Skilled Birth Attendance

Skilled Birth Attendance (SBA) refers to the presence and assistance of a trained and competent health professional—such as a midwife, nurse, or doctor—during childbirth, equipped with the necessary skills, knowledge, and tools to manage normal deliveries and identify, manage, or refer obstetric complications. It is a vital component of maternal and newborn healthcare, recognised globally as a key strategy in reducing maternal and neonatal mortality and promoting safe motherhood.

Definition and Concept

According to the World Health Organization (WHO), a skilled birth attendant is an accredited health professional trained in the skills required to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, as well as to recognise, manage, or refer women and newborns with complications.
The concept of skilled birth attendance extends beyond the presence of a trained individual. It includes access to essential drugs, functional equipment, supportive health systems, referral facilities, and emergency obstetric care. Thus, effective skilled birth attendance is not merely about who attends the birth, but also about the quality of care provided and the environment in which it occurs.

Importance of Skilled Birth Attendance

Skilled attendance at birth is a cornerstone of Safe Motherhood Initiatives and the Sustainable Development Goals (SDGs), particularly SDG 3, which aims to reduce global maternal mortality to less than 70 per 100,000 live births by 2030.
Its importance is underscored by several key benefits:

• Reduction in Maternal Mortality: Timely management of complications such as haemorrhage, obstructed labour, eclampsia, and sepsis significantly lowers maternal deaths.
• Reduction in Neonatal Mortality: Skilled attendants can promptly address birth asphyxia, infections, and prematurity-related complications.
• Prevention of Long-term Disabilities: Proper management prevents fistulas, pelvic injuries, and other morbidities linked to unsafe childbirth.
• Improved Referral Systems: Skilled attendants serve as the first line of detection and ensure timely referral to higher-level facilities when emergencies arise.
• Health Education and Counselling: They provide advice on hygiene, breastfeeding, postpartum care, and family planning, contributing to long-term maternal and child health.

Components of Skilled Birth Attendance

For SBA to be effective, several components must work together:

1. Trained and Competent Personnel: Health professionals qualified in midwifery and obstetrics.
2. Functional Health Infrastructure: Clean, well-equipped facilities with access to essential supplies, drugs, and equipment.
3. Emergency Obstetric and Newborn Care (EmONC): Availability of lifesaving interventions such as caesarean sections, blood transfusions, and neonatal resuscitation.
4. Referral and Transport Systems: Efficient mechanisms for transferring mothers and newborns in case of complications.
5. Community Awareness and Accessibility: Ensuring that women understand the importance of skilled care and can physically and financially access it.

Global and Regional Trends

Over the past two decades, significant progress has been made in expanding access to skilled birth attendance worldwide. According to global estimates, over 80% of births are now attended by skilled health personnel, compared to about 60% in 2000. However, progress remains uneven across regions.

• High Coverage Regions: Europe, North America, and East Asia report over 95% of births with skilled attendance.
• Low Coverage Regions: Sub-Saharan Africa and South Asia still have lower rates, often below 70%, due to limited healthcare infrastructure, workforce shortages, and socio-economic barriers.

Disparities also exist within countries, with urban populations having better access than rural or marginalised communities.

Barriers to Skilled Birth Attendance

Several challenges hinder universal access to skilled care during childbirth:

• Shortage of Skilled Health Workers: Many low-income countries face critical deficits in trained midwives and obstetric staff.
• Geographical Barriers: Remote or rural areas often lack accessible facilities.
• Socio-economic Constraints: Poverty, lack of transportation, and cultural practices discourage facility-based deliveries.
• Inadequate Infrastructure: Poorly equipped facilities and shortages of essential supplies reduce the quality of care.
• Cultural and Gender Norms: Preference for traditional birth attendants (TBAs) and restrictions on women’s mobility can limit skilled attendance.

Addressing these barriers requires coordinated policy interventions and investment in health systems.

Role of Traditional Birth Attendants (TBAs)

In many developing countries, traditional birth attendants still assist in a significant number of deliveries, especially in rural communities. Although TBAs possess experience and local trust, they often lack the training to manage obstetric emergencies. Modern health policies increasingly emphasise the integration of TBAs into formal healthcare systems through training, supervision, and referral linkages, allowing them to support but not replace skilled professionals.

Strategies to Improve Skilled Birth Attendance

Governments and international organisations have implemented a range of strategies to enhance SBA coverage and quality:

• Training and Deployment of Midwives: Expanding midwifery education programmes and ensuring equitable distribution of skilled workers.
• Strengthening Health Infrastructure: Improving maternal health facilities and ensuring availability of essential drugs and equipment.
• Community-Based Interventions: Raising awareness through outreach, community health workers, and maternal education campaigns.
• Financial Incentives and Health Insurance: Providing free or subsidised maternal health services to encourage facility-based deliveries.
• Policy and Governance: Establishing national frameworks that prioritise maternal and neonatal health.

Monitoring and Indicators

The proportion of births attended by skilled health personnel is a standard global indicator used to assess progress in maternal health. Data are typically collected through national health surveys and are used to monitor SDG 3 targets.
Quality monitoring also considers:

• Availability of emergency obstetric care.
• Competence and behaviour of health personnel.
• Maternal and neonatal outcomes.

Outcomes and Global Impact

Countries that have achieved high levels of skilled birth attendance show marked declines in both maternal and neonatal mortality rates. For example, nations with more than 90% SBA coverage report maternal mortality ratios below 100 per 100,000 live births, compared to over 400 per 100,000 in regions with low coverage.