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Skip to 0 minutes and 13 seconds PROF OONA CAMPBELL: OK. So “where” do births take place? Well, then, women either give birth at home, or they can move to a health facility. And it’s useful to think of facilities as being able to provide certain types of childbirth care. First, we have facilities that can only provide routine care but cannot provide emergency obstetric care. I’ll define emergency obstetric care in a minute in my next slide. Health posts, or dispensaries, might be examples of this kind of level of care. And it’s actually debatable whether there’s any advantage to having women come to such places, if they cannot expect to get any help when something goes wrong.

Skip to 1 minute and 0 seconds Next, we have facilities such as health centres, where we might expect routine childbirth care, but also some basic emergency obstetric care, which is there to help women who experience certain types of complications. Other examples of facilities providing such care might include freestanding birthing centres run by midwives to care for low-risk women, or private doctors’ clinics. Finally we have births in facilities - typically hospitals, maternity hospitals - that provide routine care but can also provide comprehensive emergency care. Note that I’ve shown a maternity waiting home near this facility.

Skip to 1 minute and 45 seconds And the idea here we’ve already described is that women, before they go into labour, move to a maternity waiting home to be close to the health facility, so that when they go into labour, they can just move over into the facility. Also note that we’ve indicated that in this comprehensive emergency obstetric care facility, there’s sometimes what’s called an alongside midwifery-led unit. The idea here is that there’s a place within the hospital or within the hospital grounds where women - again, low-risk women - can go to get care. This is an approach that’s used to try to preserve normality in birth and avoid over-medicalization.

Skip to 2 minutes and 28 seconds It’s used in the UK and in South Africa, where it’s called an OMBU, an On-site Midwifery-Led Birthing Unit. Women who are in these units are then transferred within the facility, usually to a doctor or obstetrician-led unit.

Skip to 2 minutes and 46 seconds Now, I said I would define emergency obstetric care facilities. Emergency obstetric care, or EmoC signal functions, are shortcuts to signal or describe what functions - that is, what types of childbirth services health facilities can provide. EmOC signal functions include a set of surgical procedures and a set of manual and medical procedures. If the facility can do all eight functions, it is a comprehensive emergency obstetric care facility. This is the sort of care that one might expect from a hospital, so a Caesarean-section, things like that. If a facility can only provide manual and medical functions, then it is a basic emergency obstetric care facility. In 2009, EmOC was turned into EmONC, including a ninth function, neonatal resuscitation.

Skip to 3 minutes and 46 seconds But I think we need to be careful to remember that this isn’t really enough to manage all babies with problems. In some settings where HIV is detected only in labour, we need Prevention of Mother-To-Child Transmission (PMTCT). And also, in other settings we might need some hospitals - not necessarily all of them - to have in-patient care for small and sick newborns. Also, we stated that in this course, we’re interested not just in emergencies and complications, but also in well-being. There’s a growing recognition that we need to capture and understand not just emergency care, but also the routine care that’s given to all mothers.

Skip to 4 minutes and 30 seconds Proposed signal functions for all mothers include facilities that can monitor labour and ensure infection prevention and perform AMTSL to prevent haemorrhage - Active Management of Third Stage of Labour. This is routine care for mothers. We also need to capture facilities’ abilities to provide routine care for babies, such as keeping babies warm, breast-fed, and handled in ways that prevent infection. So these are signal functions for routine care for babies. We also need to signal that facilities are open 24/7 to provide childbirth care and they are staffed adequately, have water, electricity, etcetra. And that they can refer mothers and babies with complications to higher levels if needed.

Skip to 5 minutes and 19 seconds For example, if they’re not a comprehensive emergency obstetric care facility or cannot provide care for small and sick newborns.

Skip to 5 minutes and 29 seconds OK. So that is the “where”. What about “who” attends births? Well, women can deliver completely alone, but also with others, for example, midwives. In many settings providers work effectively in teams. And given that we have a large human resource crisis, which you’ll hear about later, teams might be an effective way to address this issue of not having enough staff. Global strategies also aim to have all women deliver and give birth with a Skilled Birth Attendant, or an SBA. What is an SBA? What cadres are Skilled Birth Attendants?

Skip to 6 minutes and 11 seconds So the World Health Organization, the International Federation of Gynaecologists and Obstetricians, and the International Confederate of Midwives have jointly come up with a definition of a Skilled Birth Attendant, in which they say this is an individual who has midwifery skills. The ICM then goes on to list what the basic competencies are for basic midwifery practise. And if you want, you can look in the “See Also” section and see more details of what you saw. But what we also realise when we look at the figure is that there’s huge complexity and diversity in the different types of cadres of health professionals that do deliveries. You can see, for example, in Africa there were over 188 cadres that do delivery care.

Skip to 7 minutes and 2 seconds In the eastern Mediterranean region, there are 50. Now, putting it together, we start to see that we have a person who has skills. So that’s a Skilled Birth Attendant. They have midwifery skills. And then they are in an enabling environment where they have the drugs, equipment, and supervision that enables them to provide skilled attendance. That’s the coming together of the person who has the right skills and the environment where that care can be provided. OK. Again, putting it together, “who” attends childbirth? On this slide, we see the levels of skilled birth attendants in four different countries. And in Campbell and colleagues in figure 2, you can see examples from 50 high-, middle-, and low-income countries.

Skip to 7 minutes and 52 seconds In this slide, we see that the level of Skilled Birth Attendants ranges from nearly 100% in the United States to less than 40% in Nigeria. But we can go further than this and look at where these births are taking place. If we look here, we see in Nigeria there are many births that are not attended by Skilled Birth Attendants - so that’s in blue - but also that many are women who are delivering completely alone. That’s the light blue. Who will identify if these women run into problems when they’re in labour and help them to get to care?

Skip to 8 minutes and 28 seconds We also see, if we look in Nigeria and Kenya, that the facility births, which are in various shades of red, are more commonly attended by midwives. Those are the solid colours, rather than stippled open. And we can see that births are more likely to be in hospital– so the burgundy colours than the more red colours. We also see in yellow women who seek care in a facility and put their trust in coming to a health centre or hospital, but don’t actually get skilled attendants at birth. So this is really a failure of responding to women’s felt need to get a certain type of care.

Skip to 9 minutes and 11 seconds The other thing that we start to understand when we look at this kind of figure is that thinking about where women are might explain the extent to which we need various services. So for example, women in the health centres, so the red levels, might need emergency referral, because they’re in a place that cannot provide Caesarean-section. Also, and it’s not shown here, it’s very useful to understand to what extent births are taking place in the public sector or in the private sector. In summary, where women give birth and who attends childbirth is key to understanding a country’s maternal health situation. And we’ve also identified that transport matters, too.

Skip to 9 minutes and 57 seconds Understanding where and who give important parameters for characterising maternity care services. They give clarity on what is needed to make health systems function for childbirth, and they signal the functions that can be provided at the place of birth. They indicate whether a transfer may be needed to get the right care if women are at a lower-level facility, and they suggest the attendants’ competencies to provide routine and emergency childbirth care. They also indicate problem configurations of care and whether a woman is likely to get Skilled Birth Attendants - that is to say, the person and the place.

Skip to 10 minutes and 43 seconds There are many hot issues on how to configure maternity care in countries. On this slide, you see some of the issues and unanswered questions related to the configuration of childbirth services. The next step in the MOOC, we’ll discuss some of these, but you may also wish to consider others on your own and to share your views with other learners or discuss what works in your country.

Where and with whom do women give birth?

Where do births take place and who, if anyone, is present?

Understanding where women give birth and who attends childbirth is key to understanding a country’s maternal health situation. In this step Prof Oona Campbell (LSHTM) proposes a simple way of characterising childbirth services in terms of where women start labour, where they deliver, and who delivers them. Signal functions are used as a shorthand way of describing facility capability and the step explores what is a skilled birth attendant.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine