Quality of childbirth care provided by skilled birth attendants: A conceptual framework, new estimate of effective coverage and indicator assessment in Nepal, Senegal, and Zambia

Globally, recent increases in skilled birth attendant (SBA) coverage do not appear to be translating to proportionate reductions in maternal and neonatal mortality. One hypothesized driver is a quality gap in the childbirth care provided by health professionals. This research was conducted as part of a multi-country study to assess the quality of pre-service education of health professionals providing childbirth care and to enhance the measurement related to the coverage of SBAs and SHP. This work introduces a new metric of SBA quality, uses that metric to identify tracer indicators of quality that could be integrated into routine monitoring without the use of complex statistical methods, and identifies priorities for improving quality of care in Nepal, Senegal and Zambia. We gathered primary and secondary data, aligned to a comprehensive conceptual framework about quality of maternal and newborn care, in three “Exemplar” countries (Nepal, Senegal and Zambia). We applied latent variable analysis principles to measure quality, and constructed estimates of effective coverage of SBA. The five highest weighted indicators most predictive of quality of care were presence of a national compulsory continued development system, presence of a national licensing, relicensing and registration system, presence of a national education regulation system, proportion of health facilities with electricity available at all times, and proportion of health facilities with amoxicillin suspension available. Validity tests showed that effective SBA coverage had a stronger relationship with early neonatal mortality rates than crude SBA coverage at the subnational level. Our analysis suggests that effective SBA coverage is substantially lower than crude SBA coverage, ranging from 18% to 30% in Senegal, 25% to 43% in Nepal, and 12% to 35% in Zambia. Lower effective coverage levels demonstrated here reveal that mothers and newborns are receiving far less of the essential care than official statistics may portray. This work presents a novel approach to measure one of the most challenging concepts in global health, and the highest weighted indicators in this analysis may be useful for routine monitoring in LMICs and at the global level. These results also add to the evidence supporting a basic policy package to improve the quality of maternal and newborn care, including a national compulsory continued education system, national licensing, relicensing and registration systems and national education regulation systems. Finally, programs in these countries may benefit from using the subnational estimates to geographically tailor interventions and to improve health outcomes.