Background
Skilled birth attendant | Skilled birth attendance |
---|---|
A joint WHO/ICM/FIGO statement, endorsed by UNFPA and the World Bank defines a skilled attendant as “an accredited health professional, such as a midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” [79]. | Skilled attendance is the process by which a pregnant woman and her infant are provided with adequate care during pregnancy, labor, birth, and the postpartum and immediate newborn periods, whether the place of delivery is the home, health center, or hospital. In order for this process to take place, the attendant must have the necessary skills and must be supported by an enabling environment at various levels of the health system, including a supportive policy and regulatory framework; adequate supplies, equipment, and infrastructure; and an efficient and effective system of communication and referral/transport [80, 81]. |
Methods
Study featuresa | Assessment |
---|---|
1. Study based on explicit theory | Yes/no/unclear |
2. Adequate description of how intervention strategy adapted to local conditions | Yes/no/unclear |
3. Example given of materials or process | Yes/no/unclear |
4. Adequate description of resources required to carry out interventions | Yes/no/unclear |
5. Measure outcome before and after intervention | Yes/no/unclear |
6. Measurement method same before and after | Yes/no/unclear |
7. Period between education and outcome more than 1 year | Yes/no/unclear |
8. Author claimed positive results for interventions | Yes/no/unclear |
9. Paper included discussion of possible biases and caveats (or limitations) | Yes/no/unclear |
10. Paper included P values or confidence interval | Yes/no/unclear |
11. Analysis employed some form of modeling such as regression | Yes/no/unclear |
12. Exposure to intervention monitored | Yes/no/unclear |
1. Management systems -Personnel systems: workforce planning (including staffing norms), recruitment, hiring, and deployment -Work environment and conditions: employee relations, workplace safety, job satisfaction, and career development Work environment and conditions: employee relations, workplace safety, job satisfaction, and career development -HR information system integration of data sources to ensure timely availability of accurate data required for planning, training, appraising, and supporting the workforce -Performance management: performance appraisal, supervision, and productivity 2. Education -Pre-service education tied to health needs -In-service training (e.g., distance and blended, continuing education) - Capacity of training institutions -Training of community health workers and non-formal care providers. 3. Policy -Professional standards, licensing, and accreditation -Authorized scopes of practice for health cadres -Political, social, and financial decisions and choices that impact HRH -Employment law and rules for civil service and other employers | 4. Leadership -Support HRH champions and advocates - Capacity for leadership and management at all levels -Capacity to lead multi-sector and sector-wide collaboration - Strengthening professional associations to provide leadership among their constituencies 5. Partnership -Mechanisms and processes for multi-stakeholder cooperation (interministerial committees, health worker advisory groups, observatories, donor coordination groups) - Public-private sector agreements -Community involvement in care, treatment, and governance of health services 6. Finance -Setting levels of salaries and allowances -Budgeting and projections for HRH intervention resource requirements including salaries, allowances, education, incentive packages, etc. -Increasing fiscal space and mobilizing financial resources (e.g., government, Global Fund, PEPFAR, donors) -Data on HRH expenditures (e.g., National Health Accounts) |
Results
Education (training/task shifting)
Study, year and type | Type of training/intervention | Duration of training | Time between intervention and evaluation | Task performed by | Trained by | Area of intervention observed | Other interventions/tasks | Effects of training/results | Cost of training | Quality of study |
---|---|---|---|---|---|---|---|---|---|---|
Dusitsin [30] Thailand RCT | Tubal ligation in healthy women | – | – | Midlevel health workers | – | Operating theaters | – | No difference was found between the groups in postoperative complications (RR 2.43; 95% CI, 0.64–9.22). | – | Selection = UR |
Performance and detection = UR | ||||||||||
Attrition = UR | ||||||||||
Reporting = LR | ||||||||||
Eren [31] Philippines and Turkey controlled trial | Intrauterine device insertion by auxiliary nurse midwives | – | – | Auxiliary nurse midwives | – | Teaching hospitals | – | No difference was seen in those who were referred to a specialist after insertion of an intrauterine device (RR 0.93; 95% CI, 0.45–1.90). | Selection = UR | |
Performance and detection = UR | ||||||||||
Attrition = UR | ||||||||||
Reporting = LR | ||||||||||
Warriner [32] South Africa and Viet Nam RCT | Manual vacuum aspiration performed by a midlevel health worker, with a follow-up 10 to 14 days later. | – | – | Midwives and doctor’s assistants | – | Primary care | – | Manual vacuum aspiration was significantly greater with auxiliary nurse midwives. | Selection = LR | |
Performance = LR | ||||||||||
Detection = UR | ||||||||||
Attrition = LR | ||||||||||
Reporting = LR | ||||||||||
Warriner [33] Nepal RCT | Administration of early medical abortion | – | – | Certified nurses and auxiliary nurses | – | Primary care | Midlevel health workers had full responsibility for the management of each case. | There was no significant difference in the likelihood of an incomplete abortion between groups of patients managed by auxiliary nurse midwives and those managed by doctors (RR: 0.93; 95% CI, 0.45–1.90). Nor was the likelihood of a complication during (RR: 3.07; 95% CI, 0.16–59.1)—or an adverse event after (RR: 1.36; 95% CI, 0.54–3.40) | - | Selection = LR |
Performance = LR | ||||||||||
Detection = UR | ||||||||||
Attrition = LR | ||||||||||
Reporting = LR | ||||||||||
Mekbib [34] Ethiopia prospective (before/after) | This training focused on life-saving procedures in obstetric emergencies (C-sections, hysterectomies including management of incomplete abortion, post abortion scare, and ectopic pregnancy). | 3 rounds of training were conducted. Each for 3 months period | Interventions began in 1999, and the results were analyzed in 2001. | GPs, midwives, and other service providers in EmOC | Department of obs/gyne and master trainers | Gandhi Memorial hospital in Addis Ababa and Ambo hospital | Management and coordination | The total number of deliveries at hospital increased by 39.7% from the baseline when compared with the year 2001. Instrumental deliveries increased from 6% in 1998 to 23% in 2001. The CFR for 1999 was 7.2% based on 18 deaths and for 2001 was 4.6% based on 20 deaths. | Almost $100 000 was used | 1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10N, 11U, 12Y |
Equipment, supplies, and drugs | ||||||||||
Record keeping | ||||||||||
Blood supply | ||||||||||
Djan [35] Ghana prospective (before/after) | Midwife was trained in vacuum extraction, manual removal or retained placenta, and suturing of episiotomies and lacerations. -MOs were trained to manage obstetric emergencies. | 2 weeks training | Intervention implemented 1993 and 1994 and evaluated in 1995 | Midwives and medical officers | Koforidua, Ghana, and tertiary hospital KATH | OT, blood bank | The number of women with complications coming increased from 26 in 1993 to 73 in 1995, and the proportion of these who were referred for treatment dropped 42–14%. Surgical obstetric procedures performed increased from 23 to 90. Midwives performed 32% manual removal, 58% vacuum extractions, and 98% episiotomy repairs. No death occurred. | US$ 30 000 but mostly for equipment and supplies | 1Y, 2Y, 3Y, 4Y, 5Y, 6N, 7Y, 8Y, 9N, 10N, 11Y, 12Y | |
Maternity refurbished | ||||||||||
Revolving drug fund. Running water supply | ||||||||||
Improving access and reducing delay to care | ||||||||||
Ifenne [36] Nigeria prospective (before/after) | In-house training of midwives and residents in principles and practices of EmOC | Intervention started in 1993, and results were analyzed on 1994 and 1995. | Midwives and residents | Ahmadu Bello University Teaching Hospital | -OT restored -Maternity ward renovated -Improved access and -reduced delay to care -Blood bank and drug pack system | Admission to treatment interval was reduced from 3.7 h to 1.6 h. Proportion of women treated in less than 30 min increased from 39% to 87%. CFR fell from 14% to 11%. The annual number of women with complication declined from 326 to 65. | US$ 135 000 | 1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11U, 12Y | ||
Kruk [37] Mozambique prospective (before/after) | 2-year classroom-based instruction and 1-year internship | 2–3 years | Training began in 1983/1984 and was evaluated in 2007 | Nurses and medical assistants | Surgeons in Mozambique | Provincial hospitals | In 2002, 47 specialists and 53 AMOs performed 5 264 and 6 914 major obstetric surgeries, respectively. | The 30-year cost for obstetric surgery was $38.9 for AMOs and $144.1 for physicians. After doubling the salaries of AMOs lead to major difference in cost | 1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9Y, 10N, 11Y, 12Y | |
GHWA [38] Bangladesh prospective (before/after) | Training of MOs in obstetrics and anesthesia, nurses in midwifery, and laboratory technicians in safe blood transfusion. In 2003, a new 17-week competency-based training program, along with 1-year training on obs and gyne was introduced for MOs and nurses. | Training of MOs for 1 year. Training of nurses for 4 months. Laboratory technicians for 2 weeks. | Baseline figures were taken in 1999, and then, interventions were implemented and first evaluation took place ion 2003. | Medical officers, nurses and lab technicians | Maternal and Neonatal Health Care project personnel | Bangladesh Medical College Hospitals | Employment and retention | Natural deliveries increased by 63%, admissions of complicated cases increased by 135%, and cesarean deliveries increased by 70%. | Per trainee costs were approximately $1 550 for 1 year for MO, $1 020 for the 17-week competency-based team training, $340 for nurses, and $140 for laboratory technicians. | 1Y, 2Y, 3Y, 4Y, 5Y, 6N, 7Y, 8Y, 9N, 10U, 11Y, 12Y |
Management | ||||||||||
Monitoring and evaluation | ||||||||||
McCord [39] Tanzania prospective (before/after) | Trained AMOs to do cesarean sections and other emergency surgeries since 1963. | Tanzania started to train in 1963. Evaluation was done in 2006. | Assistant medical officers | Ministry of health | Among 1 134 complicated deliveries and 1 072 major obstetric operations, there was no significant difference between AMOs and MOs in outcomes, risk indicators, or quality. | 1Y, 2U, 3U, 4Y, 5Y, 6Y, 7U, 8Y, 9N, 10Y, 11U, 12Y | ||||
Ohnishi [40] Paraguay prospective (before/after) | Comprehensive community-based ANC program | 9 days. regarding maternal health care services, including comprehensive ANC programs, also involved hands-on practice | The pretest in 1997. Follow-up test in 1998. A post evaluation of follow-up test in June, 1999 | Health care personnel (nurses, auxiliary midwives, and auxiliary nurses) | Physicians and nurses | Caazapa Regional Hospital | The average scores of the participants’ knowledge increased significantly from 41.0 before to 60.1 after training (P < 0.001). The enrollment rates of pregnant women in ANC increased from 2.2 times per pregnancy in 1996 to 3.4 times in 1998 (P < 0.001). | 1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10Y, 11U, 12Y | ||
Rana [41] Nepal prospective (before/after) | Comprehensive EmOC specifically for C-section and other surgical procedures was provided to junior doctors. BEmOC and post abortion care to nurses, as well as anesthetic services to nurses, health assistants, and senior auxiliary health workers | Varied from 5 days to 6 months depending on the type of training | Started in 2000 and the first assessment was done in 2001 and the program lasted for 4 years till 2004. | Doctors, nurses, AWH, ANM, medical officers, lab technicians, peons | Senior doctors used clinical training and curriculum for EmOC developed by JHPIEGO and AMDD | Hospitals | Infrastructure improvements | In 5 years, 3 comprehensive and 4 basic EmOC facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9% to 16.9%; the proportion of births in EmOC project facilities increased from 3.8% to 8.3%; and the case fatality rate declined from 2.7% to 0.3%. | Technical training US$ 205 660 | 1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11Y, 12Y |
Data collection | ||||||||||
Management training US$ 97 170 | ||||||||||
Equipment | ||||||||||
Policy advocacy and community information activities | ||||||||||
Population council [42] Ghana quasi-experimental | Self-paced learning (SPL) course and the 3-week residential course. Both courses covered theoretical and clinical training in life-saving skills, obstetric and infant care, family planning counseling, and post abortion care. | 40 providers (midwives and physicians) in the experimental group received 6 months of SPL and a 1-week residential training course. In the comparison group, 35 providers attended the 3-week residential course. | Implantation started in 2001 and continued till 2004. Analysis was done during this period. | Midwives and physicians | 2 administrative regions in northern Ghana | Knowledge improved in (SLP) group following the intervention, while clinical performance improved in both groups, with the residential group performing slightly better. Mean scores for management of obs complications, PAC, and pregnancy-related complications improved significantly in the SPL group. | The self-paced learning approach cost more per learner than the residential course (US$ 2 154 versus US$ 1 330). | Selection = UR | ||
Performance and detection = UR | ||||||||||
Attrition = UR | ||||||||||
Reporting = LR | ||||||||||
Vaz [43] Mozambique quasi-experimental | Assistant medical officers with previous experience of surgical work were trained for 3 years. | 3 years | The AMOs were trained in 1992, and the evaluation took place in 1996. | Assistant medical officers | Ministry of health | No difference in indication for cesarean deliveries. The only significant difference was in the group of superficial wound separation which was slightly more (0.35% vs 0.05%) in AMO vs specialist group. | Selection = UR | |||
Performance and detection = UR | ||||||||||
Attrition = UR | ||||||||||
Reporting = LR | ||||||||||
Chilopora [44] Malawi prospective cohort study | COs were trained locally for 3 years. | 3 years | The Government of Malawi has been training clinical officers since 1974. | Clinical officers | Government of Malawi | After a 1-year internship, they were licensed to practice independently. | No significant difference in postoperative maternal health outcomes, after emergency obstetric procedures performed by CO or by medical officers (RR 0.99; 95% CI, 0.95–1.03). No significant difference in stillbirth with procedures performed by CO (RR 0.75; 95% CI, 0.52–1.09) or in early neonatal death (RR: 1.40; 95% CI, 0.51–3.87). Although 22 maternal deaths occurred in 1 875 procedures performed by CO compared with 1 in 256 procedures performed by medical officers. | 1Y, 2Y, 3Y, 4Y, 5U, 6U, 7Y, 8Y, 9Y, 10N, 11U, 12Y |
Policy implementation
Study | Policy implemented | When | Areas implemented on | Outcomes | Quality of the study |
---|---|---|---|---|---|
Efendi [12] Indonesia program evaluation (before/after) | Doctors and dentists were assigned as temporary staff on contract basis for a certain time period under “Contracted staff” or Pegawai Tidak Tetap (PTT) policy. Similarly, in the Village Midwife Program scheme, midwives were assigned to rural areas. In addition to the PTT scheme, the Special Assignment Program for Strategic Health Workers was implemented which included nurses, sanitarians, nutritionists, and other health cadres as well. | 1991 | Remote and very remote areas (division based on geographical position, access to transportation and the social economy) | Both these programs made a significant contribution to improving the availability of health workers in remote areas. As a result, in 2010, only 17% of the 9 000 very remote health centers were without a doctor, compared with 30% of 8 000 health centers in 2006. | 1Y, 2U, 3Y, 4Y, 5Y, 6U, 7N, 8Y, 9U, 10N, 11N, 12Y |
Akashi [45] Cambodia prospective (before/after) | User fees introduced at a public hospital, the National Maternal and Child Health Center (NMCHC) of Cambodia | 1997 | MOH started discussions to improve health care financing and introduce user contributions in 1995 and initiated a user-fee pilot program in selected national health facilities in 1997. | After the introduction of user fees, revenue was retained by the hospital to improve the quality of hospital services. Consequently, the patient satisfaction rate showed 92.7%, and the number of outpatients doubled. The average monthly number of delivery of babies increased from 319 to 585 in the third year after the user-fee introduction, and the bed occupancy rate also increased from 50.6% to 69.7%. As patient utilization increased, hospital revenue increased. The generatedrevenue was used to accelerate quality improvement, to provide staff with additional fee incentives to compensate their low government salaries, and to expand hospital services. | 1Y, 2U, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11N, 12Y |
Koblinsky [46] Bangladesh prospective (before/after) | In 1994, the EmOC approach dominated with assistance from the UNICEF, UNFPA, and the AMDD program in the renovation and up gradation of existing facilities and training of facility staff. With the development of the National Maternal Health Strategy in 2001, the approach broadened, building on the rights’ approach for safer motherhood and was incorporated into the ongoing Health and Population Sector Programme (HPSP) and subsequently into the Health, Nutrition and Population Sector Programme (HNPSP) | 1994 and 2001 and first evaluation took place in 1995 | EmOC at the facility level | Since 1990, the MMR in Bangladesh has declined from 514 in 1986–1990 to 400 in 2003—22% in the 11 intervening years. | 1Y, 2U, 3Y, 4Y, 5Y, 6U, 7Y, 8U, 9N, 10N, 11U, 12Y |
CSBAs providing safe delivery care at home. | |||||
Deaths from induced abortion have declined when the 1995–2005 level is compared with the pre-intervention levels of 1976–1980. | |||||
During 2000–2004, MMR was 322; only 13% of delivering-women used professional care for birthing, and 9% of births were in facilities. By 2007, 18% were delivering with professional care and 15% were in facilities. | |||||
For cesarean section in rural areas, the rate increased from 0.9% to 1.7% from 1995–1996 to 2000–2004 and then to 5.4% in 2005–2007, while in urban areas, the corresponding rates doubled—from 5.6% to 11.4% and then increased to 16.2% in 2005–2007. | |||||
The increase in the use of antenatal care has shown promise—from 27% in 1991–1994 to 60% in 2005–2007. | |||||
Rath [47] Nepal prospective (before/after) | The Nepal National Safer Motherhood Project was a collaborative intervention between the Nepal Ministry of Health and Population and the UK Department for International Development (DFID), managed by Options Consultancy Services. | 1997–2004, evaluation was done yearly | In phase 1, the Project focused mainly on improving midwifery and emergency obstetric services in selected health facilities in 3 districts and then in phase 2, to 6 districts. Two main components were developed: (i) management of service provision for women of reproductive age, including improvements to the physical infrastructure of hospitals, equipment and supplies, and training of personnel and (ii) increasing access to midwifery and obstetric services by improving the social context to enable women to utilize services. | Availability of birthing facilities | 1Y, 2U, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11U, 12Y |
Met need for emergency obstetric care was <5% in the phase 1 districts in 1997. The average annual increase in met need has been 1.3% per year over the intervention period, bringing it to the 2004 level of 14% in public sector facilities in project-supported districts. In a further 4 districts supported by UNICEF, met need increased from 1.9% to 16.9% between 2000 to 2004. | |||||
Availability of a skilled birth attendant near the home | |||||
The 2001 Demographic and Health Survey (DHS) found that only 3.1% of deliveries of the approximately 900 000 births per annum were attended by an auxiliary nurse midwife or nurse. This had increased to 8.3% in the 2006 DHS. | |||||
Free or reduced costs for services and transport | |||||
Communities valued these funds and that they increased confidence in being able to cope with emergencies. |
Combined interventions
Study | HRH management system | Others | |||||||
---|---|---|---|---|---|---|---|---|---|
Training | Policy | Management | Incentive | Supervision | Partnership | Personnel system | Intervention to evaluation duration | ||
Kayongo [50] Peru (before/after) | |||||||||
Implementation | Training sessions for 15 days with on-call duty after an analysis of the causes of maternal death, the treatment, and prevention of postpartum hemorrhage received special emphasis in the trainings. | Development of a more efficient mechanism for recordkeeping and data collection. | Quality of care was enhanced through the use of criterion-based audits. External supportive supervision and on-site quality improvement processes were used to enhance efficient service delivery. | The FEMME Project worked with community groups to form local committees. CARE’s most important partners in the FEMME Project have been the IMP in Lima, the Ayacucho DIRESA, and the Regional Hospital. | The intervention started in 2000 and the first evaluation took place in 2001 and then in next three years till 2004. | Facility setup, including adequate infrastructure, equipment, and supplies | |||
Placement of trained staff to ensure a wide distribution of technical capability to resolve obstetric emergencies. | |||||||||
Outcomes | CFR decreased from 1.7% to .01%, increase in met needs from 30% to 84% in 5 years, and a small increase in cesarean sections from 4% to 6%. | ||||||||
Quality: 1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10N, 11U, 12Y | |||||||||
Kayongo [51] Rwanda (before/after) | |||||||||
Implementations | CARE conducted several trainings to provide doctors and midwives to manage major obstetric complication. Most significant training course was a 12-module competency-based training. | Staff, including doctors and midwives, were trained and supported to ensure complete recording of case notes and filling out of registers. | Main strategies of the project were to engage the participation of district supervisors as partners for improving and transforming this process. | Stakeholders in the MoH, local partners in safe motherhood such as UNFPA, district health officials, and hospital health professionals were involved in various process of the project. | The interventions started in 2001 with first evaluation in 2002 and then consequently in 2003 and 2004. | Renovations and provision of essential equipment and supplies | |||
Outcomes | Numbers of deliveries increased by almost 25% from 2001 to 2002, and the obstetric complications managed increased by almost the same magnitude (26.5%). Cesarean section increased by 63% during this time. There was a continuous decrease in the case fatality rate over the 4 years of the project from 2.2% in 2001 to 1.8 in 2002 and finally 1.2% in 2004. | ||||||||
Quality: 1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10N, 11U, 12Y | |||||||||
Jamisse [49] Mozambique (before/after) | |||||||||
Implementations | Technicians trained in surgery and anesthesia, nurses trained as surgical assistants. MNCH nurses and midwives were trained in basic and comprehensive EmOC and management of major obstetric complications. | Supervision of the activities was the responsibility of the Ministry of Health. | Intervention started in 1998 and the first evaluation was done in 1999 and then consequent evaluations for 2 more years. | Supplementing equipment and essential supplies at the EmOC units | |||||
Radio communication and transport system was established | |||||||||
Outcomes | José Macamo Hospital, which dealt with 14% of all deliveries and 2.5% of all C-sections in 1998, was responsible for 32% of all deliveries and 38% of all C-sections in Maputo city in 2001. Mavalane never succeeded in providing comprehensive EmOC 24 h a day. It did succeed, however, in almost doubling the number of deliveries, from 2 500 in 1998 to almost 5 000 in 2001. While in 1998 the Manhica Hospital managed 29% of institutional deliveries and 8.2% of cesarean sections in the district, these percentages increased to 33% and 31.2%, respectively, in 2001. The maternal deaths per total number of deliveries occurring in the district’s institutions were 572/100 000 live births in 1998 and 433/100 000 in 2001. The case fatality rate in basic EmOC units decreased from 4.7 in 2000 to 2.4 in the first 6 months of 2002 | ||||||||
Quality: 1Y, 2U, 3U, 4Y, 5Y, 6U, 7U, 8Y, 9N, 10N, 11U, 12Y | |||||||||
Santos [52] Mozambique (before/after) | |||||||||
Implementations | The 4-week training session for basic EmOC consisted of 1 week of theory and 3 weeks of practical hands-on experience, emergency transport, and referral system. | Policy clearly endorsed EmOC | The project used the UN process indicators for obstetric services as its monitoring tools | The Medical Director of the Provincial Health Directorate and the Chief Nurse were given the responsibility to coordinate all activities of the project, which included frequent supervisory visits to the facilities. | AMDD’s partner in Mozambique was UNFPA. AMDD was supported by the Bill and Melinda Gates Foundation. | Interventions started in 1999, and first evaluation began in 2002 and was continued for 3 years till 2005. | Renovation of the hospitals, equipments and emergency drugs and supplies were provided | ||
Outcomes | Utilization among women with complications (met need or the proportion of women expected to have complications who are admitted for treatment) increased 3-fold, from 11.3% to 32.8% in all facilities. The aggregate case fatality rate (CFR) was reduced by almost half (2.9% to 1.6%). | ||||||||
Islam [48] Bangladesh (before/after) | |||||||||
Implementations | Training of medical officers was originally designed as a 6-month course but was later extended to 1 year. Training of nurses was extended from 6 weeks to 4 months. Laboratory technicians participated in a 2-week training course. | A checklist was developed for monitoring visits to training facilities to capture information such as trainees’ performance, lecture classes, opportunities for skills practice, training facility caseload, number of other trainees in the department, training problems, and general observations recorded in reports. | Trainees were provided with a monthly scholarship, book grant, travel allowance, and training materials. | Training activities were coordinated locally by the Training Coordination Committee at each medical college hospital. | UNFPA and UNICEF | Manager of the Directorate General of Health Services selected the medical officers for training, while nurses and laboratory technicians were selected from the facilities. | Intervention started in 2003 and evaluation was done in 2004. | Supply of necessary equipment and logistics. Renovations of the facilities | |
Outcomes | In 2004, 105 of the 120 sub-district hospitals had become functional for EmOC, 70 with comprehensive EmOC, and 35 with basic EmOC, while 53 of 59 of the district hospitals were providing comprehensive EmOC compared to 35 in 1999. | ||||||||
Quality: 1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10N, 11U, 12Y | |||||||||
Barker [24] Nepal (before/after) | |||||||||
Implementations | Ongoing work to incorporate training for skilled birth attendants into pre-service courses for doctors and nurses | SSMP worked with other safe motherhood stakeholders | SSMP supported Maternity Incentives | Civil society, political parties, local media, development program, and health workers. Provided technical and strategic planning support for training | Interventions started in 1997, and evaluations began in 1998 and continued till 2005 every year. | Supplies of emergency drugs and equipment | |||
Outcomes | Utilization of antenatal care services increased from 39% to 72%, delivery by a trained health worker from 9% to 19%, institutional delivery from 8% to 18%, and cesarean sections from 1% to 2.7%. CFR decreased from 0.5% to 0.4%. |