Scoping review to identify and map the health personnel considered skilled birth attendants in low-and-middle income countries from 2000-2015

Barriers to clinical learning skills development among midwifery students and newly qualified midwives in Morocco: A qualitative study

Background

In Morocco, despite various initiatives to improve the quality of reproductive healthcare, the indicators remain unfavorable. To strengthen the skills of midwives and support the achievement of Millennium Development Goals (MDGs) 4 and 5 by 2030, Morocco has developed and implemented a competency-based training framework. However, there is a lack of information on the successful implementation of this program and its impact on the quality of student midwives' preparation for practice.

Objective

This study aimed to gain a deeper understanding and explore the barriers affecting the development of clinical learning skills among midwifery students and newly qualified midwives.

Methods

This study employed a descriptive, exploratory qualitative approach. Data were collected through nine focus group discussions with 30 midwifery students and 24 newly graduated midwives between April and June 2023 from six higher education institutions in northern and central Morocco. Inductive content analysis was used to analyze the transcribed discussions.

Results

The barriers varied between locations. Overall, the internship design was inadequate, and the clinical environment was insufficient. Participants highlighted limited opportunities to experience the full range of midwifery skills. However, most midwifery students and new graduates had deficient competencies in managing high-risk situations and emergencies.

Conclusion

This work provides an overview of the nature and extent of the challenges faced by many student midwives in Morocco, resulting in newly graduated midwives being poorly prepared for the full range of midwifery practice. These findings can inform various initiatives to strengthen midwifery education at the global, regional, and national levels.

Factors associated with maternal health services utilization in Pakistan: Evidence from Pakistan maternal mortality survey, 2019

BACKGROUND

This study investigates the factors associated with maternal health services utilization in Pakistan using two outcome indicators, ideal antenatal care (IANC), defined as the pregnant woman receiving all the essential services included in standard antenatal care, and skilled birth attendance (SBA).

METHODS

This study used the Pakistan Maternal Mortality Survey 2019 data. The study utilized binary logistic regression models to investigate the adjusted association between the outcome variables, separately for IANC and SBA, and the independent variables, education, wealth, parity, and residence.

RESULTS

Wealth showed a positive association with utilization of IANC (adjusted odds ratio [AOR] = 11.48, 95% CI = 7.76, 16.99) and SBA (AOR = 4.37, 95% CI = 3.30,5. 80). Maternal age was associated only with IANC for women aged 35 or more years (AOR = 1.31, 95% CI = 1.06, 1.62). Increased likelihood of utilization of IANC and SBA services was also observed for women with formal education. Women who had 3-5 previous live births had higher odds of using IANC and SBA than women who had 1-2 or more than five previous live births. Urban residency was not correlated with either IANC or SBA.

CONCLUSION

When compared to the wealthy and educated quintile, women in the lower wealth quintile and those without any formal education were less likely to utilize ANC and SBA services. A comprehensive and multipronged approach from the health and education sectors is needed to improve maternal health in Pakistan.

Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda

Evidence-based quality care is essential for reducing sub-Saharan Africa's high burden of maternal and newborn mortality and morbidity. Provision of quality care results from interaction between several components of the health system including competent midwifery care providers and the working environment. We assessed midwifery care providers' ability to provide quality intrapartum and newborn care and selected aspects of the working environment as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) project in Benin, Malawi, Tanzania, and Uganda. We used a self-administered questionnaire to assess provider knowledge and their working environment and skills drills simulations to assess skills and behaviours. All midwifery care providers including doctors providing midwifery care in the maternity units were invited to take part in the knowledge assessment and one third of the midwifery care providers who took part in the knowledge assessment were randomly selected and invited to take part in the skills and behaviour simulation assessment. Descriptive statistics of interest were calculated. A total of 302 participants took part in the knowledge assessment and 113 skills drills simulations were conducted. The assessments revealed knowledge gaps in frequency of fetal heart rate monitoring and timing of umbilical cord clamping. Over half of the participants scored poorly on aspects related to routine admission tasks, clinical history-taking and rapid and initial assessment of the newborn, while higher scores were achieved in active management of the third stage of labour. The assessment also identified a lack of involvement of women in clinical decision-making. Inadequate competency level of the midwifery care providers may be due to gaps in pre-service training but possibly related to the structural and operational facility characteristics including continuing professional development. Investment and action on these findings are needed when developing and designing pre-service and in-service training. Trial registration: PACTR202006793783148-June 17th, 2020.

The trend in density of skilled health personnel in BRICS countries: Implication for China and India

OBJECTIVE

The similarities and differences in workforce trends in BRICS (Brazil, Russia, India, China, and South Africa) may offer reciprocal lessons for emerging economies.

METHODS

We used the Global Health Observatory data to assess the secular trends between 2001 and 2017 in the number of skilled health personnel (SHP: doctors, nurses/midwives) in BRICS compared to the average of Organization for Economic Co-operation and Development (OECD) countries.

RESULTS

Substantial efforts have been made in BRICS to increase SHP availability, as demonstrated by an average exponential growth rate (AEGR) > 0.03 in Brazil, China, and India compared to 0.01 in OECD. With an AEGR as high as 0.07 after 2008, China reached the level of SHP availability commensurate with the sustainable development goals (SDGs) in 2017. Other than China, BRICS countries had a mean number of nurses and midwives per doctor between 2001 and 2017 higher than or comparable to the OECD average (2.78). The corresponding number in China was 1.04 in 2017, lower than 2.21 in India in 2001.

CONCLUSIONS

With China as the exception, BRICS countries maintained a sustainable skills mix of SHPs. China reached the level of SHP availability commensurate with the SDGs, but SHP's skill mix was imbalanced.

Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020

BACKGROUND

Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice.

METHODS

Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice.

RESULTS

The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making.

CONCLUSION

To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Factors influencing utilisation of services provided by community midwives and their non-retention in district Thatta, Pakistan: a qualitative study protocol

INTRODUCTION

Drawing on the well-acknowledged evidence of community midwives services to address the issue of high maternal mortality, the Government of Pakistan initiated the Community Midwifery (CMW) programme in 2006 to provide skilled birth attendance to pregnant women living in rural areas. Despite a large investment in CMW programme, the availability of community midwives in rural areas following their training is a constant struggle. The concerns related to the training, support and acceptability of community midwives need to be studied in order to identify gaps in the provision of skilled maternal and newborn healthcare. Therefore, this study aims to explore factors influencing the utilisation of services provided by community midwives and their non-retention in district Thatta, Pakistan.

METHODS AND ANALYSIS

The study will use a qualitative exploratory research design. The data will be collected through semistructured interviews and an approach of purposive sampling for the selection of participants for interviews. The study will be conducted in one of the rural districts Thatta of Province Sindh, Pakistan. The data will be collected through key informant interviews (KIIs) and in-depth interviews (IDIs). The KIIs will be conducted with officials of the health department (Thatta), the provincial maternal and newborn child health programme, and the Midwifery Association of Pakistan. The IDIs will be conducted with midwifery students, community midwives working and not working in the district, and community women of district Thatta. Data will be analysed through qualitative data analysis software NVivo V.10 and the thematic analysis approach.

ETHICS AND DISSEMINATION

Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-3391-11138). The results of the study will be disseminated to the scientific community, to policy-makers involved in CMW programme training and implementation, and to the research subjects participating in the study.

Are midwives ready to provide quality evidence-based care after pre-service training? Curricula assessment in four countries-Benin, Malawi, Tanzania, and Uganda

This research sought to map midwifery pre-service training curricula as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project conducted in Benin, Malawi, Tanzania, and Uganda. We conducted the review in two phases. In the first phase, online interviews were performed with the lead project midwives in all four study countries to get an overview of midwifery care providers' pre-service training courses, registration, and licensing requirements. We performed a mapping review of midwifery care providers' pre-service training curricula from different training institutions in the four study countries during the second phase. Curricula were reviewed and mapped against the International Confederation of Midwives (ICM) Essential Competencies framework to assess whether these curricula included the minimum essential training components described in the ICM framework. We identified 10 different professional titles for midwifery care providers. The number of years spent in pre-service training varied from one and a half to four years. Ten pre-service curricula were obtained and the assessment revealed that none of the curricula included all ICM competencies. Main gaps identified in all curricula related to women-centred care, inclusion of women in decision making, provision of care to women with unintended or mistimed pregnancy, fundamental human rights of individuals and evidence-based learning. This review suggests that there are skills, knowledge and behaviour gaps in pre-service training curricula for midwifery care providers when mapped to the ICM Essential Competencies framework. These gaps are similar among the different training courses in participating countries. The review also draws attention to the plethora of professional titles and different pre-service training curricula within countries. Trial registration: PACTR202006793783148-June 17th, 2020.

Midwifery in Middle Eastern and North African countries: A scoping review

BACKGROUND

While midwives are positioned as critical providers for improving sexual, reproductive, maternal and newborn health outcomes in the Middle East and North African (MENA) countries, the standards of midwifery have not been explored systematically in this region.

AIM

The purpose of this scoping review was to provide an overview of existing literature on midwifery practice, education, and regulation in MENA countries in the context of ICM standards.

METHODS

A search was conducted inclusive of English and Persian written studies published between 2000 and 2019 in CINAHL plus; Ovid MEDLINE; PubMed; Scopus; and grey literature. Title and abstract and full-text review were performed in Covidence, and data extraction and synthesis performed using NVivo 12.

RESULTS

The initial search identified 7,994 articles. Overall, 139 studies were included in the review. Although, the primary concept of most included studies was "midwifery practice", "midwifery regulation" was addressed in limited way. Approximately 90% were from Middle Eastern countries. Forty-two per cent of studies used cross-sectional designs, and most originated from Iran, Jordan, and Palestine. Diversity was found in midwifery education, practice and regulation across the MENA countries. Midwives from different nations had uneven levels of proficiency, scope of practice, and education. Midwifery curricula were aligned with ICM competencies in some countries. Most countries had midwifery associations and were members of ICM. Some countries had regulations recognising midwifery as an autonomous profession.

CONCLUSION

Midwifery practice, education and regulation in MENA countries were not always comparable with ICM standards, although some progress was evident.

Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- and middle-income countries: Lessons from Ethiopia and Nepal

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

A systematic review of the profile and density of the maternal and child health workforce in China

BACKGROUND

To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China.

METHODS

We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally.

RESULTS

Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births).

CONCLUSIONS

Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision.

Protocol for a scoping review to identify and map in-service education and training materials for midwifery care in sub-Saharan Africa from 2000 to 2020

INTRODUCTION

Maternal and neonatal mortality are disproportionally high in low-and middle-income countries. In 2017 the global maternal mortality ratio was estimated to be 211 per 100 000 live births. An estimated 66% of these deaths occurred in sub-Saharan Africa. Training programmes that aim to prepare providers of midwifery care vary considerably across sub-Saharan Africa in terms of length, content and quality. To overcome the shortfalls of pre-service training and support the provision of quality care, in-service training packages for providers of midwifery care have been developed and implemented in many countries in sub-Saharan Africa. We aim to identify what in-service education and training materials have been used for providers of midwifery care between 2000 and 2020 and map their content to the International Confederation of Midwives' Essential Competencies for Midwifery Practice (ICM Competencies), and the Lancet Midwifery Series Quality Maternal and Newborn Care (QMNC) framework.

METHODS AND ANALYSIS

A search will be conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Sciences Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a hand search of literature from international partner organisations will be performed. Information retrieved will include study context, providers trained, focus of training and design of training. Original content of identified education and training materials will be obtained and mapped to the ICM Competencies and the Lancet Series QMNC.

ETHICS AND DISSEMINATION

A scoping review is a secondary analysis of published literature and does not require ethical approval. This scoping review will give an overview of the education and training materials used for in-service training for providers of midwifery care in sub-Saharan Africa. Mapping the content of these education and training materials to the ICM Competencies and The Lancet Series QMNC will allow us to assess their appropriateness. Findings from the review will be reflected to stakeholders involved in the design and implementation of such materials. Additionally, findings will be published in a peer-reviewed journal, and used to inform the design and content of an in-service training package for providers of midwifery care as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) study, (https://alert.ki.se/) a multi-country study in Benin, Malawi, Tanzania and Uganda.

TRIAL REGISTRATION NUMBER

PACTR202006793783148; Post-results.

Potencialidades e limitações da atuação do enfermeiro no Centro Parto Normal

RESUMO Objetivo Conhecer as potencialidades e limitações da atuação do enfermeiro no Centro de Parto Normal (CPN). Método abordagem qualitativa, do tipo exploratório e descritivo, realizado em 2018, com seis enfermeiras atuantes em CPN intra-hospitalar público na região metropolitana de Fortaleza, Ceará, Brasil. A coleta das informações ocorreu por meio de entrevista individual, com análise a partir dos pressupostos da sociologia das profissões, com foco nos temas: conhecimento e autonomia; credencialismo; divisão do trabalho; mercado de trabalho e quadro de valores. Resultado A atuação do enfermeiro no CPN potencializa as boas práticas para o parto e nascimento, bem como amplia a importância e visibilidade deste profissional no cuidado materno-infantil. O cuidado clínico e a gestão emergem como foco da ação do enfermeiro no CPN. No entanto, mesmo com a indução do Estado para essa atuação, ainda há a necessidade de reconhecimento das competências e autonomia do enfermeiro no cuidado obstétrico por outros profissionais. Conclusão e implicações para a prática Há desafios que precisam ser superados como a ampliação da autonomia e do respeito ao credenciamento do enfermeiro para atuação no CPN e a harmonização entre a gestão do processo de trabalho e gestão do cuidado clínico por este profissional.

Provision of essential evidence-based interventions during facility-based childbirth: cross-sectional observations of births in northeast Nigeria

OBJECTIVES

To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting.

DESIGN AND PARTICIPANTS

Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care.

SETTING

Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally.

MAIN OUTCOME MEASURES

Data on 50 measures of internationally recommended evidence-based interventions and good practice.

RESULTS

1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy.

CONCLUSIONS

The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.

Stimulators of medical students' interest in geriatric medicine-A Systematic Review

OBJECTIVES

This study is a systematic review on stimulators of interest in pursuing a geriatric career among medical students in different countries. The review also assessed whether there were differences or similarities based on geographic regions or income categorisations.

METHODS

A 20-year (1998-2018) review of quality primary research articles was conducted (n = 10). For analysis, studies were categorised into low- and middle-income countries (LMICs), and high-income countries, based on World Health Organization and World Bank's income grouping for the 2019 fiscal year.

RESULTS

The frequently mentioned stimulators of interest in geriatrics were as follows: cultivating positive attitudes towards older people, participation in geriatric-related interventions and positive experiences during a geriatric training. Lack of published peer-reviewed articles from the LMICs limited the researchers' ability to compare the two income groups.

CONCLUSION

Suggestions to improve future systematic reviews that consider global factors, global participation or any aspect of global inclusion are discussed.

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

INTRODUCTION

Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings.

METHODS

This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys.

RESULTS

The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014).

CONCLUSION

BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis

BACKGROUND

Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally.

OBJECTIVE

To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care.

DESIGN

Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively.

FINDINGS

Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery.

KEY CONCLUSIONS

There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

'Who assisted with the delivery of (NAME)?' Issues in estimating skilled birth attendant coverage through population-based surveys and implications for improving global tracking

The percentage of live births attended by a skilled birth attendant (SBA) is a key global indicator and proxy for monitoring progress in maternal and newborn health. Yet, the discrepancy between rising SBA coverage and non-commensurate declines in maternal and neonatal mortality in many low-income and middle-income countries has brought increasing attention to the challenge of what the indicator of SBA coverage actually measures, and whether the indicator can be improved. In response to the 2018 revised definition of SBA and the push for improved measurement of progress in maternal and newborn health, this paper examines the evidence on what women can tell us about who assisted them during childbirth and methodological issues in estimating SBA coverage via population-based surveys. We present analyses based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted since 2015 for 23 countries. Our findings show SBA coverage can be reasonably estimated from population-based surveys in settings of high coverage, though women have difficulty reporting specific cadres. We propose improvements in how skilled cadres are classified and documented, how linkages can be made to facility-based data to examine the enabling environment and further ways data can be disaggregated to understand the complexity of delivery care. We also reflect on the limitations of what SBA coverage reveals about the quality and circumstances of childbirth care. While improvements to the indicator are possible, we call for the use of multiple indicators to inform local efforts to improve the health of women and newborns.