Skilled birth attendant

A Skilled Birth Attendant (SBA) is a trained and competent health professional—such as a doctor, nurse, or midwife—who has the necessary skills to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, as well as to identify, manage, or refer complications in women and newborns. The concept of the skilled birth attendant is central to global maternal and child health strategies aimed at reducing maternal mortality and neonatal deaths.

Definition

According to the World Health Organization (WHO), a skilled birth attendant is:

“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 pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns.”

This definition emphasises both technical competency and the ability to ensure safe, respectful, and quality care during childbirth.

Importance of Skilled Birth Attendance

The presence of a skilled birth attendant during labour and delivery is one of the most critical interventions for reducing maternal and infant morbidity and mortality.

1. Reduction of Maternal Mortality

Complications such as haemorrhage, obstructed labour, sepsis, eclampsia, and unsafe abortions are major causes of maternal deaths. SBAs can manage these emergencies promptly or refer cases to higher facilities, significantly reducing fatal outcomes.

2. Reduction of Neonatal Mortality

SBAs ensure immediate care for newborns—clearing airways, maintaining body temperature, promoting breastfeeding, and managing complications like birth asphyxia or infection—thereby reducing neonatal mortality.

3. Promotion of Institutional Deliveries

By providing skilled care within health facilities, SBAs encourage institutional births where emergency obstetric and newborn care services are available.

4. Improved Quality of Care

SBAs provide evidence-based, safe, and respectful maternity care, ensuring the rights and dignity of women during childbirth.

5. Contribution to Public Health Goals

Skilled birth attendance directly contributes to Sustainable Development Goal (SDG) 3, which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 and ensure universal access to reproductive and maternal healthcare.

Core Skills and Competencies of SBAs

Skilled birth attendants are trained to perform a range of technical, clinical, and interpersonal tasks, including:

• Antenatal Care:
  • Monitoring maternal and foetal health.
  • Identifying risk factors and complications.
  • Providing counselling on nutrition, hygiene, and birth preparedness.
• Intrapartum Care (During Labour and Delivery):
  • Conducting clean and safe deliveries using aseptic techniques.
  • Monitoring labour progression using tools like the partograph.
  • Administering medications (e.g., oxytocin for prevention of postpartum haemorrhage).
  • Performing assisted deliveries when necessary.
  • Managing obstetric emergencies such as eclampsia or retained placenta.
• Postnatal and Newborn Care:
  • Assessing and stabilising both mother and baby.
  • Promoting early and exclusive breastfeeding.
  • Identifying and managing postpartum infections.
  • Providing family planning counselling and support.
• Referral Skills:
  • Recognising complications early and arranging timely referral to higher facilities with emergency obstetric care.
• Documentation and Reporting:
  • Recording vital data, delivery outcomes, and complications for health information systems.

Training and Certification

The training and certification of skilled birth attendants vary by country but generally include:

• Duration: Typically 18 months to 3 years of formal education and clinical training.
• Curriculum: Based on WHO guidelines covering maternal health, newborn care, and emergency obstetric management.
• Categories of SBAs:
  • Doctors with obstetric training.
  • Nurses and Midwives trained in maternal and neonatal care.
  • Auxiliary Nurse Midwives (ANMs) who undergo SBA training programmes to enhance their delivery skills, particularly in rural areas.

In India, the Government of India launched the Skilled Birth Attendant Training Programme in 2005 under the National Rural Health Mission (NRHM) (now part of the National Health Mission – NHM) to train ANMs, staff nurses, and lady health visitors to provide skilled care during childbirth at both community and facility levels.

Skilled Birth Attendance in India

India has made significant progress in increasing institutional deliveries and SBA coverage over the past two decades.

Key Initiatives:

• Janani Suraksha Yojana (JSY): A conditional cash transfer scheme promoting institutional deliveries by incentivising mothers and health workers.
• Janani Shishu Suraksha Karyakram (JSSK): Provides free delivery and postnatal services to mothers and newborns in government health facilities.
• LaQshya Programme: A quality improvement initiative launched by the Ministry of Health and Family Welfare in 2017 to ensure safe and respectful maternity care in labour rooms and maternity operation theatres.
• Midwifery-Led Care Units (MLCUs): Recently introduced to strengthen midwifery as a distinct cadre, following international models of safe, woman-centred childbirth care.

Progress and Achievements:

• Institutional deliveries increased from 39% (NFHS-3, 2005–06) to over 88% (NFHS-5, 2019–21).
• Maternal Mortality Ratio (MMR) reduced from 254 (2004–06) to 97 (2018–20) per 100,000 live births.
• Neonatal Mortality Rate (NMR) and Infant Mortality Rate (IMR) have also shown steady declines.

Despite these achievements, challenges remain in ensuring equitable access and maintaining quality of care across rural, tribal, and underserved regions.

Challenges in Skilled Birth Attendance

• Shortage of Trained Personnel: Many rural and remote areas face a lack of trained SBAs and qualified midwives.
• Infrastructure Constraints: Inadequate health facilities, poor sanitation, and unreliable electricity affect safe delivery practices.
• Workload and Burnout: Limited staff and high workloads can reduce the quality of care.
• Cultural and Social Barriers: Traditional birth attendants (TBAs) continue to assist home births in certain communities due to trust and accessibility.
• Retention and Motivation: Difficulty in retaining skilled personnel in rural postings due to low incentives and working conditions.
• Quality Assurance: Variation in training standards and lack of continuous skill upgradation affect service quality.

Role of Skilled Birth Attendants in Reducing Maternal Mortality

The presence of SBAs at every delivery is a key indicator of maternal health system performance. Their contribution includes:

• Ensuring Safe Deliveries: Prevention of infection, haemorrhage, and other complications.
• Timely Management of Emergencies: Early recognition and response to life-threatening conditions.
• Health Education: Promotion of birth preparedness and postnatal care.
• Integration with Health Systems: Strengthening referral linkages and data-based decision-making.