work, paid vacations, continued education, proper assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, drugs, and supplies; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce skilled birth attendants’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for skilled birth attendants to refer women to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

How up-to-date is this review?

We searched for studies published before November 2016.

Authors' conclusions: 

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

Read the full abstract...
Background: 

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

Objectives: 

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

Search strategy: 

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

Selection criteria: 

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

Data collection and analysis: 

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

Main results: 

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.

Our synthesis pointed to a number of factors affecting SBAs’ provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

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