John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Despite recent improvements in maternity care, as called for in the Millennium Development Goals, many mothers still die during childbirth in low- and middle-income countries. As part of the efforts to achieve further improvements, a new Cochrane systematic review of qualitative studies from November 2017 looks at the factors that can influence a skilled birth attendant’s ability to provide good quality maternity care. We asked lead author, Susan Munabi-Babigumira from the Norwegian Institute of Public Health to tell us more in this podcast.

Susan:  One of the strategies to improve maternity care in low- and middle-income countries is the encouragement of women to give birth in health facilities rather than at home, so that they can receive care from a skilled birth attendant, such as a midwife, doctor, or nurse. These skilled birth attendants are trained to manage a normal pregnancy and childbirth, and refer the mother and new born if complications arise. However, their skills, attitudes and behaviour, and the extent to which they work in an enabling working environment, can influence the quality of care they provide.
Therefore, we looked at what can influence skilled birth attendants’ ability to provide good quality maternity care. We included qualitative research, which investigates how people perceive and experience the world round them. Participants were skilled birth attendants including doctors, midwives, nurses, auxiliary nurses and their managers. We brought together 31 qualitative studies conducted in Africa, Asia, and Latin America that had explored their views, experiences, and behaviours; supplementing a Cochrane Review on the effects of policies to promote delivery in health facilities.
We found many influential factors. For example, insufficient numbers of health workers can lead to heavy workloads, which, in turn, may interfere with key tasks such as taking an adequate history from pregnant women; conducting examinations or providing timely care or privacy for mothers; and ensuring good hand hygiene. Health workers also reported how insufficient training and supervision, salaries and living conditions influenced their ability to provide good quality maternity care. In addition, when health facilities lacked equipment, medicines and supplies, or did not have water, electricity, and transport, the quality of care was sometimes compromised. Other factors that may play a role include the extent to which health care providers are able to work as a team and whether there is adequate trust, collaboration, and communication between health workers and with mothers.
Our findings led to a set of questions to help prompt health service managers seeking to improve maternity services or health services in general. These will help them consider the staffing situation in relation to the workload, how health workers at facilities perceive their working and living conditions, and opportunities available at the health facility to foster good inter-professional relations.
In conclusion, our synthesis highlights the human resource and infrastructural challenges that prevent health workers in some low- and middle- income countries from providing good quality maternity care. These challenges need to be addressed in order to improve maternal health services, and strengthen health systems to improve health outcomes in general.

John: If would like to delve deeper into the synthesis and see how the challenges might be identified and tackled, you’ll find the review online at Cochrane Library dot com with a search for 'skilled birth attendants'.