06 February 2017
UNEDITED DOCUMENT. USE COMMENT FEATURE AND EMAIL TO: [email protected]
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
2
Contents
Acronyms and abbreviations ............................................................................................. 4
1. Background ................................................................................................................... 5
2. Method and process ..................................................................................................... 5
3. Competent attendance in maternal and newborn health ............................................... 5
3.1 Competencies for professionals providing quality maternal and newborn care ..................... 6
4. Measurement ............................................................................................................... 8
5. Enabling factors for skilled attendance .......................................................................... 8
5.1 Education ........................................................................................................................... 8
5.2 Regulation .......................................................................................................................... 9
5.3 Enabling environment ......................................................................................................... 9
5.4 Human Resources ............................................................................................................... 9
5.5 Quality of Care.................................................................................................................... 9
5.6 Quality Maternal Newborn Care (QMNC) .......................................................................... 10
6. Operationalization ...................................................................................................... 11
7. Glossary ...................................................................................................................... 12
References ...................................................................................................................... 15
3
Acronyms and abbreviations
BEmONC
CEmONC
DHS
FIGO
ICM
MICS
RHS
SAB
SDG
QMNC
QMNHC
QMNHCP
QoC
RMNCH
SRMNH
WHO
Basic emergency obstetric and newborn care
Comprehensive emergency obstetric and newborn care
Demographic Health Surveys
International Federation of Gynaecology and Obstetrics
International Confederation of Midwives
Multiple Indicator Cluster Surveys
Reproductive Health Survey
Skilled attendance at birth
Sustainable Development Goal
Quality Maternal Newborn Care
Quality Maternal and Newborn Health Care
Qualified Maternal and Newborn Health Care Provider
Quality of Care
Reproductive, maternal, newborn and child health
Sexual, reproductive, maternal and newborn health
World Health Organization
4
1. Background
This 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
health
Quality 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.
5
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.
6
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.
7
4. Measurement
Regular 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 attendance
QMNHCP’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
Obs
1
2
3
4
5
6
7
8
Doctor
Paed
Nurse








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
international standards are met. Regulatory authorities must approve pre-registration
8
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
9
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.
10
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
11

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 packages 37.
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 decisionmaking. 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.
12
Level of care: BEmONC and CEmONC definition
Basic 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 resourcepoor 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.
13
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.
14
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16