06 February 2017UNEDITED DOCUMENT. USE COMMENT FEATURE AND EMAIL TO: maternalestimates@who.int

Competent attendance in maternal and newborn health: the definition of the competent

health care provider in maternal and newborn health.

Background to the joint statement by

WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA

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ContentsAcronyms and abbreviations...............................................................................................4

1. Background.....................................................................................................................5

2. Method and process.......................................................................................................5

3. Competent attendance in maternal and newborn health................................................53.1 Competencies for professionals providing quality maternal and newborn care......................6

4. Measurement.................................................................................................................8

5. Enabling factors for skilled attendance............................................................................85.1 Education..............................................................................................................................85.2 Regulation.............................................................................................................................95.3 Enabling environment...........................................................................................................95.4 Human Resources..................................................................................................................95.5 Quality of Care....................................................................................................................105.6 Quality Maternal Newborn Care (QMNC)............................................................................10

6. Operationalization........................................................................................................11

7. Glossary........................................................................................................................12

References........................................................................................................................15

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Acronyms and abbreviations

BEmONC Basic emergency obstetric and newborn careCEmONC Comprehensive emergency obstetric and newborn careDHS Demographic Health SurveysFIGO International Federation of Gynaecology and ObstetricsICM International Confederation of MidwivesMICS Multiple Indicator Cluster SurveysRHS Reproductive Health SurveySAB Skilled attendance at birthSDG Sustainable Development GoalQMNC Quality Maternal Newborn CareQMNHC Quality Maternal and Newborn Health CareQMNHCP Qualified Maternal and Newborn Health Care ProviderQoC Quality of CareRMNCH Reproductive, maternal, newborn and child healthSRMNH Sexual, reproductive, maternal and newborn healthWHO World Health Organization

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1. BackgroundThis discussion paper is intended to summarize the process, methods, and rationale for the review and revision of the 2004 WHO/FIGO/ICM Statement1 on the critical role of the skilled attendant.

The Sustainable Development Goal (SDG) agenda highlights the importance of continued attention to maternal and newborn health by setting, under the SDG goal 3, targets for achieving a global maternal mortality ratio of less than 70 maternal deaths per 100,000 live births, and aiming for all countries to reduce neonatal mortality to at least as low as 12 per 1,000 live births by 2030 and reduction of stillbirth2. Achieving these targets will require strong and effective strategies but also accurate measurement and monitoring of progress on key maternal and newborn health indicators. A critical progress indicator, explicitly adopted by the SDGs and the Global Strategy for Women's, Children's and Adolescents' Health, 2016-20303 is the “percentage of births delivered by skilled attendant at birth” (SAB). The statement and supporting documents will provide guidance to ensure that SAB improves quality maternal and newborn health care and support with the measurement of the indictor.

However, correct assessment of progress in coverage of SAB and its determinants will require improved definition and measurement. In 2004, WHO/FIGO/ICM issued a joint statement that defined SAB and its core functions4. Actual practice at country level is challenged by lack of guidelines, standardization of names and functions, and task shifting5. In addition, many countries have found that there are large gaps between the defined standards and competencies of existing birth attendants who are able to correctly manage common obstetric and neonatal complications6. Therefore, the SAB statement and the SAB definition was revised from the skilled birth attendant combining the health care provider with the enabling environment, and extended into the concept of competent attendance in quality maternal and newborn health with dignity.

2. Method and process Development of a draft revised definition of “skilled attendance at birth” by a core

working group: 1. a two-day expert consultation June 2016, and 2. a two-day expert workshop in January 2017.

Online constituencies consultation in March 2017.

3. Competent attendance in maternal and newborn health

DRAFT Definition of the competent health care professional in maternal and newborn healthQuality maternal and newborn health care (QMNHC) is the provision of quality care for women of reproductive age, their newborns and families, before and during pregnancy, birth, and the postnatal period and beyond. This care is provided by competent qualified maternal and newborn health care professionals (QMNHCP) who are educated and regulated as per international and national standards and who work as a team within an enabling and supportive environment.

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3.1 Competencies for professionals providing quality maternal and newborn care

Adapting the essential evidence-based competencies described by International Confederation of Midwives (ICM)7 and World Health Organization (WHO)8, the QMNCHs should be educated, trained, regulated and supported to attain these competencies.

A human rights-based approach is guiding this concept of competent attendance in quality maternal and newborn health to realize women’s1 and their newborns rights to obtain the highest attainable standards of health and well-being9. The intent is to foster accountability in accordance with human rights standards. Overall, it stresses the aim to end preventable deaths including maternal, newborn and stillbirths (survive), ensure health and well-being (thrive) and expand enabling environments (transform)10. The term “competencies” is used as the knowledge, skills and behaviours which value respect, communication, community knowledge and understanding required of the health care professional for safe practice in any setting along the continuum of care. This continuum ranges from pre-pregnancy, to pregnancy, intrapartum, post-natal and beyond. They are tailored to women’s, newborns and family’s circumstances and needs.” They answer the questions:

o “what is a health QMNHCP expected to know?” o “what does a QMNHCP do and how do they provide such care?”, and o “what constitutes the enabling environment to support them” to achieve standards

of (ensure) quality maternal and newborn care11 .

The competencies are grouped into eight categories:

COMPETENCY # 1: QMNHCP have the requisite knowledge and skills from midwifery, obstetrics, neonatology, the social sciences, public health and ethics that optimize quality, socio-cultural, biological, psychological relevant processes, and appropriate quality care for women, newborns, and their families.

COMPETENCY # 2: QMNHCP provide high quality, socio-culturally sensitive health education and contraceptive advice services to all women, newborns and families in all environments in order to promote sexual and reproductive health and rights and healthy family life.

COMPETENCY # 3: QMNHCP provide quality pre-pregnancy and antenatal care that includes early detection and treatment or referral of complications to optimize health during pregnancy.

COMPETENCY #4: QMNHCP provide and promote quality, socio-culturally sensitive care with dignity during labour, facilitate clean and safe birth and manage emergency situations to perform all signal functions of basic emergency obstetric care to optimize the health and wellbeing of women and their newborn.

1 The term women include also adolescent girls, the term mothers is included in women and by using the term women we ensure that women who might not be mothers are included.

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COMPETENCY # 5: QMNHCP provide comprehensive, quality, socio-culturally and socially sensitive postnatal care for women.

COMPETENCY# 6: QMNHCP provide quality, comprehensive care for all newborns.

COMPETENCY #7: QMNHCP provide a range of individualized, socio-culturally sensitive abortion-related services for women requiring or experiencing pregnancy termination or loss that are congruent with applicable laws and regulations and in accord with national protocols.

COMPETENCY #8: QMNHCP provide leadership within a work environment that enables effective and efficient provision of basic and comprehensive emergency obstetric and newborn health care services and supports the integration of these services within the wider health system.

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4. MeasurementRegular data collection is the backbone of a functioning health system. In regard to measurement, national population based household surveys such as the Multiple Indicator Cluster Surveys (MICS)12 or the Demographic and Health Surveys (DHS)13 and Reproductive Health Surveys (RHS)14 often use broad categories of ‘skilled and ‘unskilled’ workers. Even though the surveys capture the full range of persons at a birth, the categorization of these different types of persons is not always consistent over time and across countries. This may indeed affect trend analysis. At country-level cadres of health workers that are skilled can change due to emerging national health policy and programmes which need to be considered in data collection, analysis and interpretation. The number of contacts a SAB had with women or newborns were taken into account but not the quality of the care provided because the competencies of the professionals are unknown and unregulated and therefore it is difficult to measure.

Though, measurement of the indicator SAB will still be linked to the presence of a competent provider in maternal and newborn health at the time of birth (linked to competency 4 described earlier), several measures which are listed in the following chapter will be introduced or strengthened to improve the accuracy of measurement.

5. Enabling factors for skilled attendanceQMNHCP’s are educated and regulated as per international and national standards according to the competencies illustrated above. They are working in an enabling environment. If a QMNHCP does not possess a certain competence as listed in the table below, he or she is expected and enabled to refer to a QMNHCP who does.(During the taskforce meeting in January 2017 is was suggested to map the competencies for the professional groups; midwife, doctor and nurse according to the eight competencies. The complete table will be included in the final background document).

Competency Midwife15 Doctor NurseObs Paed

1 2 3 4 5 6 7 8

5.1 Education

Professional education and training are the basis for competent and professional, skilled and qualified QMNHCP’s. This requires a formal accreditation process to ensure national and

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international standards are met. Regulatory authorities must approve pre-registration education programmes to ensure that they prepare practitioners to meet the appropriate professional standards for entry to the register. Educators also need to obtain and maintain core competencies16,17. The provision of continuing educational pathways enables auxiliary cadres to upgrade their competencies. These should be linked to a career pathway for all QMNHCP’s.

5.2 Regulation

The overall aim for professional regulation is to ensure the safety of women and newborns by ensuring that health professionals meet required standards of care. Ideally, the regulatory body should be autonomous and regulatory and licensure processes should adhere to international standards18. For each cadre providing QMNC, a scope of practice is defined and standards for pre-registration education programmes are developed. A regular re-registration process should be in place which is linked to accredited continuous professional development to ensure continuing competence. The respective regulatory body has the capacity to provide a code of conduct and ethics to protect the public and to ensure professional behaviour is met. It provides a transparent and accessible complaints and discipline mechanism that can apply sanction and removes professionals from the registry if necessary. Legislation enables the QMNHCP to supervise auxiliary cadres as defined by countries. Regulation is likely to describe the responsibilities that the regulated professional has for support, supervision and delegation of tasks.5.3 Enabling environment

The enabling environment includes but is not limited to infrastructure and equipment. It requires a system that enables the QMNCHP to thrive and to perform to highest attainable standards. It aims to remove social, economic and professional barriers including the underlying gender inequality and to ensure a positive, respectful and safe working environment for individuals and teams to provide quality maternal and newborn care. QMNHCP’s are supported through mentorship and peer support to improve quality of care provided. Women remain at the centre of care, and coordination of care around the continuum is assured. Adequate transport and communication systems and back up services are in place to support timely referral if necessary. An open and participatory organization culture should exist where the voice and contribution of health care staff is welcomed and encouraged in shared decision making processes

5.4 Human Resources

Human resources, a driving factor of economies, are core to health service provision and workforce planning to ensure adequate numbers of QMNHC. Ethical recruitment, deployment and retention mechanisms to ensure that the supply of staff matches adequate staffing numbers. Regular data collection is essential for informed planning. Data includes headcount, percentage time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce19.5.5 Quality of Care

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Quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable, respectful and integrated within the wider health services.”20 In order to achieve this, health care must be safe, effective, timely, efficient, equitable, people-centred.21

5.6 Quality Maternal Newborn Care (QMNC)

The quality of care for women and newborns the degree to which maternal and newborn health services (for individuals and populations) increase the likelihood of timely, appropriate care for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and take into account the needs and preferences and aspirations of individual women and their families. This takes into consideration the characteristics of quality of care and two important components: 1) the quality of the provision of care and 2) the quality of care as experienced by women, their newborns and families22. Quality maternal and newborn health care (QMNHC) is the provision of effective care for women of reproductive age, their newborns and families, before and during pregnancy, birth, and the postnatal period and beyond. This care is provided by a team of maternal and newborn health care professionals who are educated, regulated, enabled and supported according to contextually-relevant standards that are high enough to ensure that they are fully competent and adequately motivated23,24.

The WHO quality of care (QoC) framework of eight domains of quality of care for pregnant women and newborns in facilities increases the likelihood that the desired individual and facility outcomes will be achieved. No matter where the woman is, the health system approach for skilled attendance is extended to provide the structure for quality improvement. The health system approach provides the structure for quality improvement in the two linked dimensions of provision and experience of care. Provision of care includes use of evidence-based practices for routine and emergency care, information systems in which recordkeeping allows review and auditing and functioning systems for referral between different levels of care. Experience of care consists of effective communication with women and their families about the care provided, their expectations and their rights; care with respect and preservation of dignity; and access to the social and emotional support of their choice. Both dimensions rely on the availability of competent, motivated quality maternal and newborn health care providers and of the physical resources that are prerequisites for good quality of care in health facilities.

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WHO Quality of care Framework for maternal and newborn health25

6. Operationalization This section will be further developed.Measurement

Increase of the use of qualitative research to complement findings from quantitative data such as surveys;

Capacity development of the Ministry of Health in data management/measurement; Mapping of the cadres in relation to their competencies; Workforce: Regular data collection not only of headcount but also percentage time

spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce;

Link with global, regional and national monitoring of the global workforce and global strategic directions for strengthening nursing and midwifery26;

Development of a standardized data-set in the area of health workforce accounts: doctors, nurses, midwives, dentists, pharmacists27

Development of a Global Platform on the labour markets28.

Education Use of tools such as ICM Guidelines for education standards29, ICM Standards

Equipment list for competency-based skills training30, WHO midwifery educator core competencies31

Regulation

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Use of tools such as the ICM regulation toolkit32, Global standards for midwifery regulation33.

Enabling environment Remove social, economic and professional barriers including the underlying gender

inequality to provide quality maternal and newborn care34. Ensure community-based services are integrated into wider health system through

effective communication, referral and transport systems.

7. Glossary

Continuum of care: The "Continuum of Care" for reproductive, maternal, newborn and child health (RMNCH) includes integrated service delivery for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. Such care is provided by families and communities, through outpatient services, clinics and other health facilities35. Continuum of care is a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care36.

The continuum of care for maternal, neonatal, and child health requires access to care provided for families and communities, by outpatient and outreach services, and by clinical services throughout the lifecycle, including adolescence, pregnancy, childbirth, the postnatal period, and childhood. Saving lives depends on high coverage and quality of integrated service-delivery packages throughout the continuum, with functional linkages between levels of care in the health system and between service-delivery packages, so that the care provided at each time and place contributes to the effectiveness of all the linked packages37.

Contraceptive advice: includes contraceptive counselling in the pre-pregnancy, pregnancy, post-partum and beyond.

Auxiliary nurse midwife: Have some training in secondary school. A period of on-the job training may be included, and sometimes formalized in apprenticeships. Like an auxiliary nurse, an auxiliary nurse midwife has basic nursing skills and no training in nursing decision-making. Auxiliary nurse midwives assist in the provision of maternal and newborn health care, particularly during childbirth but also in the prenatal and postpartum periods. They possess some of the competencies in midwifery but are not fully qualified as midwives38.

Lay health workers: Any health worker who performs functions related to health-care delivery; was trained in some way in the context maternal and newborn health care; but has received no formal professional or paraprofessional certificate or tertiary education degree. The term includes also the Traditional birth attendant (TBA): A person who assists the mother during childbirth and who initially acquired their skills by delivering babies themselves or through an apprenticeship to other TBAs. Trained traditional birth attendants have received some level of biomedical training in pregnancy and childbirth care. In this guidance, trained TBAs are considered within the category of lay health workers39.

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Level of care: BEmONC and CEmONC definitionBasic emergency obstetric and newborn care (BEmONC) is defined as seven essential medical interventions, or ‘signal functions,’ that treat the major causes of maternal and newborn morbidity and mortality: 1) antibiotics to prevent puerperal infection; 2) anticonvulsants for treatment of eclampsia and preeclampsia; 3) uterotonic drugs (e.g., oxytoxics) administered for postpartum haemorrhage; 4) manual removal of the placenta; 5) assisted or instrumental vaginal delivery; 6) removal of retained products of conception; and 7) neonatal resuscitation.Comprehensive emergency obstetric and newborn care (CEmONC) also includes blood transfusions, surgery (e.g., caesarean section), neonatal intubation and advanced resuscitation (intubation and respirator available). These advanced care components require access to advanced supplies and trained personnel, which may be burdensome for resource-poor health systems. Nonetheless, the WHO urges developing countries to integrate universal access to high-quality, life-saving emergency procedures into health facilities.

Conceptual framework of pathways leading to adequate childbirth care options40

Abbreviations: SBA=skilled birth attendant. EmOC=emergency obstetric care. BEmOC=basic emergency obstetric care. CEmOC=comprehensive emergency obstetric care. 24/7=24 h a day, 7 days a week. AMU=alongside midwifery-led unit. MWH=maternity waiting home.

Positive birth experience: A positive birth experience consists of several factors considered vital to achieve a subsequent positive spontaneous vaginal birth experience. These are the quality of care, communication and information sharing during the birth and women’s degree of control. However, the research does not consider the possibility that birth with intervention may be positively perceived41.

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Quality of care: QoC is the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred42.

Task shifting/task sharing: see lay health worker.

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References

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