Measuring Skilled Attendance in the uThungulu District, KwaZulu-Natal, in 2008

A dissertation submitted to the Department ! "u#lic $ealth Medicine Nels n %& Mandela Sch l ! Medicine 'ni(ersit) ! KwaZulu-Natal Dur#an, S uth A!rica

*n partial !ul!ilment ! the re+uirements ! r the Master in "u#lic $ealth

,)-

S lange Mianda
Super(is r- Dr Anna . ce

March 20/0

0As the candidate1s super(is r * agree2d n t agree t the su#missi n ! this dissertati n3

Super(is r- 444444444&

Date- 4444444444&

III

Dedication

I dedicate this work to my Lord Jesus Christ author and finisher of my faith, author of life, my everything. Thank you for the gift of time and life. To my family, thank you for your love, support and belief in me.

Acknowledgements
I would like to thank! The "niversity of #wa$ulu%&atal 'cholarship Committee for supporting my studies throughout the years The #wa$ulu%&atal (rovincial )epartment of *ealth +esearch ,ffice and the uThungulu *ealth )istrict for granting permission to conduct this study All hospital managers in the study hospitals -Catherine .ooth, /kombe, /showe, &kandla and 't 0ary1s hospitals2 for supporting this study All midwives for taking part in the obstetric knowledge and skills test The )epartment of (ublic *ealth 0edicine (rof Anna Coutsoudis for introducing me to the university community (rof /ddie 0hlanga -)epartment of ,bstetrics and 3ynaecology2, (rof *ugh (hilpott and 0s $o 04olo -Centre for +ural *ealth2 for your input toward the implementation of this study )r Anna oce, my supervisor, for showing interest in the study and for providing constructive

advice and active support. *er patience and encouragement have helped me achieve more than I thought I could All my 0(* colleagues 5riends at 3lenridge Church International, .ridget Thomas, /mma Anyachebelu, .ukky Ade6umo, Celdi Lu4olo for your friendship and spiritual support.

Declaration
I 'olange 0ianda declare that! -i2 The research reported in this dissertation, e7cept where otherwise indicated, is my original work. -ii2 This dissertation has not been submitted for any degree or e7amination at any other university. -iii2 This dissertation does not contain other person1s data, pictures, graphs or other information, unless specifically acknowledged as being sourced from other persons. -iv2 This dissertation does not contain other persons1 writing, unless specifically acknowledged as being sourced from other researchers. 8here other written sources have been 9uoted! a2 Their words have been re%written but the general information attributed to them has been referenced. b2 8here their e7act words have been used, their writing has been placed inside 9uotation marks, and referenced. -v2 8here I have reproduced a publication of which I am an author, co%author or editor, I have indicated in detail which part of the publication was actually written by myself alone and have fully referenced such publications. -vi2 This dissertation does not contain te7t, graphics or tables copied and pasted from the internet, unless specifically acknowledged, and the source being detailed in the dissertation and the references section.

Signature- 444444444&

Date- 4444444444&

Abstract
,ackgr und The 0illennium )evelopment 3oals call for two%third and three%9uarter reductions in (erinatal 0ortality +ates and 0aternal 0ortality +atios. The main strategy towards achieving these reductions is to increase access to skilled attendance. *owever, it cannot be confirmed that all health professionals are skilled in managing women in labour, nor that they are functioning in enabling environments. To measure the provision of skilled attendance, this study was undertaken in five Level : *ospitals in the uThungulu *ealth )istrict of #wa$ulu%&atal. The ob6ectives of the study were! :. To establish perinatal outcomes for each Level : *ospital in uThungulu *ealth )istrict. ;. To evaluate the 9uality of intrapartum care provided in Level : *ospitals in uThungulu *ealth )istrict. <. To evaluate the obstetric knowledge of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. =. To evaluate the obstetric skills of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. >. To evaluate the environment in which births are attended in Level : *ospitals in uThungulu *ealth )istrict. ?. Compare the 9uality of care, the knowledge, skills and environment with perinatal outcomes. Meth ds (erinatal outcomes -(&0+, 5'.+, /&&)+ and (CI2 were calculated for each hospital@ maternity case records of women who have delivered in these Level : *ospitals were audited to assess the 9uality of intrapartum care@ obstetric knowledge and skills of midwives were assessed@ as was the enabling environment within which midwives worked, which included a measurement of their workload. A correlation between perinatal outcomes and the 9uality of intrapartum care, knowledge and skills and the enabling environment was performed to determine whether variables were associated.

II %esults The overall (&0+ for five hospitals in uThungulu *ealth )istrict was <: per :AAA births. Three hospitals demonstrated (&0+s below <A per :AAA, while the other two showed rates above => per :AAA. The combined 5'.+ for the five hospitals was ? per :AAA births, the combined /&&)+ was :; per :AAA live births. The (CI in all hospitals ranged between < and =. An audit of maternity case records revealed that all hospitals have a high overall mean percentage score per record. *owever, analysis of subsets showed good performance in recordings on the labour graph, but poor performance in the admission assessment and in the management of labour. The #ruskal%8allis &on%(arametric Test showed a statistically significant difference in overall scores amongst hospitals -pBA.A:2, suggesting differences in performance in all five hospitals in terms of the 9uality of care provided.

,verall, all hospitals scored poorly on tests of obstetric knowledge and skills. There were no statistically significant differences in the overall knowledge median scores and subsets median scores amongst hospitals -pBA.AC2, indicating that all five hospitals performed on a similar level in terms of obstetric knowledge. *owever, all hospitals performed differently in relation to obstetric skills, as there was a statistically significant difference in the overall skill median scores amongst hospitals -pBA.AA;2. Three hospitals met the enabling environment standard. All hospitals but one scored poorly on referral, and the availability of supervision on both shifts. ,ne hospital scored poorly on drugs and supplies. ,verall no hospitals reported the presence of all the elements of the enabling environment. Three hospitals had acceptable workloads. &o association could be detected between variables. *owever, there were trends that can be traced in different hospitals. 5 nclusi ns In 'outh Africa, from the )emographic and *ealth 'urvey, D=E of deliveries are assisted by skilled attendant. 8hile an attendant may be present, one cannot say that skilled attendance has been provided, as it has been shown for uThungulu *ealth )istrict.

III

Table of Contents
)/)ICATI,&........................................................................................................................ III AC#&,8L/)3/0/&T'........................................................................................................ I )/CLA+ATI,&...................................................................................................................... A.'T+ACT........................................................................................................................... I T*+// *,'(ITAL' 0/T T*/ /&A.LI&3 /& I+,&0/&T 'TA&)A+). ALL *,'(ITAL' ."T ,&/ 'C,+/) (,,+LF ,& +/5/++AL, A&) T*/ A AILA.ILITF ,5 '"(/+ I'I,& ,& .,T* '*I5T'. ,&/ *,'(ITAL 'C,+/) (,,+LF ,& )+"3' A&) '"((LI/'. , /+ALL &, *,'(ITAL' +/(,+T/) T*/ (+/'/&C/ ,5 ALL T*/ /L/0/&T' ,5 T*/ /&A.LI&3 /& I+,&0/&T. T*+// *,'(ITAL' *A) ACC/(TA.L/ 8,+#L,A)'. ..................................................................................................... II TA.L/ ,5 C,&T/&T'........................................................................................................ III LI'T ,5 TA.L/'...................................................................................................................GI )/5I&ITI,& ,5 T/+0'...................................................................................................... GIII AC+,&F0'.........................................................................................................................G LI'T ,5 A..+/ IATI,&'................................................................................................... G I :. .AC#3+,"&)...................................................................................................................: :.: I&T+,)"CTI,&............................................................................................................: :.; (+,.L/0 'TAT/0/&T................................................................................................< T*/ 0)3' CALL 5,+ T8,%T*I+) +/)"CTI,&' I& (&0+ A&) T*+//%H"A+T/+ +/)"CTI,&' I& 00+. T*/ 0AI& 'T+AT/3F T,8A+)' AC*I/ I&3 T*/'/ +/)"CTI,&' I' T, I&C+/A'/ ACC/'' T, )/LI /+F .F A '#ILL/) ATT/&)A&T. *A I&3 /G(/+I/&C/) A&)
'#ILL/) 0/)ICAL */L( )"+I&3 C*IL).I+T* I' I0(,+TA&T A&) A C+ITICAL I&T/+ /&TI,& T, +/)"C/ 0AT/+&AL A&) (/+I&ATAL 0,+TALITF. T*/+/5,+/ */ALT* 8,+#/+' 0"'T ./ T+AI&/) A&) (+, I)/) 8IT* /''/&TIAL '#ILL', #&,8L/)3/, '"((LI/' A&) /H"I(0/&T, T, ATT/&) )/LI /+F /55/CTI /LF, /'(/CIALLF I& (,,+ A&) +"+AL A+/A' -0/&3'T/A. ;AA?, (:>@ ./LL /T AL ;AA<, (;;D@ 0AC),&AL) A&) 'TA++' ;AA;, (<2...............................< ALT*,"3* 'I3&I5ICA&T /55,+T' *A / .//& 0A)/ T, I&C+/A'/ '#ILL/) ATT/&)A&C/, 0AT/+&AL A&) (/+I&ATAL 0,+TALITF A+/ 'TILL *I3* I& 0A&F C,"&T+I/'. 5,+ /GA0(L/, I& ',"T* A5+ICA, I;E ,5 )/LI /+I/' ,CC"+ I& */ALT* 5ACILITI/' -),* ;AA=, (:=2. T*I' '*,"L) 0/A& T*AT 8,0/& A&) T*/I+ .A.I/' *A / ACC/'' T, A '#ILL/) ATT/&)A&T. ."T T*/ 'A I&3 0,T*/+' +/(,+T ;AA;%;AA= '*,8' T*AT =:.;E ,5 0AT/+&AL )/AT*' A+/ A'',CIAT/) 8IT* '".%'TA&)A+) CA+/ I& L/ /L : *,'(ITAL' A&) <;.:E A+/ A'',CIAT/) 8IT* A)0I&I'T+ATI / (+,.L/0' -&CC/0) ;AA>, (:A, :;2. T*/ 'A I&3 .A.I/' ;AA?%;AAC +/(,+T '*,8' T*AT :?E ,5 ALL (/+I&ATAL )/AT*' A+/ */ALT* CA+/ 8,+#/+ +/LAT/) A&) :;E A'',CIAT/) 8IT* A)0I&I'T+ATI / (+,.L/0' -(ATTI&',& /T AL ;AAI, (;>%;?2. .............................................................................................< I& ./&I&, JA0AICA, /C"A),+ A&) +8A&)A, 'T")I/' *A / '*,8& T*AT T*,"3* '#ILL/) ATT/&)A&T' 8/+/ A AILA.L/, T*/F *A / I&A)/H"AT/ #&,8L/)3/ A&) '#ILL' I& 0A&A3I&3 ,.'T/T+IC LI5/ T*+/AT/&I&3 C,&)ITI,&' -#,.LI&'#F /T AL ;AA?, (:<DA2. I& 3*A&A A&) C,T/ )1I ,I+/, A T*I+) ,5 *,'(ITAL .I+T*' 8/+/ ATT/&)/) .F "&H"ALI5I/) 0I)8I5/+F A''I'TA&T' 8IT*,"T A&F 5,+0 ,5 '"(/+ I'I,& -#,.LI&'#F /T AL ;AA?, (:<DA2..........................................................................................................................<

........................................................................................................................................= T*/'/ ,.'/+ ATI,&' A+/ I&)ICATI,&' T*AT T*/ (+, I'I,& ,5 '#ILL/) ATT/&)A&T' -.,T* 8IT* +/3A+) T, T*/ ATT/&)A&T A&) T*/ /&A.LI&3 /& I+,&0/&T2 I' (+,.L/0ATIC. T*/+/5,+/ A& /G(L,+AT,+F 'T")F 0/A'"+I&3 '#ILL/) ATT/&)A&C/
8A' +/H"I+/) T, /'TA.LI'* T*/ (+, I'I,& ,5 '#ILL/) ATT/&)A&T' I& T/+0' ,5 T*/

IG
H"ALITF ,5 CA+/ (+, I)/), T*/ ,.'T/T+IC #&,8L/)3/ A&) '#ILL' ,5 */ALT* (+, I)/+', A&) T*/ /&A.LI&3 /& I+,&0/&T 8IT*I& 8*IC* T*/F 8,+#. .........................= :.< +/L/ A&C/ ,5 T*/ 'T")F........................................................................................= :.= 'C,(/ ,5 T*/ 'T")F..................................................................................................> :.> +/'/A+C* AI0 A&) ,.J/CTI /'................................................................................> :.? 'T+"CT"+/ ,5 T*/ )I''/+TATI,&.............................................................................? T*I' C*A(T/+ )+A8' T,3/T*/+ T*/ I&5,+0ATI,& ,.TAI&/) 5+,0 T*/ LIT/+AT"+/ T*AT A((LI/' T, '#ILL/) ATT/&)A&C/ AT .I+T* A&) IT' 0/A'"+/0/&T. IT 'TA+T' 8IT* )/5I&I&3 '#ILL/) ATT/&)A&C/ A&) (+, I)/' T*/ +ATI,&AL/ 5,+ '#ILL/) ATT/&)A&C/ AT .I+T*. T*I' I' 5,LL,8/) .F T*/ )/'C+I(TI,& ,5 )I55/+/&T 0/T*,)' I)/&TI5I/) I& T*/ LIT/+AT"+/ 5,+ T*/ A''/''0/&T ,5 '#ILL/) ATT/&)A&C/, A&) T*/ C*ALL/&3/' I&, A&) I&T/+ /&TI,&' 5,+, /&'"+I&3 '#ILL/) ATT/&)A&C/. T*/ C*A(T/+ CL,'/' 8IT* C,&C/(T"AL 5+A0/8,+#' 5,+ '#ILL/) ATT/&)A&C/ I)/&TI5I/) I& T*/ LIT/+AT"+/ A&) T*/ C,&C/(T"AL 5+A0/8,+# "'/) I& T*/ 'T")F. ...............................................................C ;.; 8*AT I' '#ILL/) ATT/&)A&C/J...............................................................................D ;.< 8*F '#ILL/) ATT/&)A&C/ AT .I+T*J...................................................................:: ;.= 0/A'"+I&3 '#ILL/) ATT/&)A&C/.........................................................................:; ;.> 'T")I/' ,& T*/ 0/A'"+/0/&T ,5 '#ILL/) ATT/&)A&C/....................................:> ;.? C*ALL/&3/' I& /&'"+I&3 '#ILL/) ATT/&)A&C/..................................................:C ;.C I&T/+ /&TI,&' T, I&C+/A'/ '#ILL/) ATT/&)A&C/..............................................:D ;.I C,&C/(T"AL 5+A0/8,+# "'/) I& T*/ 'T")F......................................................:I ;.:A C,&CL"'I,&...........................................................................................................;A T*I' C*A(T/+ *A' (+, I)/) A& , /+ I/8 ,5 T*/ /GI'TI&3 LIT/+AT"+/ ,& '#ILL/) ATT/&)A&C/ AT .I+T* I& 3/&/+AL. IT *A' (+/'/&T/) T*/ +ATI,&AL/ 5,+ '#ILL/) ATT/&)A&C/, (+, I)I&3 / I)/&C/ T*AT '#ILL/) ATT/&)A&T' ,(/+ATI&3 8IT*I& A& /&A.LI&3 /& I+,&0/&T L/A) T, 0AJ,+ )/C+/A'/' I& 0AT/+&AL A&) (/+I&ATAL 0,+TALITF. IT *A' AL', (+/'/&T/) 0/A'"+/' ,5 '#ILL/) ATT/&)A&C/ A&) )I55IC"LTI/' I& T*/ 0/A'"+/0/&T ,5 '#ILL/) ATT/&)A&C/. C*ALL/&3/' I& /&'"+I&3 '#ILL/) ATT/&)A&C/ A&) I&T/+ /&TI,&' T, I&C+/A'/ '#ILL/) ATT/&)A&C/ 8/+/ AL', )I'C"''/). 5I&ALLF C,&C/(T"AL 5+A0/8,+#' 5,+ '#ILL/) ATT/&)A&C/ A&) T*/ C,&C/(T"AL 5+A0/8,+# "'/) I& T*/ 'T")F 8/+/ )I'C"''/). . .;: <. 0/T*,),L,3F.............................................................................................................;; <.: I&T+,)"CTI,&..........................................................................................................;; <.; +/'/A+C* AI0 A&) +/'/A+C* ,.J/CTI /'............................................................;; <.< T*/ 'T")F 'IT/........................................................................................................;; <.= +/'/A+C* )/'I3&....................................................................................................;= <.> 'T")F (/+I,)..........................................................................................................;= <.? 'T")F (,("LATI,& A&) 'A0(LI&3........................................................................;> <.C A+IA.L/' 0/A'"+/).............................................................................................;C T*/ &,&%(A+A0/T+IC I&)/(/&)/&T A+IA.L/' -+/(+/'/&TI&3 )I0/&'I,&' ,5 '#ILL/) ATT/&)A&C/2 T*AT 8/+/ 0/A'"+/) 8/+/ H"A&TITATI /, &"0/+ICAL A+IA.L/' A&) A+/ '"00A+I$/) I& TA.L/ <.? A' 5,LL,8!..................................................................;D <.D )ATA C,LL/CTI,& 0/T*,)', I&'T+"0/&T' A&) (+,C/)"+/'.............................;D <.I 0/A'"+/' TA#/& T, /&'"+/ 'T")F ALI)ITF A&) C,&T+,L 5,+ (,T/&TIAL .IA'/'.......................................................................................................................................<: <.:A )ATA 0A&A3/0/&T A&) )ATA 'T,+A3/.............................................................<< <.:: )ATA A&ALF'I' .....................................................................................................<= T*/ )/(/&)/&T A+IA.L/' 8/+/ (A+A0/T+IC &"0/+ICAL A+IA.L/' )/5I&/) A'!

..................................................................................................................................................<? <.:; /T*ICAL C,&'I)/+ATI,&'.....................................................................................<C <.:< LI0ITATI,&' ,5 T*/ 'T")F...................................................................................<D

G <.:= C,&CL"'I,&...........................................................................................................<D =.: (/+I&ATAL ,"TC,0/'.............................................................................................=A =.; H"ALITF ,5 I&T+A(A+T"0 CA+/............................................................................=: =.< ,.'T/T+IC #&,8L/)3/ ,5 */ALT* CA+/ 8,+#/+'. ...........................................== =.= ,.'T/T+IC '#ILL' ,5 */ALT* CA+/ 8,+#/+'.......................................................=? =.> /&A.LI&3 /& I+,&0/&T.........................................................................................>; =.? A'',CIATI,& ./T8//& (/+I&ATAL ,"TC,0/' A&) H"ALITF ,5 I&T+A(A+T"0 CA+/, ,.'T/T+IC #&,8L/)3/ A&) '#ILL', A&) T*/ /&A.LI&3 /& I+,&0/&T...................>= =.C C,&CL"'I,&.............................................................................................................>> >. )I'C"''I,& ....................................................................................................................>C >.; H"ALITF ,5 I&T+A(A+T"0 CA+/ ...........................................................................>I >.> T*/ /&A.LI&3 /& I+,&0/&T.................................................................................?; T*+// *,'(ITAL' 0/T T*/ /&A.LI&3 /& I+,&0/&T 'TA&)A+). ALL *,'(ITAL' ."T ,&/ 'C,+/) (,,+LF ,& +/5/++AL, A&) T*/ A AILA.ILITF ,5 '"(/+ I'I,& ,& .,T* '*I5T'. ,&/ *,'(ITAL 'C,+/) (,,+LF ,& )+"3' A&) '"((LI/'. , /+ALL &, *,'(ITAL' +/(,+T/) T*/ (+/'/&C/ ,5 ALL T*/ /L/0/&T' ,5 T*/ /&A.LI&3 /& I+,&0/&T. 'T")I/' .F 3.A&3)A)/ /T AL -;AA<2 A&) 0CCA8%.I&&' /T AL -;AA=2 L,,#/) AT T*/ /&A.LI&3 /& I+,&0/&T@ *,8/ /+ &, )/TAIL' ,& T*/I+ +/'"LT' 8/+/ +/(,+T/). T*/ /&A.LI&3 /& I+,&0/&T +/5/+' T, C,&)ITI,&' I& 8*IC* '#ILL/) ATT/&)A&T' 8,+# T, (+, I)/ 8,0/& 8IT* CA+/ )"+I&3 C*IL).I+T*.T*/
/L/0/&T' ,5 T*/ /&A.LI&3 /& I+,&0/&T I)/&TI5I/) I& T*/ LIT/+AT"+/ A+/ LI'T/) A&) )/5I&/) I& '/CTI,& ;.;.;. +/'"LT' 5+,0 T*/L/ /L : *,'(ITAL' I& "T*"&3"L" */ALT* )I'T+ICT '"33/'T T*AT T*/ /& I+,&0/&T I' &,T 5"LLF /&A.LI&3, T*"' T*/ &//) 5,+ H"ALITF I0(+, /0/&T I&ITIATI /' T, A))+/'' T*/ A AILA.ILITF ,5 )+"3', /H"I(0/&T 0AI&T/&A&C/ A&) I&/55/CTI / '"(/+ I'I,&. ............................................................................................?; >.? A'',CIATI,& ./T8//& (/+I&ATAL ,"TC,0/' 8IT* T*/ H"ALITF ,5 I&T+A(A+T"0 CA+/, T*/ ,.'T/T+IC #&,8L/)3/ A&) '#ILL' A&) /& I+,&0/&T.............?; #,T$//, T K C,"(/+, I ;AA?, L8*AT I&T/+ /&TI,&' ), ',"T* A5+ICA& H"ALI5I/) ),CT,+' T*I&# 8ILL +/TAI& T*/0 I& +"+AL *,'(ITAL' ,5 T*/ LI0(,(, (+, I&C/ ,5 ',"T* A5+ICAJM 5A0ILF 0/)ICI&/, ,L. <I, &, =, ((. ;DD%;IA.......................................................................?I A((/&)IG :. ?! I&5,+0/) C,&'/&T 5,+0...................................................................D> T*/ +/'/A+C* 'T")F, I&CL")I&3 T*/ A., / I&5,+0ATI,&, *A' .//& )/'C+I./) T, 0/ ,+ALLF. I "&)/+'TA&) 8*AT 0F I& ,L /0/&T I& T*/ 'T")F 0/A&' A&) I ,L"&TA+ILF A3+// T, (A+TICI(AT/. I *A / .//& 3I /& A& ,((,+T"&ITF T, A'# A&F H"/'TI,&' T*AT I 0I3*T *A / A.,"T (A+TICI(ATI,& I& T*/ 'T")F...................................D>

T,TAL........................................................................................................................:AI &A0/ ,5 T*/ +/ I/8/+ ............................................................................................::: A'# T*/ 0I)8I5/ I& C*A+3/ ,5 T*/ LA.,"+ 8A+).....................................................::: I5 F," *A / T, +/5/+ A& ,.'T/T+IC /0/+3/&CF *,8 L,&3 ),/' IT TA#/ 5,+ T*/ A0."LA&C/ T, A++I /J 0AGI0"0!NNNNNN 0I&I0"0!NNNNN.. ::: 8*IC* I' F,"+ +/5/++AL *,'(ITALJ.............................................................................::: +/5/++AL ::: .L,,)..............................................................................................................................::; C,00/&T ,& /H"I(0/&T!...............................................................................................::<

GI

List of Tables

List of Figures

5I3"+/ =. :! 0/A& , /+ALL (/+C/&TA3/ 'C,+/ (/+ +/C,+), .F L/ /L : *,'(ITAL I& "T*"&3"L" */ALT* )I'T+ICT, J"&/ ;AAD............................................................................=< 5I3"+/ =. ;! #&,8L/)3/ 0/)IA& (/+C/&TA3/ 'C,+/' .F L/ /L : *,'(ITAL I& "T*"&3"L" */ALT* )I'T+ICT, J"&/ ;AAD..................................................................................................=> 5I3"+/ =. <! LA.,"+ 3+A(* /G/+CI'/ I 0/)IA& (/+C/&TA3/ 'C,+/ .F L/ /L : *,'(ITAL I& "T*"&3"L" */ALT* )I'T+ICT, J"&/ ;AAD............................................................................=D 5I3"+/ =. =! LA.,"+ 3+A(* /G/+CI'/ II O 0/)IA& (/+C/&TA3/ 'C,+/ .F L/ /L : *,'(ITAL I& "T*"&3"L" */ALT* )I'T+ICT, J"&/ ;AAD........................................................................=I 5I3"+/ =. >! ((* 'TATI,& % , /+ALL 0/)IA& (/+C/&TA3/ 'C,+/, .F L/ /L : *,'(ITAL I& "T*"&3"L" */ALT* )I'T+ICT, J"&/ ;AAD............................................................................>:

GII

List of Appendices
A((/&)IG :. :! (,'T3+A)"AT/ /)"CATI,& C,00ITT// A((+, AL.............................C? A((/&)IG :. ;! .I,0/)ICAL +/'/A+C* /T*IC' C,00ITT// A((+, AL........................CC A((/&)IG :. <! (/+0I''I,& 5+,0 T*/ (+, I&CIAL */ALT* +/'/A+C* A&) #&,8L/)3/ 0A&A3/0/&T )I I'I,&..........................................................................................................CD A((/&)IG :. =! *,'(ITAL (/+0I''I,&P'"((,+T L/TT/+'................................................CI A((/&)IG :. >! L/TT/+ T, 0.,&3,L8A&/ *,'(ITAL....................................................D= A((/&)IG :. ?! I&5,+0/) C,&'/&T 5,+0.......................................................................D> A((/&)IG :. :! (,'T3+A)"AT/ /)"CATI,& C,00ITT// A((+, AL.............................C? A((/&)IG :. ;! .I,0/)ICAL +/'/A+C* /T*IC' C,00ITT// A((+, AL........................CC A((/&)IG :. <! (/+0I''I,& 5+,0 T*/ (+, I&CIAL */ALT* +/'/A+C* A&) #&,8L/)3/ 0A&A3/0/&T )I I'I,&..........................................................................................................CD A((/&)IG :. =! *,'(ITAL (/+0I''I,&P'"((,+T L/TT/+'................................................CI A((/&)IG :. >! L/TT/+ T, 0.,&3,L8A&/ *,'(ITAL....................................................D= A((/&)IG :. ?! I&5,+0/) C,&'/&T 5,+0.......................................................................D>

GIII

Definition of Terms
/arly neonatal death rate The number of live born infants that die in the first week of life per :AAA live born infants -(/( ;AAD, p=C2. A health facility that provides basic obstetric, surgical, medical, paediatric and psychiatric care. Includes anaesthetic facility - oce ;AA>, p7ii2. A maternal death is Lthe death of a woman while pregnant or within =; days of the termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from incidental or accidental causesM -8*, :II;, p=2. The maternal mortality ratio is the number of maternal deaths in a given time period per :AA AAA live births during the same time period -Abou$ahr and 8ardlaw ;AA=, p=2. A person who has successfully completed the prescribed course of studies in midwifery and ac9uired the re9uisite 9ualifications to be registered andPor legally licensed to practice midwifery -8*,PIC0P5I3, ;AA=, pC2. The partograph is a simple chart to record and monitor the progress of labour and other essential maternal and fetal observations. It can provide an early indication that emergency obstetric care is needed -"&5(A ;AA=a, p:I2.

Level : *ospital

0aternal mortality ratio

0idwife

(artograph -partogram2

(erinatal inde7 care

The ratio of the perinatal mortality rate to the low birth weight rate -(/( ;AAD, p>A2.

(erinatal mortality rate

&umber of all perinatal deaths per :AAA total births. (erinatal deaths include all stillbirths that weigh more than >AA grams and early neonatal deaths -(/( ;AAD, p=A2.

'killed attendant

*ealth professional providing care during childbirth -8*,PIC0P5I3, ;AA=, pC2. This professional needs to have a set of skills, defined as core midwifery skills, to provide effective care during childbirth. A skilled attendant needs to be able to

GI conduct normal deliveries and recogni4e, manage and refer obstetric complications -8*,P IC0P5I3, ;AA=, pC2. 'killed attendance The process by which women are provided with ade9uate care during labour, delivery and the early postpartum period and re9uires both skilled attendant and the enabling environment -8*,PIC0P5I3, ;AA=, pC2.

'tillbirth

+efers to an infant born dead after ? months of intra%uterine life -(/( ;AAD, p=<2. 'tillbirth is divided in stillbirth that occurs before the onset of labour -macerated stillbirth2 and those that occur during labour -fresh stillbirth2 -(/( ;AAD, p=>2. The stillbirth rate is the number of stillborn infants per :AAA total births -(/( ;AAD, p==2.

Acronyms
)/(A0 5I3, IC0 0)3 +C,3 '/+A "&5(A "&IC/5 8*, )/C/&T+ALI'/) (+,3+A00/ 5,+ A)
A&C/)

0I)8I

/'

International 5ederation of 3ynaecology and ,bstetrics International Confederation of 0idwives 0illennium )evelopment 3oals +,FAL C,LL/3/ ,5 ,.'T/T+ICI&A' A&) 3F&A/C,L,3I'T' ',"T*/+& /)"CATI,& A&) +/'/A+C* ALLIA&C/ "nited &ations (opulation 5und "nited &ations ChildrenQs 5und 8orld *ealth ,rgani4ation

G I

List of abbreviations
Adm A&C .( )g ),* /m,C /&&)+ 5C 5*+ 5'.+ *I *rly 0C 0CH 00+ 07 ,'C/ (CI (I* (&0+ ((* +esus T Admission Antenatal care .lood pressure )iagnosis )epartment of *ealth /mergency obstetric care /arly neonatal death rate 5etal condition 5etal heart rate 5resh still birth rate *uman immuno%deficiency virus *ourly 0aternal condition 0ultiple choice 9uestions 0aternal mortality ratio 0anagement ,b6ective structured clinical e7amination (erinatal care inde7 (regnancy induced hypertension (erinatal mortality rate (ost%partum haemorrhage +esuscitation Temperature

1. Background
1.1 ntroduction
/very year women and babies die during childbirth and IDE of these deaths occur in the developing world -8*, ;AA>, pC%I2. 3lobal efforts place maternal and perinatal mortality at the centre of their activities and this is evidenced in the 0illennium )evelopment 3oals -0)3%= and 0)3%>2 that call for a two%third reduction in under%five mortality and a three% 9uarter reduction in maternal mortality ratio -00+2 by the year ;A:> using the year ;AAA as a baseline -Lawn et al ;AA?, p:=C=@ (attinson ;AA?, p:2. The estimated perinatal mortality rate in ;AAA for the world is =C per :AAA births -8*, ;AA?, p:D2, and the estimated maternal mortality ratio in the same year is =AA per :AA AAA live births -Abou$ahr and 8ardlaw ;AA=, p:;2. The highest numbers of perinatal deaths occur in the developing world -8*, ;AA?, p;A2, and the highest numbers of maternal deaths are almost e9ually shared between Africa and Asia -Abou$ahr and 8ardlaw ;AA=, p:A@ "&5(A ;AA=a, p:;2. 8hile perinatal and maternal mortality estimates are still high mainly in Africa and Asia, 'outh Africa has made considerable progress in monitoring these deaths with the introduction of the Confidential /n9uiry into 0aternal )eaths and the implementation of the (erinatal (roblem Identification (rogramme, resulting in the publication of the 'aving 0others and 'aving .abies reports -(attinson ;AA?, piv2. These reports reflect on the causes of perinatal and maternal deaths and provide appropriate recommendations on how to avoid them -(attinson ;AA?, piv2. )espite national efforts towards alleviating maternal and child deaths, perinatal mortality in 'outh Africa is still high across the country -(attinson ;AA?, piv2. The 'outh African perinatal mortality rate estimate in ;AAA is << per :AAA births and the (&0+ for #wa$ulu%&atal in the same year is =A per :AAA births - ella ;AA<, p:>2. The tables below give some figures of maternal mortality for the year ;AAA for different regions of the world -Abou$ahr and 8ardlaw ;AA=, p;;%;?2 and provide information on the 'outh African and the #wa$ulu%&atal perinatal mortality rate over a three%year period -*'T ;AA?, p=2.

; Ta#le /& /- MM% estimates per /00 000 li(e #irths #) %egi n in 2000&
Regions Global estimates Africa Sub-Saharan Africa South Africa Maternal mortality ratio per 100 000 live births Perinatal mortality per 1000 births

400 830 920 110

47 62 33

Ta#le /& 2- KwaZulu-Natal and S uth A!rica estimated "NM% 2006-2007 per /000 #irths&
Year Perinatal mortality K a!ulu-"atal South Africa

#00$ #00% #00&

50.7 41.3 40.3

38.4 38.2 34.9

The estimates in Table :.: show high maternal mortality ratios in Africa as a whole but particularly in sub%'aharan Africa. The table also shows a high maternal mortality ratio for 'outh Africa. Table :.; shows slight decreases in perinatal mortality over a three%year period, demonstrating a slow move towards the 0)3%= target of a two%third reduction in perinatal mortality. The decreases shown in perinatal mortality may suggest that the 9uality of care provided by maternity units in the country is improving. Achieving the 0)3%= target in the remaining five years is challenging but still possible. In order to monitor 0)3% = and% >, three indicators are defined for measuring progress towards the reduction of perinatalPmaternal mortality. The first is the under five%mortality rate -"nited &ations ;AAD, p;A2, which refers to the probability of dying between birth and e7actly five years of age. The second is the maternal mortality ratio, referring to the number of maternal deaths for every :AA AAA live births -Lawn et al ;AA?, p:=C=@ "&5(A ;AA=a, p:<@ "nited &ations ;AAD, p;=2. )ue to the lack of accurate data on maternal deaths especially in developing countries, the "nited &ations selected another indicator to monitor the process of reducing maternal and perinatal mortality! the proportion of births attended by skilled health personnel -8*, ;AAC, p<@ "&5(A ;AA<, p:=2. The choice of this indicator is based on the evidence of the relationship between having a skilled health worker at delivery and the reduction of maternal and perinatal mortality -3raham et al ;AA:, p::D%:;=2. 8ith few e7ceptions, almost all countries where skilled attendance is more than DAE have low 00+s and (&0+s -"&5(A ;AA=a, p:>2. The proportion of deliveries attended by skilled health personnel, therefore, is a key indicator for 0)3% = and% >.

<

+eductions in perinatal mortality are also dependent on the availability of skilled attendance. (erinatal deaths may be easier to monitor than maternal deaths, which are relatively infre9uent events -Akalin et al :IIC, p<<A2. Therefore perinatal outcomes are used as an outcome measure of skilled attendance in the present study.

1.! "roblem statement

The 0)3s call for two%third reductions in (&0+ and three%9uarter reductions in 00+. The main strategy towards achieving these reductions is to increase access to delivery by a skilled attendant. *aving e7perienced and skilled medical help during childbirth is important and a critical intervention to reduce maternal and perinatal mortality. Therefore health workers must be trained and provided with essential skills, knowledge, supplies and e9uipment, to attend delivery effectively, especially in poor and rural areas -0engsteab ;AA?, p:>@ .ell et al ;AA<, p;;D@ 0ac)onald and 'tarrs ;AA;, p<2. 3lobally, trends in delivery assisted by skilled attendants are shown to be rising. +esults from household surveys report an increase in women who can access professional care. )espite these results, there are still women left without care, particularly in developing countries, thus leading to maternal and perinatal deaths -#oblinsky et al ;AA?, p:<CC2. In sub%'aharan Africa and south%Asia, skilled attendance is shown to be more accessible in urban areas than rural areas mainly -#oblinsky et al ;AA?, p:<CC2. Although significant efforts have been made to increase skilled attendance, maternal and perinatal mortality are still high in many countries. 5or e7ample, in 'outh Africa, I;E of deliveries occur in health facilities -)o* ;AA=, p:=2. This should mean that women and their babies have access to a skilled attendant. .ut the 'aving 0others report ;AA;%;AA= shows that =:.;E of maternal deaths are associated with sub%standard care in level : hospitals and <;.:E are associated with administrative problems -&CC/0) ;AA>, p:A, :;2. The 'aving .abies ;AA?%;AAC report shows that :?E of all perinatal deaths are health care worker related and :;E associated with administrative problems -(attinson et al ;AAI, p;>%;?2. In .enin, Jamaica, /cuador and +wanda, studies have shown that though skilled attendants were available, they have inade9uate knowledge and skills in managing obstetric life threatening conditions -#oblinsky et al ;AA?, p:<DA2. In 3hana and Cote )1Ivoire, a third of

= hospital births were attended by un9ualified midwifery assistants without any form of supervision -#oblinsky et al ;AA?, p:<DA2. These observations are indications that the provision of skilled attendants -both with regard to the attendant and the enabling environment2 is problematic. Therefore an e7ploratory study measuring skilled attendance was re9uired to establish the provision of skilled attendants in terms of the 9uality of care provided, the obstetric knowledge and skills of health providers, and the enabling environment within which they work.

1.# $elevance of t%e study

The study is placed within the conte7t of 0)3s =%>, which call for a reduction of the (erinatal and 0aternal 0ortality. 8orldwide, skilled attendance is recogni4ed as the critical factor towards achieving 0)3s =%> and it is used as one of the indicators to measure the attainment of these goals. Currently, evidence e7ists in favour of skilled attendance, confirming the relationship between having a skilled health worker at delivery and the reduction of maternal and perinatal mortality. Although the percentage of women attended by health professionals may be increasing worldwide and in 'outh Africa in particular, (&0+ and 00+ are not being reduced in 'outh Africa. 0any of these deaths could have been avoided, as most of them were health provider and administrative related -(attinson et al ;AAI, p;>%;?2. )espite the publication of the 'aving 0others and 'aving .abies reports, it has been noticed that the avoidable factors reported in the first report are the same as reported in recent editions -(attinson ;AA?, pv2. This is an indication of no progress and a lack of the implementation of the recommendations provided in the reports. 0oreover, there is very little information about the competence of skilled attendants -their knowledge and skills2 as well as the elements that contribute to the enabling environment within which they work. The Rproportion of deliveries with skilled attendance1 is used as a pro7y measure for skilled attendance indicating only the presence of a health professional at delivery -*ussein et al ;AA=, p:?:2. Therefore, in order to e7plore the issue of skilled attendance, this study is designed to establish the level of skilled attendance in uThungulu *ealth )istrict, one district in rural #wa$ulu%&atal.

>

1.& 'cope of t%e study

This study is an e7ploratory pilot study, e7ploring the relationship between perinatal outcomes, the 9uality of care provided, the obstetric knowledge and skills of midwives and the enabling environment. The study comprises five level one hospitals in the uThungulu *ealth )istrict. This study setting is selected because there is an e7isting 9uality improvement initiative in the district as part of the Area Three Learning Comple7 initiated by the Centre for +ural *ealth -C+* ;AAC2. +esults from this study will add to the interventions re9uired to improve learning activities for health care workers in this district. 0idwives were selected as a focus in the study because they are mostly responsible for the conduct of normal deliveries and refer in case of complications, especially in rural settings -*arvey et al ;AAC, pCD<2.

1.( $esearc% aim and ob)ectives

1.(. 1 'tudy aim
The aim of the study is to measure the provision of skilled attendance in Level : *ospitals in uThungulu *ealth )istrict.

1.(.! *b)ectives of t%e study

:. To establish perinatal outcomes for each Level : *ospital in uThungulu *ealth )istrict. ;. To evaluate the 9uality of intrapartum care provided in Level : *ospitals in uThungulu *ealth )istrict. <. To evaluate the obstetric knowledge of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. =. To evaluate the obstetric skills of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. >. To evaluate the environment in which births are attended in Level : *ospitals in uThungulu *ealth )istrict. ?. Compare the 9uality of care, the knowledge, skills and environment with perinatal outcomes.

1.+ 'tructure of t%e dissertation

Chapter : has presented the background of the study, the statement of the problem, relevance and scope of the study, and the aim and ob6ectives of the study. Chapter ; reviews e7isting literature on skilled attendance, describes different methods used to measure skilled attendance, and presents the conceptual framework used in the study. Chapter < outlines the methodology adopted to assess the provision of skilled attendance, the study instruments, the ethical considerations and study limitations. Chapter = presents the findings of the research in various formats! statements, tables and graphs. Chapter > discusses the main findings of the study and makes concluding remarks and recommendations to improve skilled attendance at birth. The appendices present letters of permissions and the study instruments used for data collection -Appendices I through III2.

!. Literature review
!.1 ntroduction
This chapter draws together the information obtained from the literature that applies to skilled attendance at birth and its measurement. It starts with defining skilled attendance and provides the rationale for skilled attendance at birth. This is followed by the description of different methods identified in the literature for the assessment of skilled attendance, and the challenges in, and interventions for, ensuring skilled attendance. The chapter closes with conceptual frameworks for skilled attendance identified in the literature and the conceptual framework used in the study. +elevant literature was identified as follows! /lectronic databases -0edLine%(ub0ed, 'cience )irect and 3oogle 'cholar2 and electronic 6ournals -the International Journal of 3ynaecology and ,bstetrics, +eproductive *ealth Journal, 'outh African 0edical Journal, 0idwifery@ Tropical )octor and The Lancet.com2 were searched using the following key words! 'killed attendance at birth A&) maternal health@ skilled attendance at delivery A&) 9uality maternal care@ skilled attendance A&) assessment@ skilled attendance A&) measurement@ competency assessment A&) health care A&) skilled attendance A&) perinatal mortality@ (erinatal care A&) skilled care@ perinatal mortality A&) health workers@ midwives A&) knowledge@ midwives A&) skill@ skilled attendance A&) clinical competence. The 8orld *ealth ,rganisation website was searched. /7perts in the field of maternal health were consulted and additional information was obtained from them. The reference list at the end of identified literature was used to identify further literature. Articles provided during the 0aster of (ublic *ealth 0aternal and &ewborn *ealth module were also used. The literature was limited to /nglish documents. The referencing system used is the *arvard referencing style.

!.! ,%at is skilled attendance'killed attendance comprises the presence of a skilled attendant and the enabling environment in which skilled attendance may be provided -0ac)onagh ;AA>, p=@ 3raham et al ;AA:, p:AA2.

!.!.1 'killed attendants

R'killed attendants1 refers to health professionals providing care to women during childbirth -8*,PIC0P5I3, ;AA=, pC2. These professionals need to have a set of skills, defined as core midwifery skills, to provide effective care during childbirth. 5or e7ample, they need to be able to conduct normal deliveries and recogni4e, manage and refer obstetric complications -8*,P IC0P5I3, ;AA=, pC2. )epending on the level of care -level : or ;2 or geographic location -urban versus rural2 the skills re9uired might vary in order to respond to the needs of a particular population. *owever, universally, all skilled attendants are e7pected to perform the core midwifery functions defined by the "nited &ations -Carlough and 0cCall ;AA>, p;A:@ 3raham et al ;AA:, p:A;%:A=2 :. 'afely conduct a normal delivery using aseptic techni9ue ;. Implement active management of the third stage of labour <. (rovide immediate care of the newborn, including resuscitation =. 0anage most postpartum haemorrhage through the use of parenteral o7ytocics, controlled cord traction and abdominal massage of the fundus of the uterus >. 0anually remove the placenta ?. 0anage eclampsia through the provision of parenteral antihypertensives C. +ecogni4e and manage postpartum infection through the use of parenteral antibiotics D. (erform assisted vaginal delivery through the use of a vacuum e7tractor I. 0anage incomplete abortions with manual vacuum aspiration -0 A2 :A. #now how to refer women to the ne7t level of care and stabili4e them for their 6ourney. The types of skilled attendants identified in the literature -8*,PIC0P5I3, ;AA=, pC2 comprise! O O 0idwife! a person who has completed the prescribed courses in midwifery and has ac9uired the license to practice midwifery@ &urse with midwifery skills! a nurse who has ac9uired knowledge and skills in midwifery@

I O O )octor! a doctor who has ac9uired midwifery skills through training@ ,bstetrician! a medical doctor who has speciali4ed in the medical management and care of pregnancy and childbirth.

!.!.! .nabling environment

The enabling environment refers to conditions in which skilled attendants work to provide women with care during childbirth. The elements of the enabling environment identified in the literature include the availability of sufficient health professionals, essential e9uipment, essential drugs, supervision, referral systemsPtransport and a manual of protocols for obstetric management -3raham et al ;AA:, pIC@ 8*,PIC0P5I3, ;AA=, p:=2. In order to be provided with effective care during childbirth, women need the assistance of health professionals in numbers proportional to the deliveries in each facility. 5or e7ample, the +oyal College of ,bstetricians and 3ynaecologists -+C,32 recommend :.:> midwives per woman in labour -+C,3 :III, p<=2. In 'outh Africa, the health system faces many human resource problems, especially a shortage and a maldistribution of healthcare workers. The 'outh African )epartment of *ealth has attempted to address the shortage of health professionals by implementing various interventions, including increasing salaries, introducing scarce skills and rural allowances and upgrading clinics and hospitals. )espite these efforts, the supply and distribution of health professionals in the country has not improved -#ot4ee and Couper ;AA?, p;DD2. Intrapartum birth asphy7ia is responsible for high perinatal mortality in 'outh Africa and ade9uate fetal monitoring during labour is a key task to prevent these deaths. *owever, due to serious staff shortages faced by the country, especially of midwives, it is difficult for each labour to be effectively monitored and prevent neonatal deaths -.amford et al ;AA?, p>;@ elaphi and (attinson ;AAC, p:AA%:A;, .uchmann and (attinson ;AA?, pD%:A@ (attinson et al ;AA>, p?2. &ot only is there need for enough midwives conducting deliveries, there is also need for other elements of the enabling environment! a labour ward should be provided with essential e9uipment and facilities to assist midwives in their work. These include! delivery bed with wedge, trolley%bed with cot sides, sphygmomanometer, stethoscope, clinical thermometer, haemoglobinimeter, hand%held )oppler instrument, cardiotocograph, basic ultrasound scanner,

:A intravenous infusion pump, vacuum e7tractor and suction, obstetric forceps, delivery repair pack, cervical removal pack, cusco vaginal speculum, symphysiotomy knife, fully e9uipped resuscitation trolley, defibrillator. The number re9uired of each item depends on the level of care, the si4e of the labour ward as well as the number of patients treated -.artlett et al ;AA?, p>D2. "&IC/5P8*,P"&5(A -:IIC, p;?2 propose that the availability of drugs be checked by whether the signal drugs of in6ectable antibiotics, in6ectable o7ytocics and in6ectable anticonvulsants are available. ,7ytocics are mainly used to reduce the risk of maternal postpartum haemorrhage, whereas in6ectable antibiotics are used to control mild infections, and in6ectable anticonvulsants to manage patients with severe pre%eclampsia and eclampsia. ,bstetric haemorrhage is the main cause of maternal mortality in the world -8*, ;AA>, p?<2. Therefore, timely access to safe blood products -red blood cells, platelets, plasma and cryoprecipitate2 is a life saving measure to prevent severe anaemia in women with obstetric haemorrhage -&CC/0) ;AA>, pC;@ 8*, :II:, pDA@ (admanabhan et al ;AAI, p:;>@ 8*, ;AAD, p:C2. In sub%'aharan Africa, the lack of blood for transfusion is shown to be a contributing factor to maternal mortality. The reason for this deficiency is poverty and a lack of donors -.ates et al ;AAD, p:<<<, &CC/0), ;AA>, pD:2. In Latin America, to avoid the lack of blood for transfusion, a campaign was implemented in the general population to encourage voluntary blood donation. The provision of 9uality services to donors was also ensured -Cru4 ;AAC, p;I<2. 5or complications beyond the capacity of the health facility, midwives are e7pected to refer to the ne7t level of care for appropriate management. To do so, there is a need for an effective referral system and an e9uipped ambulance within an hour of call -&CC/0) ;AA>, p;;2. Transport between facilities is problematic in 'outh Africa, accounting for I.CE of all maternal mortality and :.>E of perinatal mortality due to birth asphy7ia -&CC/0) ;AA>, p::@ .amford et al ;AA?, p>=2. Cost and long distance between institutions are other reasons hindering effective use of the referral system -Jahn and )e .rouwere, ;AA:, p;;I2. 5or the management of obstetric complications, the use of drugs and referral routes should be according to protocols of management defined for each level of care. In 'outh Africa, cases of perinatal and maternal deaths were recorded as a result of failure to comply with e7isting protocols -.amford et al ;AA?, p?D@ &CC/0) ;AA?, p::>2. /nsuring compliance to a manual

:: of protocols for obstetric management is therefore imperative. This can be achieved through supportive supervision. It has been shown that regular supervision motivates staff and helps maintain high standards of care -"&5(A ;AA?, p:;%:<@ 0aclean ;AA<, p:?>2. In 'outh Africa, the &ational )epartment of *ealth has published 0aternity Care 3uidelines that serve as a basis for protocols of obstetric management at local level -)o* ;AA;, p<:%:A=@ )o* ;AAC2.

!.# ,%y skilled attendance at birt%Across the developing world, women and children die unnecessarily as a result of pregnancy and childbirth. 3lobally, countries including 'outh Africa are committed to reducing maternal and perinatal mortality. Towards the attainment of the millennium development goals, increasing the proportion of deliveries assisted by skilled attendants is the key strategy towards these reductions -(attinson ;AA?, p:@ 8*,PIC0P5I3, ;AA=, p:@ "nited &ations :III, p<:2. In both developed and developing countries a number of effective interventions can be performed by skilled attendants to decrease maternal and perinatal mortality. In order to effectively manage the main obstetric complications and causes of maternal mortality -postpartum haemorrhage, obstructed labour, sepsis and pregnancy related induced hypertension2 -8*, ;AA>, p?<@ "&5(A ;AA=a, pI2 skilled attendants must able to recogni4e these conditions and manage them appropriately -0aclean "ndated, p<:2. Their competency could lead to high percentage reductions in maternal mortality as reflected in Table ;.:. -8*,P"&5(AP"&IC/5P8orld .ank :III, p>A2. Ta#le 2& /- Minimum skills re+uired ! skilled attendants in identi!)ing and managing #stetric c mplicati ns&
'auses of maternal mortality (hat s)ille* atten*ants *o to prevent maternal mortality (hat s)ille* atten*ants can *o to manage obstetric complications + of *eaths preventable by s)ille* atten*ants

Postpartum haemorrhage

Active management of third stage of labo r 'se of %artogra%h 'se of ase%tic techni) e *arl# identification and management of %reeclam%sia

,bstructe* labour Sepsis Pregnancy in*uce* hypertension

!"#tocics$ terine massage$ man al removal of %lacenta$ fl ids and blood. (aesarean section$ s#m%h#siotom# Antibiotics$ removal of infected material +agnesi m s l%hate$ anti-h#%ertensives$ deliver#.

30& 70& 50& 20&

:; The underlying causes of perinatal mortality are, in most cases, the same factors as those leading to maternal mortality, and include poor health during pregnancy and inade9uate intra% and postpartum care -0aclean "ndated, p<C2. It has been shown that traditional birth attendants are unable to treat complications leading to maternal and perinatal death and should rather be e9uipped to refer -Carlough and 0cCall ;AA>, p;A:, )e .ernis et al ;AA<, p<I%>C2. *ence, ade9uate skilled care during pregnancy and in the intra% and postpartum period could help reduce up to ?<E of all perinatal deaths and <>%>AE of neonatal deaths. The breakdown of skilled care interventions that help reduce neonatal mortality by cause of death is described in Table ;.; -)armstadt et al ;AA>, p:, >2. Through effective maternal and fetal monitoring, skilled attendants can prevent birth asphy7ia. In the case of birth asphy7ia they can resuscitatePventilate the baby or apply cardiac massage where needed. They can also diagnose preterm birth and refer for proper care -0aclean "ndated, p<C2. Ta#le 2& 2& Skilled care inter(enti ns in reducing ne natal deaths #) cause ! death&
Perio* of intervention S)ille* care interventions + of *eaths preventable by cause of neonatal *eaths

-nfections Pregnancy -ntrapartum O O O O O Postpartum O ,amil# care -.illed maternal and immediate neonatal care *mergenc# obstetric care /+" of com%lications0 Antibiotics for %remat re r %t re of membranes Antenatal corticosteroids for %reterm labo r *"tra care for lo1 birth 1eight babies /e"tra 1armth$ h#giene and feeding0 (ase +" for %ne monia *mergenc# neonatal care2 +" of serio s illness /infections$ as%h#"ia$ %remat rit# and 3a ndice0 20-50& 10-20& 3-9&

.irth asphy/ia 30-45& 20-60& -

Prematurity 5-10& 25-50& 20-50&

1-10&

O O

20-55& 30-70&

0-5&

15-40&

!.& /easuring skilled attendance

Considerable evidence e7ists on the association between skilled birth attendance and maternalPperinatal mortality. It is clear that the presence of life saving skills is essential in the reduction of maternalPperinatal mortality -"&5(A ;AA?, p<@ Chowdhury et al ;AAC, p:<;A2.

:< 0oreover, skilled birth attendance at birth is being used as an indicator to measure the attainment of the 0illennium )evelopment 3oals -*ussein et al ;AA=, p:?:@ *arvey et al ;AAC, pCD<2. *owever this measure reflects only on the presence of health care providers at delivery, not on their competencies nor on the environment within which they work. It cannot be confirmed that all health professional are skilled in managing women in labour unless their skills have been assessed -*ussein et al ;AA=, p:?:@ 0ac)onagh ;AA>, pI2. The assessment of skilled attendance at delivery has been slow and difficult in many countries -#oblinsky et al ;AA?, p:<CI2. This is due to the confusion between the terms attendance and attendant. 5or e7ample, the 8orld *ealth ,rgani4ationQs 0aking (regnancy 'afer Initiative focuses on the skilled attendant -health professional with midwifery skills2, whereas the 'killed Care Initiative in .urkina 5aso, #enya and Tan4ania considers the entire concept of skilled attendance, including the care provider and the enabling environment -*ussein K Clapham ;AA>, p;I?%;IC2. Apart from terminology issues, there is also a lack of consistency in the definition of skilled attendance. 5or e7ample, in 0alawi, ward attendants are considered as part of skilled attendants, and in &epal, traditional birth attendants were earlier included in the estimates of the proportion of births by a skilled attendant, but e7cluded later on -3raham et al ;AA:, p:AA@ *ussein K Clapham ;AA>, p;I?%;IC2. Therefore, in order to distinguish the elements of skilled attendance, various methods are being used. These include! measuring the presence of skilled attendants -doctors, midwives, and nurses2, measuring the knowledge and skills of attendants, and measuring the enabling environment.

!.&.1 /easuring t%e presence of skilled attendants

To be able to achieve two%third and three%9uarter reductions in perinatal and maternal mortality, enough skilled professionals conducting deliveries are re9uired, and they need to be accessible. A crude measure of the presence of skilled attendants is the proportion of deliveries attended by a skilled attendant. To determine the presence of skilled attendants, household surveys are used. In these surveys women are asked what type of health professional assisted in their most recent delivery. +esults are presented as the percentage of deliveries by category of skilled attendant! doctor, midwife, nurse and other. These surveys do not give any indication of the knowledge or skills of attendants -*arvey et al ;AAC, pCD<2.

:= A more sophisticated measure has been proposed for the measurement of skilled attendants at birth! the partnership ratio -3raham et al ;AA:, p:;=2. This refers to the ratio of deliveries attended by a doctor versus a midwife. 5rom analysing the association between partnership ratios and maternal mortality, the ideal partnership ratio -(+2 is :>, D>! where :>E of deliveries are attended by doctors and D>E of deliveries are attended by midwives -3raham et al ;AA:, p:;=@ "&5(A ;AA<, p:;2. This is in line with the estimate that :>E of all deliveries will result in a complication, and will re9uire higher%level care -0aine et al :IIC, p;=2.

!.&.! /easuring t%e knowledge and skills of attendants

In order to maintain and improve high standards of care, a health system needs regular assessment of the performance of health professionals. This will help to identify gaps in the knowledge and skills of providers and the need for training. 0ethods to measure the performance of health providers include! written tests, computerised tests, review of medical records and simulations, as reflected in Table ;.< -#ak et al ;AA:, p:A%::2. Ta#le 2& 6- Meth ds t assess the per! rmance ! health pr !essi nals attending #irths&
Metho* (ritten test (hat is assesse* Abilities$ traits and .no1ledge. (linical decision ma.ing s.ills. 0o a*ministere* (ase st dies. A*vantages O O O (ase st dies. O O -tandardisation of ) estions. 4o1 cost. !b3ectivit# in scoring. (onsistenc# of the cases. !b3ectivit# in scoring. 8roviders are not a1are. 4o1 cost. -tandardised testing. 1isa*vantages O -.ills cannot be meas red.

'omputerise * test

Revie of me*ical recor*s

(om%etence.

7ecord a dit.

O O

O O O O O

Anatomic mo*els

(om%etenc# in %h#sical actions.

-tations.

5nabilit# to eval ate com%etencies involving %h#sical actions 6igh cost 5ncom%leteness of records. +issing records 8oor ) alit# of records. 5nabilit# to sim late.

:>

!.&.# /easuring t%e enabling environment

The measurement of the enabling environment must include the measurement of the factors that are essential elements for health worker performance. The assessment can be done by using methods described in Table ;.= -#ak et al ;AA:, p::@ 0cCaw%.inns et al ;AA=, p::, :;2. Ta#le 2& 8- Meth ds used t measure the ena#ling en(ir nment&
Metho* Revie of me*ical recor*s (hat is assesse* 8erformance of health %roviders in managing normal deliver# and obstetric com%lications. 9o assess the level of s %ervision$ training$ and motivation. 0o a*ministere* 7ecord a dit. A*vantages O O 8roviders are not a1are 4o1 cost. 1isa*vantages O O O 5ncom%leteness of records +issing records 8oor ) alit# of records. 9ime cons ming (om%le" and diffic lt to anal#se.

Survey of health care or)ers

-nventory of health care facilities

Availabilit# of essential dr gs$ e) i%ment and s %%lies in each hos%ital.

,ree listing of elements contrib ting 9o the %erformance of health care 1or.ers. -tr ct red (hec.lists observation.

Assess man# items at the same time.

O O

4o1 cost.

:iffic lt to have a one-si;e fits all chec.list.

!.( 'tudies on t%e measurement of skilled attendance

Although the percentages of deliveries attended by skilled attendants have increased worldwide, not every health professional can be considered a skilled attendant -*ussein et al ;AA=, p:?:2. 'ome studies measuring skilled attendance were identified in the literature@ however it seems that most studies measure one or other dimension of attendance. 5ew, with the e7ception of *ussein et al -;AA=2, attempt to measure the full dimensions of attendance. )etails on identified studies measuring the dimensions of skilled attendance are presented in Table ;.>.

:? Ta#le 2& 7- Studies n the measurement ! skilled attendance&

Stu*y Mc'a .inns et al #00%3 2arget group -.illed birth attendants. Metho*s use* O O O O O O <ritten test -elf assessment Anatomic models !bservation chec.list - rve# of %roviders 5nventor# of maternit# services. 1escription of the stu*y Assess2 O 9he com%etence= %erformance of s.illed attendants O 9he enabling environment. Results O 9here is little correlation bet1een %rovider>s self assessment and c rrent s.ills and .no1ledge. 5nade) ate monitoring of labo r in most cases 5nfre) ent %erformance of some ne1born %ost%art m care .e# tas.s. After ade) ate training$ +(6< ma# be considered to be s.illed attendant. ,e1 records meet the criteria for s.illed attendance. 9here is a 1ide difference bet1een %rovider>s c rrent com%etence and the <6! standards.

'arlough an* Mc'all #00&

+aternal and child health 1or.ers /+(6<0.

Anatomic models

0ussein et al #00%

+aternit# records.

O O

0arvey et al #004

6ealth %roviders attending births /doctors$ medical st dents and n rses0.

O O

(linical records -.illed birth attendance inde" <ritten test Anatomic models.

Assess 1hether +(6< co ld achieve the minim m level of com%etence re) ired to meet the definition of s.illed attendant. +eas re the e"tent of s.illed attendance at birth. 9o assess 1hether health %ersonnel en merated in ho sehold s rve#s fit the <6! definition of s.illed attendant.

:C

!.+ C%allenges in ensuring skilled attendance

This section presents some of the challenges encountered in ensuring skilled attendance. 3lobally, the provision of skilled attendance is slow. There are still gaps in coverage between developing and developed countries, rich and poor and those living in urban and rural areas -#oblinsky et al ;AA?, p:<CI, :<DI@ "&5(A ;AA?, p<2. Long distance and several hours or days of walking are strong hindrances to accessing skilled attendance. The provision of skilled attendance is hampered by health professional shortages, mostly in rural areas of sub%'aharan Africa and south%Asian countries. This is mainly due to health professional migration to countries like the "nited #ingdom or the "nited 'tates of America -#oblinsky et al ;AA?, p:<CI@ "&5(A ;AA=b, p:D2. ,ther factors affecting access to skilled attendance are e7pensive health services and poor attitude of health care workers -Thaddeus and 0aine :II=, p:AI:% ::AA2. An analysis of maternal and perinatal deaths shows substandard care in the intrapartum period, and a lack of basic obstetric knowledge and skills. This finding suggests that a review is necessary of the education and training received by medical and midwifery students -0oran et al ;AA?, p<C2. This corroborates the findings by *arvey et al -;AA=, p;AC2, and #oblinsky et al -;AA?, p:<DA2. Thus even if the proportion of deliveries attended by a skilled professional have increased, few are receiving care of ade9uate standard. In places where skilled attendance is accessible, there are women who remain out of reach of maternal services for other reasons@ for e7ample, due to gender disparities and lack of decision% making power, where the husband as the head of household, decides on the type of care and provider re9uired for the wife -Fesudian ;AA=, p:2. ,ther factors hindering access to skilled attendance are lack of education, customs and traditional beliefs, age and marital status -#oblinsky et al ;AA?, p:<D:@ 0pembeni et al ;AAC, p>@ Chowdhury et al ;AAC, p:<;<2.

:D

!.0 nterventions to increase skilled attendance

To address the factors hindering the provision of skilled attendance, different strategies have been adopted around the world. The 8*, has passed resolutions re9uesting member countries to develop plans that will promote retention of health care workers. 5or e7ample, the #ampala )eclaration urges member countries to ensure ade9uate incentives and a safe working place for health care workers. It also recommends an e9uitable distribution of health workers across urban versus rural areas -8*,% ,/C) ;AAD, p;A%;:@ 0ac)onagh ;AA>, p;A, ;:2. "pgrading health workers1 skills is essential to ensuring women and babies have access to skilled attendance. This can be achieved by! training nurses in midwifery skills@ training of general practitioners in obstetric surgery@ or training nurses and midwives in anaesthetic skills -)e .ernis et al ;AA<, p<I%>C2. 5or e7ample, in Tunisia all medical practitioners have a compulsory four%month training in obstetrics and gynaecology@ in .otswana there has been a focus on developing additional skills in midwives and doctors@ in 0alaysia all doctors working at district hospitals have four to seven months training in obstetrics, including obstetric emergencies@ and in 'ri Lanka midwifery training has been compulsory for doctors since :I:> -0ac)onagh ;AA>, p:<2. In $ambia, the )emocratic +epublic of the Congo and 3hana, the category of midlevel health professional has been created to provide anaesthesia, assisted deliveries or surgery, especially in rural areas -0ac)onagh ;AA>, p;:@ 0aclean ;AA<, p:?=2 /ducation and e7posure to mass media have been shown to be factors that empower women towards the utili4ation of skilled attendants. /ducation enhances women1s status in society through knowledge and e7posure to the modern world -Fesudian ;AA=, p:A@ 0ac)onagh ;AA>, p:<2.

:I

!.1 Conceptual frameworks for skilled attendance

A number of authors have presented conceptual frameworks to describe the relationship between different elements of skilled attendance. This section presents the models identified in the literature and the subse9uent section presents the conceptual framework used in the current study. Ta#le 2& 9- 5 nceptual !ramew rks ! r skilled attendance at deli(er)&
'onceptual frame or)s (0,67"5PA67"-'856 (orl* .an)9 1::: 1escription (onsiders the %artnershi% bet1een different health %rofessionals able to care for normal and com%licated deliveries$ and the enabling environment. 8laces s.illed attendants in the conte"t of a health care centre s %%orted b# the district hos%ital as the referral hos%ital in case of emergenc#. 8laces s.illed attendants in the conte"t of district hos%itals 8laces s.illed attendants in the conte"t of the entire health s#stem and e"%lores the relationshi% bet1een different elements of the health s#stem that %la# a role in red cing maternal and %erinatal mortalit# and morbidit#. 8laces s.illed attendants in the conte"t of the comm nit#$ s %%orted b# an enabling environment$ to %rovide maternal health care$ and b# a referral s#stem in cases of emergenc#. 5ocus 6ealth %rofessionals and the enabling environment.

(0,9 1::%

-.illed attendants and level of care.

Safe Motherhoo* -nter Agency Group ;Koblins)y #000< .ell et al #00$

-.illed attendants and level of care. -.illed attendants and the health s#stem.

S)ille* Atten*ance 5or 8very ,ne ;0ussein et al #00%<

-.illed attendants$ comm nit#$ enabling environment and referral s#stem.

!.2 Conceptual framework used in t%e study

The conceptual framework used in this study is reflected in 5igure ;.: and draws on the frameworks described above. It presents skilled attendance in the conte7t of the health system and within a community. The health system constitutes the enabling environment that provides essential support to meet the community1s needs for delivery care. At the centre of the diagram, midwives are presented as the principal element without which the needs of the community will

;A not be met. ,n the left side are represented the elements -knowledge and skills, protocols of management for obstetric complications, drugs and supplies, e9uipment, supervision and referral systemP transport and midwife workload2 considered as essential for midwives to render good 9uality care during normal deliveries and complicated deliveries. ,n the right side are represented the perinatal outcomes as the result of the combination of different components of skilled attendance.

Kno le*ge an* s)ills

S)ille* atten*ant S)ille* atten*ance 8nabling environment Perinatal outcome s

-Protocol of M/ -1rugs = Supplies -8>uipment -Supervision -Referral6transport -(or)loa*

Patient relate* factors

:igure 2& /- 5 nceptual !ramew rk used in the stud)&

!.13 Conclusion

;: This chapter has provided an overview of the e7isting literature on skilled attendance at birth in general. It has presented the rationale for skilled attendance, providing evidence that skilled attendants operating within an enabling environment lead to ma6or decreases in maternal and perinatal mortality. It has also presented measures of skilled attendance and difficulties in the measurement of skilled attendance. Challenges in ensuring skilled attendance and interventions to increase skilled attendance were also discussed. 5inally conceptual frameworks for skilled attendance and the conceptual framework used in the study were discussed.

;;

#. /et%odology
#.1 ntroduction
This chapter describes the methodology used to measure the provision of skilled attendance in Level : *ospitals in uThungulu *ealth )istrict. The chapter starts by restating the study aim and ob6ectives, and proceeds to present the study site, the research design, the study period, the study population and sampling, the variables measured in the study, the data collection procedures and instruments, the measures taken to ensure study validity, data management and storage processes, data analysis, and the ethical considerations in this study. 5inally, the study limitations are discussed.

#.! $esearc% aim and researc% ob)ectives

The aim of the study was to measure the provision of skilled attendance in Level : *ospitals in uThungulu *ealth )istrict, with the following ob6ectives! :. /stablish perinatal outcomes for each Level : *ospital in uThungulu *ealth )istrict. ;. /valuate the 9uality of intrapartum care provided in Level : *ospitals in uThungulu *ealth )istrict. <. /valuate the obstetric knowledge of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. =. /valuate the obstetric skills of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. >. /valuate the environment in which births are attended in Level : *ospitals in uThungulu *ealth )istrict. ?. Compare the knowledge, skills, environment and 9uality of care with perinatal outcomes.

#.# T%e study site

The study was implemented in the uThungulu *ealth )istrict, located in rural #wa$ulu%&atal. Its main commercial centre is the port town of +ichards .ay. It is bordered by the $ululand *ealth )istrict in the north, the iLembe *ealth )istrict in the south, the u0khanyakude *ealth )istrict in the east and the u04inyathi *ealth )istrict in the west.

;<

"Thungulu *ealth )istrict has a population of DID I:< and comprises si7 local authority areas -#$& )o* ;AAD2. The *ealth )istrict has two Level ; *ospitals, si7 Level : *ospitals, == 5i7ed Clinics and := 0obile Clinics, which visit ;>? points. The *ealth )istrict also has si7 local authority clinics -#$& )o* ;AAD2. As other typical rural districts, uThungulu is isolated geographically, with poor transport and infrastructure and difficult communication -C+* ;AAC2. The Level : *ospitals in uThungulu *ealth )istrict are -#$& )o* ;AAD2! % % Catherine .ooth *ospital, which is a :CA%bed hospital, with a catchment population of appro7imately ;AA AAA people. /kombe *ospital, situated in a deeply rural area in the &kandla 0agisterial )istrict, off the #ranskop and 'ilutshana main road in the midlands of #wa$ulu%&atal. It has ? residential clinics and < mobile clinics with <A visiting points, and serves a catchment population of D> AAA people. % % /showe *ospital, with =?A beds serving a largely rural population estimated to be around <AA AAA. 0bongolwane *ospital, built by Catholic missionaries in :I<C, has :C? usable beds and supports > clinics. It provides health care to an appro7imate catchment population of ?I AAA in the community of ,yaya and its surroundings. % % &kandla *ospital, a ;:;%bedded hospital in the &kandla 0unicipality. It has :: community services clinics that operate ;=%hours and serves a catchment population of about ID ?:C. 't 0ary1s #wa0agwa4a *ospital situated in the 0ton6aneni 0unicipality. It has :=: authori4ed beds and < fi7ed clinics. It serves a catchment population of ?A AAA people. The hospital was taken over by the )epartment of *ealth from the Anglican )iocese of $ululand on : &ovember ;AAA. 'ome of these hospitals are difficult to access due to poor roads. They are under%resourced, with poor staffing and with poor prospects of recruiting more health care workers because of being located in isolated areas -C+* ;AAC2.

;=

#.& $esearc% design

This study was an observational descriptive study, which was conducted in two phases! :2 A retrospective phase, which assessed! O O ;2 (erinatal outcomes, utilising data from the maternityPdelivery register. The 9uality of intrapartum care, through an audit of maternity case records.

A cross%sectional phase, which evaluated! O O O The obstetric knowledge of health workers attending deliveries in Level : *ospitals, utilising a multiple%choice 9uestionnaire -0CH2. The obstetric skills of health workers, using an ob6ective structured clinical e7amination -,'C/2. The enabling environment, using a maternity unit review form.

#.( 'tudy period

The protocol of the study was submitted to the (ostgraduate /ducation Committee in &ovember ;AAC and approval was granted on the Cth 0arch ;AAD -Appendi7 :.:2. It was submitted to the "niversity1s .iomedical +esearch /thics Committee -.+/C2 -ref ./,=:PAD2 on the :<th 0arch ;AAD and full ethical approval was obtained on the :Ath July ;AAD -Appendi7 :.;2. The protocol was also submitted to the (rovincial )epartment of *ealth1s +esearch 0anagement division -ref *+#0A>PAC2 in August ;AAC and permission for the study to proceed was received in July ;AAD, subse9uent to obtaining full ethical approval from .+/C -Appendi7 :.<2. (ermission to undertake the study in each hospital was sought from hospital managers and this was obtained between 0arch and June ;AAD -'ee Appendi7 :.=2. )ata was collected from :>th July to :Ith 'eptember ;AAD as presented in Table <.:. Ta#le 6& /- Data c llecti n time schedule&
Month ;#00?< @uly August September 0ospital

'3 .ooth n=a n=a 3rd -4th

8)ombe n=a 8th 5th

8sho e 15th n=a 15th-16th

")an*la 16th n=a 18th-19th

St Mary 17th -18th 25th n=a

;>

#.+ 'tudy population and 'ampling

#.+.1 'tudy population45nits of analysis
This study was located within Level : *ospitals in the uThungulu *ealth )istrict. In order to meet the ob6ectives of the study there were different units of analysis! :. To establish perinatal outcomes, the unit of analysis consisted of births in Level : *ospitals. ;. To assess the 9uality of intrapartum care, the unit of analysis consisted of maternity case records of women who delivered in Level : *ospitals. <. To assess the obstetric knowledge and skills of health workers, the unit of analysis consisted of all registered midwives working in labour wards in Level : *ospitals. 0idwives were used in this study because most women in labour in public Level : *ospitals in 'outh Africa are attended by registered midwives, who conduct normal deliveries and refer in case of complications. =. 5or the assessment of the enabling environment, the unit of analysis was the labour ward in Level : *ospitals.

#.+.! 'ampling strategy

A multi%stage sampling approach was implemented. 5irstly, all Level : *ospitals in uThungulu *ealth )istrict were selected for study! Catherine .ooth, /kombe, /showe, 0bongolwane, &kandla and 't 0ary1s #wa0agwa4a hospitals. Thus no sampling was applied to select the hospitals. 5urther sampling strategies are described in Table <.;. Ta#le 6& 2- Sampling strateg) per stud) p pulati n2unit ! anal)sis&
,bAective Stu*y Population6 7nit of Analysis Sampling Strategy

9o assess %erinatal o tcomes

?irths

(onvenience sam%ling @ all births recorded in the deliver# register of each hos%ital for the 12-month %eriod %rior to the commencement of the st d# /A l# 2007-A ne 20080

;? Ta#le 6& 2- Sampling strateg) per stud) p pulati n2unit ! anal)sis ;c nt&<
9o assess the ) alit# of intra%art m care +aternit# case records (onvenience sam%ling @ maternit# case records of all 1omen 1ho delivered in the 4evel 1 6os%itals in the month %rior the commencement of the st d# /A ne 20080. 5ncl ded 1ere all 1omen admitted 1ith a cervical dilatation of less than 8cm$ *"cl ded 1ere 1omen 1ith a cervical dilatation of 8cm or more /beca se this 1o ld have not allo1ed the monitoring of labo r from the onset of labo r0$ and 1omen admitted for elective caesarean section. (onvenience sam%ling - all registered mid1ives 1or.ing in labo r 1ards in 4evel 1 6os%itals$ %resent on the da# of data collection$ both on the da# and night shift. All labo r 1ards 1ere assessed$ th s no sam%ling 1as a%%lied.

9o assess obstetric .no1ledge and s.ill

7egistered +id1ives

9o assess the enabling environment

4abo r 1ards

#.+.# 'ampling si6e

All ? Level : *ospitals in uThungulu *ealth )istrict were included in the study. 0bongolwane *ospital did not return signed permission for the study, and thus the study was not implemented in this hospital -see Appendi7 :.>2. Thus the total number of Level : *ospitals studied was five ->2, as were the total number of labour wards assessed with regards to evaluating the enabling environment. Table <.< presents the si4e of the study sample by unit of analysis. Ta#le 6& 6- Si=e ! the stud) sample #) unit ! anal)sis&
'3.ooth 368 18 3 0ospitals 8)ombe 8sho e ")an*la 722 2520 1592 30 2 83 6 112 9 St Mary 1335 56 5

.irths ;@uly #004@une #00?< Maternity case recor*s ;@une #00?< Mi* ives ;on *ay of *ata collection<

8ith regard to the selection of the maternity case records, all maternity case records of women admitted with cervical dilatation less than Dcm in the month prior to the commencement of the study were selected. All maternity case records of women with cervical dilatation of Dcm or more, and of women admitted for elective caesarean section were e7cluded. 8hen actually

;C retrieving from the hospital archives the patient files that held the maternity case records, some files were missing and some had the maternity case records missing. Thus Table <.= presents e7planatory data on the actual sample si4e of maternity case records audited in each Level : *ospital. The table presents the number of deliveries in each hospital for June ;AAD, the total number of records for inclusion, the number of records e7cluded by reason for e7clusion, and the number of records missing. Ta#le 6& 8- >?planat r) data n the actual sample si=e ! maternit) case rec rds audited in each @e(el / $ spital in uThungulu $ealth District&
'3.ooth 32 18 0 14 6 2 6 0 18 8)ombe 58 30 0 28 12 7 3 0 30 0ospitals 8sho e 183 83 25 75 26 19 6 24 83 ")an*la 168 130 2 36 19 8 9 0 112 St Mary 146 56 16 74 14 16 12 32 56

B mber of admissions 7ecords for incl sion Admitted earl# not monitored 9otal records e"cl ded *"cl2 (ervical dil.C8cm
*"cl2 ??A *"cl2 (=*"cl2 +issing files

9otal records revie1ed

8ith regard to the selection of registered midwives, the total sample si4e includes midwives present on the day of data collection, both on the day and night shift. Table <.> presents the number of midwives on the day and night shift per hospital. Ta#le 6& 7- Num#er ! midwi(es n da) and night shi!t per h spital&
0ospital '3.ooth 8)ombe 8sho e ")an*la St Mary "umber of mi* ives per shift 1ay "ight 2 1 1 1 4 2 7 2 3 2 2otal 3 2 6 9 5

#.0 7ariables measured

This section describes the parametric and non%parametric variables that were measured in the study, by study ob6ective. The perinatal outcomes were the outcomes measured in the study, representing the end presumed effect of skilled attendance. The variables selected to measure perinatal outcomes

;D were numerical dependent variables. )ata was e7tracted from the maternity register where the rates were calculated as follow! % % % % (erinatal mortality rate -(&0+2! the number of all perinatal deaths were counted and added and then divided by the total number of births and multiplied by :AAA. 5resh stillbirth rate -5'.+2! the number of all fresh stillbirths were counted and added and then divided by the total number of births and multiplied by :AAA. /arly neonatal death rate -/&&)+2! the number of all early neonatal deaths were divided by the total number of live births and multiplied by :AAA. (erinatal inde7 care! the perinatal mortality rate was divided by the percentage of low birth weight babies. The non%parametric independent variables -representing dimensions of skilled attendance2 that were measured were 9uantitative, numerical variables and are summari4ed in Table <.? as follow! Ta#le 6& 9- N n-parametric (aria#les&
Area assesse* D alit# of intra%art m care 6ealth 1or.er .no1ledge Bariables -core for2 - Admission assessment - 4abo r gra%h - 4abo r management Eno1ledge score of mid1ives for ho1 to deal 1ith2 - Bormal deliver# - !bstetric com%lications - 65F in %regnanc# -.ill score of mid1ives to2 - (orrectl# inter%ret information %lotted on a labo r gra%h - (orrectl# %lot information on a labo r gra%h - (orrectl# diagnose and manage 886 *nabling environment score based on availabilit# of2 - 8rotocols of management - 8rotocol for referral s#stem - *ssential dr gs - *ssential e) i%ment - Acce%table mid1ife 1or.load - - %ervision 2ype of variable D antitative n merical$ inde%endent

D antitative n merical$ inde%endent

6ealth 1or.er s.ills

D antitative n merical$ inde%endent

*nabling environment

the D antitative n merical$ inde%endent

#.1 Data collection met%ods8 instruments and procedures

;I This section describes the data collection methods, instruments and procedures used in the study, by study ob6ective. Table <.C describes the variables, data items, data sources, and data collection tools. (erinatal outcomes were obtained by e7tracting data from maternity registers in each hospital, through the use of a data e7traction form -see Appendi7 ;2. The researcher herself counted the total births above >AAg, total fresh stillbirths, total macerated stillbirths, total early neonatal deaths and the total low weight births for each month under review. These were recorded on the data e7traction form by month and then totalled for the :;%month period under study. The 9uality of intrapartum care was assessed by auditing maternity case records with the use of the original (hilpottP oce Labour +ecord +eview Checklist -)o* ;AAC, p:>I2 -'ee Appendi7 <2. The obstetric knowledge of midwives was assessed through the use of a <A%9uestion 0ultiple Choice Huestions -0CH2 -see Appendi7 =2, which covered seven topic areas! &ormal labour, cord prolapse, prolonged labour, postpartum haemorrhage, pregnancy induced hypertension, *I and puerperal sepsis. Huestions were adapted from the ;AA> (erinatal /ducation (rogram -(/( ;AA>2. All midwives in each hospital were tested simultaneously to prevent those finishing a test from discussing it with colleagues not yet tested. The knowledge test was administered in written form. The midwives recorded their answers on an answer sheet and each correct answer was awarded one point. The obstetric skills of midwives were assessed through the administration of an ,b6ective 'tructured Clinical /7amination -,'C/2 -see Appendi7 >2. Three instruments developed by the )ecentralised (rogramme for Advanced 0idwives were used to test the ability of midwives to! -:2 use the partograph as a decision%making tool in labour and delivery@ -;2 plot information on a partograph@ and -<2 manage postpartum haemorrhage. The ,'C/ was conducted with each midwife individually. The answers to the ,'C/ were recorded on a marking sheet -see Appendi7 >2 and marked against a model answer. ,ne point was awarded for each correct answer. In order to assess whether the environment was enabling, the oceP(hilpott facility review Checklist was used -see Appendi7 ?2, which measured the presence or absence of written protocols for the management of obstetric complications, the availability of key drugs,

<A e9uipment and supplies, which are referred to as Lessential elementsM of obstetric care. 0idwives workload was also assessed. The checklists in each hospital were completed by the researcher, who reviewed the labour ward with the help of the midwife%in%charge. Ta#le 6& A- Summar) ! data c llected, data s urce and data c llecti n t
Bariables 8B+7 ,-?7 *BB:7 8(5 -core for2 Admission assessment 4abo r gra%h 4abo r management. Eno1ledge score for mid1ives> abilit# to2 1. (ond ct normal deliver# 2. +anage obstetric com%lications 3. +anage 65F in %regnanc#. 1ata items 9otal births 9otal ,-? 9otal +-? 9otal *BB: 9otal ?irths G2.5.g 91ent# five items (overing admission$ labo r gra%h$ labo r management 30 ) estions on seven to%ics /normal labo r$ cord %rola%se$ %rolonged labo r$ 886$ 65F$ 856 and % er%eral se%sis0. 1ata source :eliver# register

ls&

1ata collection tools :ata e"traction form /see A%%endi" 20

+aternit# case records

+id1ives

8hil%ott=Foce 4abo r 7ecord 7evie1 (hec.list /see A%%endi" 30 +(D ans1er sheet /see A%%endi" 40.

<: Ta#le 6& A- Summar) ! data c llected, data s urce and data c llecti n t
-.ill score for +id1ives> abilit# to2 1. (orrectl# inter%ret information on a labo r gra%h. *"ercise involving mid1ives in inter%reting information on a labo r gra%h2 this covered$ ris. factors$ diagnosis of %rolonged labo r and +". *"ercise involving mid1ives in %lotting information on a labo r gra%h. 9his covered ,67$ mo lding$ ca% t$ cervical dilation$ descent of head$ fetal %osition$ terine contractions$ maternal information$ dr gs$ maternal ?8H % lse$ maternal 90$ rine o t% t. -tation 1here mid1ives diagnosed 886 and described the +" of 886. 4ist of items considered as essential s %%lies$ e) i%ment and infrastr ct re for 4evel 1 6os%itals.

ls ;c nt<&

!-(* station

+ar. sheet /see A%%endi" 5.10

2. (orrectl# %lot information on a labo r gra%h.

!-(* station

+ar. sheet /see A%%endi" 5.20

3.(orrectl# diagnose and managing 886. *nabling environment score based on the availabilit# of2 % 8rotocols of +" % 8rotocol for referral % *ssential dr gs % *ssential e) i%ment % - %ervision % +id1ives> 1or.load

!-(* station !bservation

+ar. sheet /see A%%endi" 5.30. Foce=8hil%ott ,acilit# 7evie1 chec.list /see A%%endi" 60.

#.2 /easures taken to ensure study validity and control for potential biases
This section deals with the potential biases in this study and how they were controlled for. /& Selecti n #ias This could have been introduced in the study design phase. The research utili4ed convenience sampling by selecting! % All births in the twelve%month period preceding the commencement of the study -based on the assumption that births occurring in a facility in a twelve%month period would not be different from births occurring in any other twelve%month period.

<; % 0idwives on duty on the day of data collection -it was assumed that their presence on the day of data collection was random@ this does not represent a complete picture of obstetric knowledge and skills of midwives in each hospital2. % The district within which the study was located. The study site was not randomly selected@ the choice of the district was made in relation to the e7isting 9uality improvement initiative in the district, part of the Area Three Learning Comple7 initiated by the Centre for +ural *ealth. 'election bias could have also been introduced in the study implementation phase. The researcher might have omitted records meeting the inclusion criteria or might have included those not meeting the inclusion criteria while selecting maternity case records for review. $ w c ntr lled ! r % % % All Level : *ospitals were included in the study. *owever 0bongolwane hospital chose not to participate. All midwives on duty on the day of data collection were included in the study. The information obtained from the study -knowledge and skills2 will not be generalised but will be treated as pilot study with the prospect for further investigations on a larger scale -including a representative sample of midwives attending births in Level : hospitals and a representative sample of Level : hospitals in #wa$ulu%&atal for instance2. 2& *n! rmati n #ias This might have been introduced in the study design phase by selecting! % 0aternity case records! data are stored differently in hospitals with some being more organi4ed than others. In some hospitals, the maternity case records were incomplete, in some they were missing. % All midwives on duty on the day of data of data collection! not representative of all midwives in the district, this will not give the real picture of the knowledge and skills of midwives in each hospital. $ w c ntr lled ! r % % Incomplete records were not included in the study. The researcher herself collected and analysed data, to avoid information bias.

<< % 0idwives and hospitals were identified using a code to avoid mi7ing of results or to avoid attributing results wrongly. -5or e7ample! symbols identified hospitals, numbers identified midwives on day shift and letters midwives on night shift2. % The information obtained from the study will not be generali4ed but will be treated as pilot study with the prospect for further investigations on a larger scale. 6& Management #ias Introduced in the study analysis phase, when data is manually captured from 9uestionnaires and tests, errors may occur. $ w c ntr lled ! r All data were stored, captured and analysed in a similar way to avoid management bias. )ata were doubly entered in /7cel and the 'tatistical (ackage for the 'ocial 'ciencesS -'(''2 version :>.A to control for capturing errors. 8& Measurement #ias Introduced in the study design phase@ more than one measurement instruments was used, adapted from previous studies, whose validity and reliability were not reported. $ w c ntr lled ! r % The labour record review form was first piloted at /kombe *ospital on the :>th of July to test its applicability. &o revision was needed on the study instrument as it could easily be used. % The multiple%choice 9uestionnaires and ,'C/ 9uestions were piloted at 't 0ary1s *ospital to test their applicability. &o revision was needed for the multiple%choice 9uestionnaire.

#.13 Data management and data storage

)ouble data entry was performed by the researcher, using 0icrosoft /7cel and the 'tatistical (ackage for the 'ocial 'ciencesS -'(''2 version :>.A. A. &o discrepancies between data were noted. )ata was stored on a personal computer, using a password to prevent unauthori4ed access. .ack%up copies of the data were saved on a personal flash disc. The paper tools were kept

<= safely in a personal case. )ata will be kept in a safe place until the results of the study are published.

#.11 Data analysis

The data was analysed using '('' version :>.A. The descriptive analytical analyses performed are described below.

#.11.1 "erinatal outcomes

(erinatal outcomes were calculated as described in 'ection <.C.

#.11.! Analysis of t%e 9uality of intrapartum care

To assess the 9uality of intrapartum care, maternity case records of women who delivered in the month prior to the commencement of the study were reviewed. Twenty%five items covering the admission assessment, labour graph and labour management were assessed using the original (hilpottP oce Labour +ecord +eview Checklist -)o* ;AAC, p:>I2. To obtain a percentage score of the 9uality of intrapartum care, the total number of completed items on the (hilpottP oce checklist were summed and divided by the total number of items on the maternity case record, and finally multiplied by one hundred. 'cores were also obtained for sub%sets by dividing the number of completed items in each subset divided by the total number of items in the sub%set. #ruskal 8allis &on%(arametric Test -e9uivalent of A&, A test2 was used to determine differences in mean scores and median subset scores between hospitals. The level of significance was set at A.A> ->E2. 'eventy percent -CAE2 was used as an acceptable score. This was adapted from acceptable scores of performance suggested in the (erinatal /ducation (rogramme manual.

#.11.# :nowledge assessment

In calculating the obstetric knowledge score of midwives, one point was awarded for each correct answer. To calculate midwives1 individual knowledge scores, points were summed up and individual scores were divided by the total number of 9uestions -<A2 and multiplied by one hundred, to obtain a percentage score. An e7ploratory analysis of the distribution of the overall knowledge scores was performed to determine whether the data was normally distributed. It was found that most of the data was negatively skewed, thus the median and inter9uartile ranges were used as summary statistic measures. 'cores for each of the si7 topic areas -sub%

<> sets2 were also calculated by dividing the total points earned for each sub%set, by the number of 9uestions in each sub%set and multiplied by one hundred. #ruskal 8allis &on%(arametric Test was used to determine differences in knowledge median scores between hospitals. The level of significance was set at A.A> ->E2. /ighty percent -DAE2 was used as passing mark. This was adapted from acceptable scores of performance suggested in the (erinatal /ducation (rogramme manual.

#.11.& 'kills assessment

In calculating the obstetric skill score of midwives, one point was awarded for each correct answer. To calculate midwives1 individual total skill scores, individual scores were summed and divided by the total number of 9uestions and multiplied by one hundred, to obtain a percentage score. As this data was also negatively skewed, the median and inter9uartile ranges were used as summary statistic measures. 'cores for each of sub%sets were also calculated by dividing the points earned for each sub%set, by the number of 9uestions in each sub%set and multiplied by one hundred. #ruskal 8allis &on%(arametric Test was used to determine differences in skills median scores between hospitals. The level of significance was set at A.A> ->E2. /ighty percent -DAE2 was used as passing mark. This was adapted from acceptable scores of performance suggested in the (erinatal /ducation (rogramme manual.

#.11.( .nabling environment assessment

Checklists in each hospital were completed by the researcher with the help of the midwife in charge. The items were dichotomous variables Ryes O no1. ,ne point was awarded to Ryes1 responses and a score was obtained for each hospital by summing up the number of items that scored Ryes1 divided by the number of items on the checklist multiplied by one hundred, to obtain a percentage score for the enabling environment. 'eventy five percent -C>E2 was used as the acceptable overall score for the enabling environment. This was adapted from the study by oce -;AA>2.

<?

#.11.+ Association between perinatal outcomes and 9uality of intrapartum care8 obstetric knowledge and skills8 and t%e enabling environment
)ue to the skewed data, 'pearman1s correlation was used to determine the relationship between the dependant and independent variables. The dependent variables were parametric numerical variables defined as! % % % % (erinatal 0ortality +ate -(&0+2! the number of all perinatal deaths were counted and added and then divided by the total number of births and multiplied by :AAA. 5resh 'tillbirth +ate -5'.+2! the number of all fresh stillbirths were counted and added and then divided by the total number of births and multiplied by :AAA. /arly &eonatal )eath +ate -/&&)+2! the number of all early neonatal deaths were divided by the total number of live births and multiplied by :AAA. (erinatal Care Inde7! the perinatal mortality rate was divided by the percentage of low birth weight babies. The independent variables were non%parametric 9uantitative, numerical variables. They are listed and defined below! % % Huality of intrapartum care The 'core for! Admission assessment, Labour graph, Labour management *ealth worker knowledge The knowledge score of midwives for how to deal with! &ormal delivery, ,bstetric complications, *I in pregnancy. % *ealth worker skills The skill score of midwives to! Correctly interpret information, plotted on a labour graph, correctly plot information on a labour graph, correctly diagnose and manage ((* % /nabling environment The enabling environment score based on the availability of! (rotocols of management, (rotocol for referral system, /ssential drugs, /ssential e9uipment, Acceptable midwife workload, 'upervision.

<C

#.1! .t%ical considerations

#.1!.1 .t%ical approval and permissions
All the necessary approvals and permissions were obtained -see section <.>2. *owever 0bongolwane *ospital did not return a signed form, not confirming nor declining their participation in the study. A letter was sent on the Ith ,ctober ;AAD to the 0bongolwane *ospital 0anager stating that the consent form had not been received, and that this would be regarded as declining participation in the study unless otherwise communicated by the *ospital 0anager. &o reply was received. In the letter it was stressed that non%participation would not carry any negative conse9uences for the hospital -see Appendi7 :.>2.

#.1!.! .t%ical principles supported by t%e study

To ensure good 9uality research, the following ethical principles were observed in the design of the study protocol and its implementation! % "rinciple ! Aut n m)- all the necessary information pertaining to the research was made available and discussed with all hospital managers and midwives, and written informed consent was obtained from each hospital and midwife -'ee Appendi7 :.?2. % "rincipal ! #ene!icence- no overt harm was inherent in the design of this study. The research was designed with the intent of determining the 9uality of skilled attendance in Level : *ospitals. +evealing a poor 9uality of skilled attendance may carry unintended negative conse9uences for the hospitals and midwives that participated in the study, for e7ample if hospital, district or provincial managers use the results of the study in a negative way. An attempt to manage this will be made in the way that feedback on the study is provided and in providing recommendations arising from the study. The feedback will include identifying opportunities for supervision and in%service training. % 5 n!identialit)- the information gathered from delivery registers, maternity case records and midwives remained institutional and not personal! no record was kept of the maternity case records reviewed. 0idwives and hospitals were identified using symbolic, alphabetical and numerical coding to ensure their anonymity -e.g. T -A2 and A: for the first midwife2.

<D % B#ligati n t !eed#ack- the results of the study will be fed back to each hospital and to the district on completion of the e7amination process.

#.1# Limitations of t%e study

3iven logistical and budgetary limitations, this study can only be considered as a pilot study. This e7ploratory study cannot be considered as representative of hospitals and health care workers in the province of #wa$ulu%&atal. The study covered five of the si7 Level : *ospitals in the uThungulu *ealth )istrict. It would have been of greater value if 0bongolwane *ospital had agreed to participate in the study. Their non%inclusion in the study does not allow a complete picture of skilled attendance in Level : *ospitals in the uThungulu *ealth )istrict as a whole. In the audit of maternity case records, there were missing files and incomplete records particularly at /showe, &kandla and 't 0ary1s *ospitals. This limited the proportion of records that could actually be reviewed. )ue to the shortage of midwives in Level : *ospitals, the knowledge and skills tests were administered in the midst of normal duty. 'ome labour wards were very busy. This may have affected the 9uality of response by midwives. Convenience sample of midwives was used in the study rather than a survey. This may have affected the internal validity of the study. It is not possible to determine to what degree midwives in this sample are representative of all midwives in each Level : *ospital in the uThungulu *ealth )istrict. 5urthermore, the study could not control for potential confounders such as! differences in training, years of e7perience between midwives and within hospitals.

#.1& Conclusion
This section described the methodology used in this study. It restated the study aim and ob6ectives. It presented the research aim and ob6ectives, the study site, the study design, the study period, the study population and sampling. It went on to describe the variables measured in the study, the data collection procedures and instruments, the measures taken to ensure study

<I validity, data management and storage processes, data analysis, and the ethical considerations in this study. 5inally, it discussed the study limitations.

=A

&. $esults
This chapter presents the results of the study according to the study ob6ectives. The main aim of the study was to measure the provision of skilled attendance in Level : *ospitals in uThungulu *ealth )istrict, with the following ob6ectives! :2 /stablish perinatal outcomes for each Level : *ospital in uThungulu *ealth )istrict. ;2 /valuate the 9uality of intrapartum care provided in Level : *ospitals in uThungulu *ealth )istrict. <2 /valuate the obstetric knowledge of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. =2 /valuate the obstetric skills of health workers attending births in Level : *ospitals in uThungulu *ealth )istrict. >2 /valuate the environment in which births are attended in Level : *ospitals in uThungulu *ealth )istrict. ?2 Compare the 9uality of care, the knowledge, skills and environment with perinatal outcomes. The chapter starts by presenting the perinatal outcomes calculated for each hospital, and then proceeds to present the 9uality of intrapartum care, the results of the knowledge and skills tests, and the results on the enabling environment and workload of midwives. 5inally, the association is measured between perinatal outcomes and 9uality of care, obstetric knowledge and skills, and the enabling environment.

&.1 "erinatal outcomes

Table =.: presents raw perinatal data -total number of births, live births, fresh stillbirths, macerated stillbirths and low birth%weight births2 by hospital, from July ;AAC to June ;AAD.

=: Ta#le 8& /- "erinatal data #) @e(el / $ spital uThungulu $ealth District, Cul) 200A t Cune 2008&
0ospital '3.ooth 8)ombe 8sho e ")an*la St Mary 2otal 2otal births 2otal live births 5S. MS. 8""1 C.(

368 722 2520 1592 1335 6537

358 701 2472 1572 1309 6412

1 11 22 1 3 38

9 10 26 19 23 87

7 13 17 26 13 76

42 97 257 168 133 697

5rom these data perinatal outcome indicators were calculated and presented in Table =.;. The perinatal mortality rate -(&0+2 for the five hospitals combined was <: deaths per :AAA births and ranged from ;? in /showe to =C per :AAA births in /kombe. The fresh stillbirth rate -5'.+2 for the five hospitals was ? deaths per :AAA births and ranged from : in &kandla to :> per :AAA births in /kombe. The early neonatal death rate -/&&)+2 for the five hospitals was :; deaths per :AAA live births and ranged from C in /showe to ;A per :AAA live births in Catherine .ooth. The perinatal care inde7 -(CI2 for the five hospitals was < and ranged from < in /showe, &kandla and 't 0ary to = in Catherine .ooth and /kombe. Ta#le 8& 2- "erinatal utc mes #) @e(el / $ spital in uThungulu $ealth District, Cul) 200A t Cune 2008&
0ospital '3.ooth 8)ombe 8sho e ")an*la St Mary 2otal P"MR 5S.R 8""1R P'-

46 47 26 29 29 31

3 15 9 1 2 6

20 19 7 17 10 12

4 4 3 3 3 3

&.! ;uality of intrapartum care

To assess the 9uality of intrapartum care, maternity case records were reviewed of women who delivered in the month immediately prior to the commencement of the study. A total of >DC maternity case records were selected in the district, but only ;II ->:E2 maternity case records were reviewed! :D -?E2 from Catherine .ooth *ospital, <A -:AE2 from /kombe *ospital, D< -;DE2 from /showe *ospital, ::; -<CE2 from &kandla *ospital and >? -:IE2 from 't 0ary1s *ospital. The breakdown of records reviewed by hospital is presented in Table <.= and is reproduced in Table =.< below.

=;

Ta#le 8& 6- >?planat r) data n the actual sample si=e ! maternit) case rec rds audited in each @e(el / $ spital in uThungulu $ealth District&
'3.ooth 32 18 0 14 6 2 6 0 18 8)ombe 58 30 0 28 12 7 3 0 30 0ospitals 8sho e 183 83 25 75 26 19 6 24 83 ")an*la 168 130 2 36 19 8 9 0 112 St Mary 146 56 16 74 14 16 12 32 56

B mber of admissions 7ecords for incl sion Admitted not monitored 9otal records e"cl ded *"cl2 (ervical dil.C8cm *"cl2 ??A *"cl2 (=*"cl2 +issing files 9otal records revie1ed

In the following section, the results of the maternity case record review are presented! firstly, presented is the overall percentage of maternity case records with each item recorded, and secondly, the score per subset in the maternity case record, by Level : *ospital. The details are reflected in Tables =.= and =.>. Ta#le 8& 8- "ercentage ! maternit) case rec rds with each item rec rded, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
-tems '3.ooth nD1? 8)ombe nD$0 8sho e nD?$ ")an*la nD11# St Mary nD&E 2otal nD#::

A*mission assessment

AB( card revie1ed Adm. form com%lete :iagnosis H +" Adm. do ble chec.ed 7is. factors recorded ,67 I hrl# -tate of li) or :egree of mo lding (ontractions I hrl# :ilatation :il.-correct %lotting 4evel of head 4 hrl# +aternal ?8 +aternal 90 7ecord of dr gs H fl ids

Cabour graph

22 61 61 0 55 88 83 83 100 100 100 94 94 94 61

83 93 93 0 93 100 100 100 100 100 100 100 96 96 70

89 100 100 0 98 100 100 100 100 100 100 100 100 98 72

74 100 99 0 95 99 99 100 100 100 100 100 99 94 98

64 100 98 0 73 91 89 85 96 100 100 100 80 78 50

74 97 96 0 90 97 97 96 99 100 100 99 95 91 72

=< Ta#le 8& 8& "ercentage ! maternit) case rec rds with each item rec rded, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008 ;c nt<&
-tems '3.ooth nD1? 8)ombe nD$0 8sho e nD?$ ")an*la nD11# St Mary nD&E 2otal nD#::

M/ of labour +" recorded after 8F form - mmar# of ,( - mmar# of labo r - mmar# of +( :ecision on f rther +" 9ime of ne"t revie1 +" :o ble chec.ed 4hl# "e born 5inal summary ,verall score ,orm com%leted Active +" of 3rd stage - mmar# of labo r

83 77 77 77 77 33 0 100 72 100 71

93 93 93 93 93 83 0 50 93 100 85

92 92 92 92 92 84 0 98 92 97 88

75 76 76 76 77 6 0 97 71 86 80

66 66 66 66 66 10 0 98 64 98 72

81 81 81 81 81 38 0 91 78 94 79

5igure =.: shows the overall mean percentage score: per record by Level : *ospital. It highlights that the hospitals have high mean overall percentage scores per record. Comparison with the #ruskal 8allis &on%(arametric Test shows that there is a statistically significant difference in scores amongst hospitals -pBA.A:=2.

100 90 80 70 60 50 40 30 20 10 0

85 71

88

80 72

:igure 8& /- Mean (erall percentage sc re per rec rd, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
:

To obtain the overall mean percentage score per record, the number of records with completed items were summed up and divided by the number of items on the maternity case records multiplied by one hundred.

Mean + score per Reco r*

C.Booth

Ekombe

Eshowe

Nkandla

St Mary

==

Table =.> presents maternity case records subset scores by Level : *ospital in uThungulu *ealth )istrict. The subsets include! the admission assessment, the labour graph and the management of labour. The labour graph was further divided into the monitoring of fetal condition -5C2, monitoring of labour progress -L(2 and monitoring of maternal condition -0C2. The table shows variable median scores between hospitals in the admission assessment -range <?E%C;E2 and in the scores for the management of labour -range =IE%CIE2. The range is narrower in the overall subset score for the labour graph -D?E%IIE2. *owever, more careful analysis of the components of the labour graph reveal that the range is narrower for the monitoring of fetal condition -D>E%:AAE2, almost non%e7istent for the monitoring of labour progress -IIE%:AAE2, and a very wide range for the monitoring of maternal condition -range >?E%IIE2. Comparison of subset scores with of #ruskal 8allis &on%(arametric Test shows statistically significant differences in the median subset scores between hospitals, as reflected in Table =.>. Ta#le 8& 7- Maternit) case rec rd re(iew- Su#set sc res and di!!erence in median su#set sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth nD$ A*m3 assessment Cabour graph Monitoring 5' Monitoring CP Monitoring M' M/ of labour 8)ombe nD# 8sho e nDE ")an*la nD: St Mary nD& 'his>uare pvalue

36 85 85 98 77 66

67 96 100 100 96 78

72 97 100 100 99 78

68 98 99 100 96 55

65 85 88 99 55 48

45.5 50.8 37.9 9.7 42.5 111.8

G0.001 G0.001 G0.001 0.045 G0.001 G0.001

&.# *bstetric knowledge of %ealt% care workers.

In order to assess the obstetric knowledge and skills of health workers, the unit of analysis consisted of all registered midwives working in labour wards of Level : *ospitals in the uThungulu *ealth )istrict. A total of twenty%five midwives from the five hospitals completed the knowledge test! three from Catherine .ooth, two from /kombe, si7 from /showe, nine from &kandla and five from 't 0ary1s. The breakdown of the number of midwives who participated in the study is presented in Table <.> in Chapter <.

=>

5igure =.; shows the median, ma7imum and minimum values and inter%9uartile range for the overall knowledge test scores by hospital. It highlights differences in scores between providers within and amongst hospitals. The lowest individual knowledge score -<;E2 is recorded at /showe *ospital and the highest individual scores -?AE@ >IE2 at Catherine .ooth and 't 0ary1s hospitals respectively. The lowest overall median score -=DE2 is recorded at &kandla *ospital and the highest overall median score ->IE2 at 't 0ary1s *ospital. #ruskal 8allis &on%(arametric Test shows no statistically significant difference in the overall knowledge scores between hospitals -pBA.AC2.
sc or e s p er h o s pi ta l le * g e m e *i a n + K n o

70

60

50

40

30

'3.ooth

8)ombe

8sho e

")an*la

St Mary

:igure 8& 2- Kn wledge median percentage sc res #) @e(el / $ spital in uThungulu $ealth District, Cune 2008& Table =.? presents the knowledge median subset scores by hospital, e7pressed as a percentage. It also presents the difference in knowledge median subset scores by means of #ruskal 8allis &on%

=? (arametric Test, which shows no statistically significant differences in the knowledge median subset scores amongst hospitals. Ta#le 8& 9- B(erall kn wledge median su#set sc res and di!!erence in kn wledge median su#set sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth nD$ "ormal labour Prolapse* cor* Prolonge* labour PP0 0-B P-0 Sepsis 8)ombe 8sho e nD# nDE ")an*la nD: St Mary nD& 'his>uare P-value

42 67 100 44 78 67 33

43 50 75 50 83 33 50

43 58 75 33 72 28 67

42 39 72 56 74 37 44

52 50 80 73 80 60 50

4.1 1.88 2.87 4.30 0.44 7.09 4.44

0.38 0.75 0.57 0.36 0.97 0.34 0.38

&.& *bstetric skills of %ealt% care workers

Twenty%five midwives from the five hospitals completed the test of obstetric skills. The breakdown of the number of midwives by hospital is presented in Table <.> in Chapter <. (articipants were evaluated on two partograph e7ercises and a postpartum haemorrhage -((*2 station. The results are first presented as a median aggregated skill score; per hospital, then per individual e7ercise.

&.&.1 Aggregated skill score

Table =.C shows the median aggregated skill score by Level : *ospital. The highest score -?<E2 is recorded at 't 0ary1s *ospital. A statistically significant difference was found in the median aggregated skill score amongst hospitals -pBA.AA;2. Ta#le 8& A- Median aggregated skill sc re and di!!erence in median aggregated skill sc re, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth nD$ S)ill score 8)ombe nD# 8sho e nDE ")an*la nD: St Mary nD& 'hi s>uare P-value

57

57

54

56

62

17.4

0.002

The skill scores for each hospital were obtained by summing up the number of correct answers divided by the total number of 9uestions multiplied by one hundred.

=C

&.&.! Labour <rap% .=ercise

The first e7ercise assessed midwives1 ability to interpret information already plotted on a labour graph. The results are presented in 5igure =.<. The lowest individual skill score -=?E2 was recorded at /showe *ospital@ whilst the highest individual skill score -C;E2 was recorded at &kandla *ospital. The median skill scores are above >AE in four out of five hospitals. The lowest median score -=DE2 was recorded at &kandla *ospital whilst the highest median score -?>E2 was recorded at 't 0ary1s *ospital. #ruskal 8allis &on%(arametric Test shows no statistically significant differences in the overall Labour 3raph /7ercise I median scores between the five hospitals -pBA.>?A2. Table =.D shows the Labour 3raph /7ercise I median subset scores and differences in the median subset scores per hospital. 't 0ary scored highest on identification of risk factors -C?E2, Catherine .ooth on diagnosis -?IE2 and /kombe on management ->AE2. There are statistically significant differences in the median scores for the identification of risk factors -pBA.A;>2 and diagnosis -pBA.AA:2.

Ta#le 8& 8- @a# ur Draph >?ercise * su#set median sc res and di!!erences in su#set median sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth nD$ Ris) factors 1iagnosis M/ 8)ombe nD# 8sho e nDE ")an*la nD: St Mary nD& 'hi s>uare p-value

69 100 14

57 50 50

61 100 37

69 50 37

76 50 42

11.1 17.6 6.10

0.025 0.001 0.192

=D

80

70

60

:igure 8& 6- @a# ur Draph >?ercise * median percentage sc re #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&

&.&.# Labour <rap% .=ercise

The second partograph e7ercise assessed the abilities of midwives to correctly plot information on a labour graph. 5igure =.= shows the scores for Labour 3raph /7ercise II! the lowest individual score -><E2 was recorded at /showe *ospital, and the highest individual skill score -DAE2 at &kandla *ospital. The highest median score -CDE2 was recorded at 't 0ary1s *ospital and the lowest median score -?>E2 at /showe *ospital. ,verall #ruskal 8allis &on%(arametric Test shows no statistically significant difference in the Labour 3raph /7ercise II amongst the five hospitals.

Cab our Gra ph 8/e rcis e-me* ian + scor e per hos pita l

50

40

30

20

'3.ooth

8)ombe

8sho e

")an*la

St Mary

=I

Cabour Graph 8/ercise -- - me*ian + score per hospital

80 70 60 50

'3.ooth

8)ombe

8sho e

")an*la

St Mary

:igure 8& 8- @a# ur Draph >?ercise ** E median percentage sc re #) @e(el / $ spital in uThungulu $ealth District, Cune 2008& The Labour 3raph /7ercise II subset scores are presented in Table =.:A. It shows high scores in all five hospitals in different subsets. It also shows no statistically significant difference in median subset scores amongst hospitals. Ta#le 8& F- @a# ur Draph >?ercise **- median su#set sc res and di!!erences in median su#set sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth nD$ 5etal con*ition Progress of labour Maternal con*ition 8)ombe nD# 8sho e nDE ")an*la nD: St Mary nD& 'hi s>uare p-value

63 80 75

67 80 67

63 66 80

70 80 100

73 80 80

9.57 6.11 5.40

0.48 0.19 0.24

>A

&.&.& "ost> partum %aemorr%age station

5igure =.> shows differences in scores recorded for the ((* station, for midwives within and amongst hospitals. The lowest individual ((* score -<:E2 was recorded at 't 0ary1s hospital and the highest individual score -CDE2 was recorded at &kandla *ospital. The highest median score -C>E2 was recorded at &kandla *ospital and the lowest median score -=<E2 at 't 0ary1s *ospital. #ruskal 8allis &on%(arametric Test shows a statistically significant difference in the median scores recorded for the ((* 'tation amongst hospitals -pBA.AAD2.

>:

PP0 station G Me*ian + score per hospital

80

70

60

50

40

30

'3.ooth

8)ombe

8sho e

")an*la

St MaryFs

:igure 8& 7- ""$ Stati n - B(erall median percentage sc re, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&

>;

Post- partum haemorrhage station

5igure =.> shows differences in scores recorded for the ((* station, for midwives within and amongst hospitals. The lowest individual ((* score -<:E2 was recorded at 't 0ary1s hospital and the highest individual score -CDE2 was recorded at &kandla *ospital. The highest median score -C>E2 was recorded at &kandla *ospital and the lowest median score -=<E2 at 't 0ary1s *ospital. #ruskal 8allis &on%(arametric Test shows a statistically significant difference in the median scores recorded for the ((* 'tation amongst hospitals -pBA.AAD2.

&.( .nabling environment

5or the assessment of the enabling environment, the unit of analysis was the labour ward in Level : *ospitals. Table =.:A shows the availability of essential e9uipment and supplies in each study hospital<. The overall uThungulu *ealth )istrict enabling environment score is C=E. The lowest enabling environment score ->CE2 is recorded at &kandla *ospital and the highest enabling environment score -D=E2 at /showe and 't 0ary1s *ospital. Ta#le 8& /0- >na#ling en(ir nment sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth Protocols of management 8mergency response Pac)e* cells 5reeHe *rie* plasma -nAectable antibiotic -nAectable anti- convulsants -nAectable o/ytocics At least # .P machines At least # '2G machines At least # stethoscopes 5etoscope 1optone At least # Bacuum e/tractor "eonatal resus3 facilities ,perating theatre Supervision on both shifts by m6 Supervision on *ay shift by A1M Supervision on night shift by A1M
<

8)ombe

8sho e

")an*la

St Mary

2otal

1 0 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 0

1 0 0 0 1 0 1 0 0 1 1 0 1 1 1 1 1 1

1 1 0 1 1 1 1 0 1 1 1 0 1 1 1 1 1 0

1 0 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 0

1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0

100 20 40 60 100 80 100 40 80 100 80 60 80 100 100 80 80 20

To obtain the overall enabling environment score for each hospital all items available in each hospital were summed up then divided by the total number of items on the checklist multiplied by one hundred.

><
Acceptable 2otal + or)loa*

1 15 78

1 12 63

0 16 84

0 11 57

1 16 84

40 14 74

Table =.:: presents the enabling environment subset scores by hospital. The subsets include! referral, drugs and supplies, e9uipment, supervision and workload. The table shows variable scores between hospitals in the referral subset ->AE%:AAE2, in the scores for drug and supplies -=AE% :AAE2, supervision and workload -AE%:AAE2. *owever, the table shows that the range is narrower for the e9uipment subset -?;E%:AAE2.

>= Ta#le 8& //- >na#ling en(ir nment su#set sc res, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
'3.ooth Referral 1rugs an* supplies 8>uipment Supervision (or)loa* 8)ombe 8sho e ")an*la St Mary

50 100 87 33 100

50 40 62 100 100

100 80 75 33 0

50 100 62 0 0

50 100 100 33 1

Table =.:; presents midwives1 workload8 by hospital for June ;AAD. Three out of five hospitals have an acceptable workload ratio -:.:> midwives per woman in the labour ward2 as recommended by the +C,3 -:III, p<=2. Ta#le 8& /2- Midwi!e w rkl ad, #) @e(el / $ spital in uThungulu $ealth District, Cune 2008&
"umber of *eliveries @une #00? '3.ooth 8)ombe 8sho e ")an*la St Mary Average number of *eliveries6#%hour *ay "umber of mi* ives6#%hour *ay Mi* ife6*elivery ratio

36 59 183 131 114

1.5 2.4 7.6 5.4 4.7

4 9 5 6 7

2.66 3.75 0.65 1.11 1.48

&.+ Association between perinatal outcomes and 9uality of intrapartum care8 obstetric knowledge and skills8 and t%e enabling environment
'pearman correlation was used to determine the relationship between the dependent -perinatal outcomes2 and independent -9uality of intrapartum care, obstetric knowledge and skills and the enabling environment2 variables. ,verall there was no significant correlation detected between perinatal outcomes and the 9uality of intrapartum care, the obstetric knowledge and skills and the

To calculate midwives workload an average of deliveries per midwives per day was obtained by dividing the number of deliveries in June ;AAD and divided by the number of midwives in each Level : *ospital in uThungulu )istrict on both shifts -dayPnight2 divided by the number of days -<A days2 in the month. To obtain the acceptable workload the number of midwives was divided by the average number of deliveries per ;=%hour day. The standard of :.:> midwives to one woman set by the +oyal College of ,bstetricians and 3ynaecologists -+C,32 was used as standard acceptable workload -+C,3 :III, p<=2.

>> enabling environment. Table =.:< shows the 'pearman1s correlation coefficients and p%values. All were neither clinically nor statistically significant. Ta#le 8& /6- Spearman1s c rrelati n #etween dependent and independent (aria#les&

P"MR 5S.R 8""1R

Iuality of intrapartum care rho p -0.35 0.55 0.50 0.39 -0.60 0.28

,bstetric )no le*ge rho 0.10 0.10 0.60 p 0.87 0.87 0.28

,bstetric s)ills

8nabling environment rho -0.20 -0.10 -0.20 p 0.74 0.84 0.74

rho 0.00 0.60 -0.50

p 1.00 0.28 0.39

&.0 Conclusion
This chapter has presented the findings of the study, analysed using descriptive and inferential statistics. ,verall and subset scores were calculated where appropriate. )escriptive statistics were used to provide indicators of perinatal care, a summary of the 9uality of intrapartum care -revealing high mean overall scores in the different hospitals2, the obstetric knowledge and skills of midwives -showing variable median scores between hospitals2 as well as the enabling environment and the workload of midwives. #ruskal%8allis Tests was used to determine differences in median labour record subset between hospitals showing statistically significant differences of scores amongst hospitals. #ruskal%8allis Test was used to determine differences in knowledge and skill median scores amongst hospitals,

>? showing no statistically significant difference in the overall knowledge scores amongst hospitals. *owever, a statistically significant difference was detected in the median overall skill score amongst hospitals. 'pearman correlations were used to determine relationships between perinatal outcomes, the 9uality of intrapartum care and obstetric knowledge and skills of midwives and the enabling environment and no correlation between variables was found.

>C

(. Discussion
The main aim of the study was to measure the provision of skilled attendance in Level : *ospitals in the uThungulu *ealth )istrict. (erinatal outcomes were assessed as indicators of the effectiveness of skilled attendance and as a measure of the 9uality of intrapartum care. The dimensions of skilled attendance that are discussed include! the 9uality of intrapartum care, the knowledge and skills of midwives, and the enabling environment. The overall provision of skilled attendance is also discussed. Implications for practice, interventions in the health system and for further research are identified.

(.1 "erinatal outcomes

There is controversy as to whether perinatal mortality rates can be used as pro7y measures for maternal mortality. 0aternal deaths are infre9uent and cannot therefore be used effectively for measuring the impact of skilled attendance. A high proportion of perinatal mortality can be averted by the provision of skilled attendance at birth. Therefore perinatal care indicators remain effective measures of the 9uality of care, particularly the perinatal care inde7 -(attinson et al ;AAI, p>2. ,verall the (&0+ -<: per :AAA births2 for the five hospitals in the uThungulu *ealth district compares well with the national rate -<D.D per :AAA births2 for district hospitals and with the provincial rate -=:.; per :AAA births2 reported in the 'aving .abies ;AA?%;AAC report -(attinson et al ;AAI, p>2. Three hospitals -/showe, &kandla and 't 0ary2 all demonstrated (&0+s below <A per :AAA, while the other two -/kombe and Catherine .ooth2 have rates above => per :AAA. The combined 5'.+ for the five hospitals is ? per :AAA births. It is difficult to compare this with national rates, as the 'aving .abies ;AA?%;AAC report -(attinson et al ;AAI, p>2 includes an indicator of 5resh 'till .irths U /arly &eonatal )eaths -)ay :2 rate while the previous 'aving .abies ;AA<%;AA> report -0+C +esearch "nit for 0aternal and Infant *ealth Care 'trategies et al "ndated, pJ2 reports on the overall 'till .irth +ate. The more comparable inde7 may be the 5'.U/&&) -):2 rate, which is reported to be :?.; per :AAA for district hospitals nationally -(attinson et al ;AAI, p>2. The 5'.+ -:> per :AAA2 for /kombe hospital appro7imates this, while the 5'.+ for all four other hospitals is below :A per :AAA births, with three -Catherine .ooth, &kandla and 't 0ary2 showing 5'.+s of less than > per :AAA.

>D

The combined /&&)+ for the five hospitals is :; per :AAA live births. Compared with the national -:;.> per :AAA live births2 and provincial rate -:>.= per :AAA live births2 -(attinson et al ;AAI, p>2 most hospitals perform poorly, with Catherine .ooth, /kombe and &kandla hospitals all showing /&&)+' of :C%;A per :AAA live births. A more helpful analysis of early neonatal deaths would be separating those that die on )ay : post delivery versus those that die later in the first week of life. )eaths on )ay : are measure of the 9uality of intrapartum care and deaths from day ;%C are a measure of the 9uality of newborn care. The 'aving .abies report ;AA?%;AAC proposes a new inde7 for measuring the 9uality of intrapartum care! the 5'.U/&&) -:d2 -(attinson et al ;AAI, p=2. It must be assumed that higher /&&)+s in the uThungulu )istrict *ospitals, in the light of very low 5'.+s, represent a high proportion of early neonatal deaths on day one. This may apply in Catherine .ooth, &kandla and 't 0ary1s hospitals. *owever, in /kombe *ospital, both the 5'.+ and the /&&)+ are very high, indicating both poor intrapartum and newborn care. In /showe *ospital, both rates are low, indicating good intrapartum and newborn care. The (CI in all hospitals ranged between < and =, and the combined (CI reported for the hospital in the district is <. All hospitals performed poorly when compared with the national -;.:2 and provincial -:.D2 inde7 -(attinson et al ;AAI, p>2. LThe perinatal care inde7 is a true measure of the 9uality of intrapartum careM -(attinson et al ;AAI, p>2 and poor performance against this inde7 suggests that a high proportion of babies of good weight are dying. These deaths could be averted. 5rom the measure of perinatal outcomes in the uThungulu *ealth )istrict, it appears that three hospitals -/showe, &kandla and 't 0ary2 are performing generally well. .ut the (CI still indicates a poor 9uality of care and thus all have deaths that could be avoided. 5urther research is recommended to study the causes and avoidable factors in these deaths. &ational surveys -(attinson et al ;AAI, p :>2 show that in district hospitals, 6ust over ;AE of deaths could be associated with the health care provider and 6ust under :>E with administrative problems, indicating problems both with the skilled attendants and the enabling environment.

>I

(.! ;uality of intrapartum care

0aternity case records are the main source of information in the labour ward. They contain antenatal, intrapartum and postpartum information of women admitted in labour. 0any times information on care is recorded in maternity case records but not performed. *owever, there are cases where care is not documented but was performed -'andin%.o6o et al ;AA?, pJ2. 8hen auditing the 9uality of care, if the information is not recorded, it must be assumed that the procedure was not performed -*ussein et al ;AA=, p:??2. All hospitals have high overall mean percentage scores per record. In the study by oce -;AA>2 scores of CAE were only reached after an intervention was implemented@ whereas in the study by *ussein et al -;AA=2 most items of the maternity record were not recorded, although they did not measure the same parameters used in the current study. The #ruskal%8allis &on%(arametric Test showed a statistically significant difference in scores amongst hospitals, suggesting that all five hospitals do not perform at a similar level in terms of the 9uality of care provided. (oor scores on the admission assessment suggest that any risk factors present during antenatal care may not be recogni4ed on admission and the appropriate plan for delivery may not be made. This calls for further research to investigate the relationship between the 9uality of admission assessment and perinatal outcomes. This may result in the need for in%service training and the need for a supervision intervention. All hospitals scored similarly well on the recording of findings on the labour graph. This is not consistent with the findings by *ussein et al -;AA=2! their study reports only :>.=E of completed labour graphs. It is noted that in all hospitals, the management of labour scored most poorly. This is consistent with the findings by 3bangbade et al -;AA<2 and 0cCaw%.inns et al -;AA=2! their studies report labour monitoring to be inade9uate in most records reviewed. (oor scores on the management of labour suggest that findings recorded on the labour graph are not being interpreted to inform the ongoing management of labour. 5urther research is re9uired to investigating the relationship between the interpretation of findings on the labour graph and perinatal outcomes. This may also

?A result in need for training and supervision interventions to improve the capacity of midwives to interpret findings and make management decisions. Comparison of the subsets with #ruskal%8allis &on%(arametric test shows statistically significant differences in scores amongst hospitals. This suggests that labour monitoring is not performed at the same level in all five hospitals.

(.# *bstetric :nowledge

,verall, all hospitals scored poorly on the knowledge test. &o hospital met the (/( standard of DAE. These results compare with *arvey et al -;AAC2, 3bangbade et al -;AA<2 and 0cCaw%.inns et al -;AA=2! their studies report midwives1 inade9uate obstetric knowledge in Jamaica, +wanda, /cuador and .enin. All hospitals performed better on prolonged labour and *I but scored poorly on each of the other subsets. There were no statistically significant differences in the overall knowledge median scores and subsets median scores amongst hospitals, indicating that all hospitals perform on a similar level in terms of obstetric knowledge. The results suggest that midwives in Level : *ospitals do not comply fully with the definition of skilled attendant as provided in section ;.;.: and do not have the minimum knowledge re9uired of midwives in identifying and managing obstetric complications. (oor knowledge scores suggest inade9uate knowledge in midwives to monitor, manage and supervise labour and call for training initiatives for midwives in the management of labour.

(.& *bstetric 'kills

The overall skill scores amongst hospitals were poor and did not meet the set standard -DAE2. This is consistent with the findings by *arvey et al -;AA=2! their study shows midwives1 skills scores around =D.;E. Three of five hospitals have high scores on plotting information on the labour graph, consistent with the findings of the labour record review. These results are not consistent when compared to the study by *arvey et al -;AA=2. In their study, midwives scored poorly on plotting information on the labour record. *owever, high scores were recorded on midwives1 ability to interpret information on a labour graph. 8hereas in the current study, all hospitals had similarly poor

?: scores in interpreting information on a labour graph. This is consistent with the findings of the labour record review where low scores were found on the management of labour. ,verall, there was not a statistically significant difference in median scores on the Labour 3raph /7ercise I and II amongst hospitals, indicating that midwives1 obstetric skills -in plotting and interpreting information on a labour graph2 in the study hospitals are similar. *owever, there was a statistically significant difference in the post%partum haemorrhage median scores amongst hospitals suggesting that hospitals perform on a different level in terms of the management of post% partum haemorrhage. Increasing the proportion of deliveries assisted by skilled attendants is the key strategy towards reductions in maternal and perinatal mortality. There are a number of interventions that can be performed by skilled attendants to decrease maternal and perinatal mortality and these are listed in section ;.< -Table ;.:2. *owever, the above results demonstrate that there is a need for reviewing the education and training received by midwives, as suggested by the literature in section ;.?. (oor scores on plotting and interpreting information on a labour graph suggest that there are difficulties in the ability of midwives to transfer knowledge to skills. It also indicates differences in abilities to record versus interpret findings on the partograph for the management of labour. This has similar implications as the poor scores in the management of labour! there is a need for training and supervision interventions to improve the capacity of midwives to interpret findings and make management decisions. There are a number of interventions that can be performed by skilled attendants to decrease maternal and perinatal mortality and these are listed in section ;.< -Table ;.:2. *owever, the above results demonstrate that there is a need for reviewing the education and training received by midwives, as suggested by the literature in section ;.?. (oor scores on plotting and interpreting information on a labour graph suggest that there are difficulties in the ability of midwives to transfer knowledge to skills. It also indicates differences in abilities to record versus interpret findings on the partograph for the management of labour. This has similar implications as the poor scores in the management of labour! there is a need for training and supervision interventions to improve the capacity of midwives to interpret findings and make management decisions.

?;

(.( T%e enabling environment

Three hospitals met the enabling environment standard. All hospitals but one scored poorly on referral, and the availability of supervision on both shifts. ,ne hospital scored poorly on drugs and supplies. ,verall no hospitals reported the presence of all the elements of the enabling environment. 'tudies by 3bangdade et al -;AA<2 and 0cCaw%.inns et al -;AA=2 looked at the enabling environment@ however no details on their results were reported. The enabling environment refers to conditions in which skilled attendants work to provide women with care during childbirth.The elements of the enabling environment identified in the literature are listed and defined in section ;.;.;. +esults from theLevel : *ospitals in uThungulu *ealth )istrict suggest that the environment is not fully enabling, thus the need for 9uality improvement initiatives to address the availability of drugs, e9uipment maintenance and ineffective supervision. Three hospitals had acceptable workloads. Compared with perinatal outcomes two hospitals that have acceptable workload have high (&0+ and high (CI -=2 and do less than :AA deliveries per month. This suggests that staff shortages may play less of a role as determinants of poor 9uality of care than is usually attributed by health workers. The 'outh African health system suffers an overall shortage of and maldistribution of healthcare workers. Though staff shortages may play less of a role in the determination of the 9uality of care, a gap still e7ists in the coverage of health professionals in rural areas. This calls for a review of policies pertaining to the deployment of healthcare workers in the country to ensure an e9uitable distribution of health professionals between urban versus rural areas.

(.+ Association between perinatal outcomes wit% t%e 9uality of intrapartum care8 t%e obstetric knowledge and skills and environment.
&o association could be detected between variables. *owever, there are trends that can be traced in different hospitals. 5or e7ample, all hospitals reported a high (CI, an indication of poor 9uality of care, and poor scores in knowledge and skills of midwives. This could suggest a relationship between these variable that was however not shown in the study. (erinatal outcomes in two -Catherine .ooth and /kombe2 of the five hospitals were worse and the (CI reported in these

?< hospitals were high =, suggesting a relationship between poor perinatal outcomes and poor 9uality of care. The lack of association between variables might have been as a result of! % % )ata analysed and presented at hospital level rather than individual level. ,ther factors influencing perinatal outcomes not measured in this study. 5or e7ample!

women related factors -poor health, poor nutrition, and delay in seeking health care2, socio% economic factors -poverty2, and causes of perinatal mortality.

?=

(.0 Conclusion
This section looks at the strengths and weaknesses in each hospital with regards to the provision of skilled attendance and presents a conclusive remark. ,verall, all hospitals tend to share a similar pattern on perinatal outcomes, the 9uality of intrapartum care, obstetric knowledge and skills and the enabling environment. Catherine .ooth and &kandla hospitals performed similarly poorly on (&0+, /&&)+ and (CI, but have good 5'.+. /kombe performed poorly on all perinatal outcomes and this is consistent with poor (CI. /showe and 't 0ary1s performed well on all perinatal outcomes but did poorly on (CI. Catherine .ooth, &kandla and 't 0ary1s hospitals have an overall high mean percentage score for the completion of labour records, which is an indication of good 9uality care. *owever, they performed poorly on the admission assessment and the management of labour, indicating a lack of appropriate plan for the labour. 8hen most hospitals performed poorly on the management of labour, /kombe performed relatively well. /showe is the only hospital that performed well on all record review subsets. This result however, is not consistent with poor (CI. All hospitals share the same pattern with regard to obstetric knowledge with very poor overall scores. 'imilarly, all hospitals scored poorly on normal labour, prolapsed cord, ((*, (I* and sepsis, an indication of inade9uate obstetric knowledge across all hospitals. They all scored well on prolonged labour and *I . All hospitals performed poorly on overall skill scores. Catherine .ooth and /showe hospitals performed poorly on all skills subset@ /kombe, &kandla and 't 0ary are performed well on plotting information on a labour graph. 't 0ary1s and Catherine .ooth hospitals both have an acceptable enabling environment and acceptable workload, whereas &kandla hospital has neither an acceptable enabling environment nor an acceptable workload. /kombe hospital does not have an acceptable enabling environment but acceptable workload. /showe hospital has an acceptable enabling environment but not an acceptable workload.

?>

8ith few e7ceptions, almost all countries where skilled attendance is more than eighty percent -DAE2 have low 00+s and (&0+s. In 'outh Africa, from the )emographic and *ealth 'urvey, eighty four percent -D=E2 of deliveries are assisted by a skilled attendant. *owever, while an attendant may be present, one cannot say that skilled attendance is provided. This has been shown in uThungulu *ealth )istrict, as reflected in poor 9uality of care, inade9uate obstetric knowledge and skills of midwives and a lack of an enabling environment across different hospitals. +elatively low perinatal mortality rates in three hospitals while the 9uality of care provided is poor might be the result of doctors1 interventions. *ealth care workers include doctors and midwives@ however doctors were not included in the study. 5urther research is re9uired to evaluate the partnership ratio of deliveries solely attended by midwives versus those attended by doctors. There may be a need to investigate the patient profile! low risk deliveries may be self%referring to Level : *ospitals and high risk to Level ; *ospitals. )espite of 9uality improvement initiatives being implemented in /showe, &kandla and 't 0ary1s hospitals, their performance is far from being satisfactory. The differences between the hospitals reported in the summary above may indicate that initiatives to improve the 9uality of care must be tailored to the specific problems in each hospital.

??

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?D

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!t"dies in Healt, !ervi'es Or#anisation, :C, pp. ;;>%;=;.

?I #ak, &, .urkhalter, 0 K Cooperet, A ;AA:, 0easuring the competence of healthcare providers1, -,e 6"ality ss"ran'e Pro7e't, .ethesda. #oblinsky, 0 ;AAA, -,e Mot,er Care E8perien'e: -e',ni'al Cons"ltation 9Ens"rin# s3illed

attendan'e at delivery. 3eneva. &ew Fork! '0IA3P5CI. #oblinsky, 0, 0atthews, $, *ussein, J, 0avalanka, ), 0ridha, 0, Anwan, J, Achadi, /, Ad6ei ', (admanabhan, ( K an Lerberghe, 8, ,n behalf of the 0aternal 'urvival 'eries 'teering 3roup ;AA?,13oing to scale with professional skilled care1 -,e /an'et, vol.<?D, no I>==, pp. :<CC%:<D?. #ot4ee, T K Couper, I ;AA?, L8hat interventions do 'outh African 9ualified doctors think will retain them in rural hospitals of the Limpopo province of 'outh AfricaJM 5amily 0edicine, vol. <I, no =, pp. ;DD%;IA. #unst, A/ K *ouweling, T ;AA:, RA global picture of poor%rich differences in the utilisation of delivery care1, Studies in Health Services Organisation , vol.17. Lavender, T K 0alcolmson, L :III, RIs the partogram a help or a hindranceJ An e7ploratory study of midwives1 views1 -,e Pra'tisin# Mid2i%e, vol.;, pp. ;<%C. Lawn, J, Cousens, ', $upan, J K the Lancet &eonatal 'urvival 'teering Team ;AA>, R= million neonatal deaths! whenJ 8hereJ 8hyJ1 -,e /an'et, vol.<?>, pp. DI:%IAA. Lawn J, Tinker A, 0un6an6a '( K Cousens, ' ;AA?, R8here is maternal and child health nowJ1 -,e /an'et, vol.<?D, pp. :=C=%:=CC. Loren4, & :I?C, Monitorin# labo"r in ("r3ina%aso: 2it, spe'ial 'onsiderations on t,e introd"'tion o% a ne2 labo"r ',art, .issertation, "niversity of London. 0ac)onagh, ' ;AA>, RAchieving skilled attendance for all@ a synthesis of current knowledge and recommended actions for scaling up1, )5I) Healt, 1e'o"rses Centre, pp. :%<C. 0ac)onald, 0 K 'tarrs, A ;AA;, R!3illed 'are d"rin# ',ildbirt, in%ormation boo3let R, 5amily Care International. Information Booklet. Family Care International (FCI).

CA

0aclean, 3) undated. Competence of 'killed attendant. In 'killed attendance! a review of the evidence. Family Care International0 0aclean, 3) ;AA<, RThe challenge of preparing and enabling skilled attendants to promote safer childbirth1 Mid2i%ery, vol.:I, pp. :?<%:?I. 0aine, ), Akalin, 0$, 8ard, 0 K #amara, Columbia "niversity. &ew Fork. 0cCaw%.inns, A, .arkhtaler, .+, /dson, 8, *arvey, 'A K Antonakoset, C ;AA=, Operation 1esear', 1es"lts0 !a%e mot,er,ood st"dies* 1es"lts %rom $amai'a0 Competen'y o% s3illed birt, attendants, t,e enablin# environment %or s3illed attendan'e at delivery, in* ,ospital delays in obstetri' 'are 4do'"mentin# t,e )rd delay5. Huality Assurance (ro6ect. 0engsteab, / ;AA?, !3illed attendan'e at delivery: t,e 'ase o% :oba, Eritrea, )issertation, "niversity of the 5ree 'tate, .loemfontein, +'A. 0oran, &i6e, 'nyman K 'teyn ;AA?, Antenatal care. In !avin# (abies 200)*200+: Fi%t, perinatal 'are s"rvey o% !o"t, %ri'a. (attinson +C ed. Tshepesa (ress, (retoria. 0pembeni, &0, #illewo, $, Leshabari, 0T, 0assawe, '&, Jahn, A, 0ush, ), K 0wakipa, * ;AAC. R"se pattern of maternal health services and determinants of skilled care during delivery in southern Tan4ania! implications for achieving the 0)3%> targets1. (MC Pre#nan'y and C,ildbirt,, vol.C, pp. ;I. &ational Committee on Confidential /n9uiries into 0aternal )eaths -&CC/0)2, ;AA>, -,ird report on Con%idential En;"iries into Maternal .eat,s in !o"t, %ri'a 2002*200<0 )epartment of *ealth. (retoria. :IIC, -,e desi#n and eval"ation o% Maternal

Mortality Pro#rammes. Centre for (opulation and 5amily *ealth, 'chool of (ublic *ealth,

C: &ational Committee on Confidential /n9uiries into 0aternal )eaths -&CC/0)2, ;AA?, Fo"rt, Interim 1eport on Con%idential En;"iries into Maternal .eat,s in !o"t, %ri'a * C,an#in# Patterns in Maternal .eat,s =>>?*200). )epartment of *ealth. (retoria. (admanabhan, A, 'chwart4, J K 'pitalnik, 'L ;AAI, Transfusion therapy in (ostpartum *aemorrhage. !eminars in Perinatolo#y, vol.<<, pp. :;=%:;C. (attinson, +C, 8oods, ), 3reenfield, ) K elaphi, ' ;AA>, RImproving survival rates of newborn infants in 'outh Africa1, 1eprod"'tive Healt,, vol.;, no =, iewed ;A 0ay ;AAI V http!PPwww.reproductive%health%6ournal.comPcontentP;P:P=W. (attinson, +C ;AA?, Huality of care. In !avin# (abies 200)*200+: Fi%t, perinatal 'are s"rvey o% !o"t, %ri'a. (attinson +C ed. Tshepesa (ress, (retoria. (attinson, . K elaphi, ' *ardy, . 0oran, & 8ilhelm, ' ;AAI, ,verview. In !avin# (abies 200@*200A: !i8t, perinatal 'are s"rvey o% !o"t, %ri'a. (attinson +C ed. Tshepesa (ress, (retoria. (erinatal /ducation (rogramme -(/(2 ;AA>, Maternal Healt, Care Man"al =. (erinatal /ducation (rogram Trust. (erinatal /ducation (rogramme -(/(2 ;AAD, !avin# Mot,ers and (abies: learnin# pro#ramme

%or pro%essionals0 )eveloped by the (erinatal /ducation (rogramme, /lectric .ook 8orks -/.82. (eterson, #,, 'vensson, 0L K Christensson, # ;AAA, R /valuation of an adapted model of the 8orld *ealth ,rganisation partogram used by Angolan midwives in a peripheral delivery unit1, Mid2i%ery, vol.:?, pp. D;%D. +oyal College of ,bstetricians and 3ynaecologists -+C,32 :III, -o2ards sa%er ',ildbirt,: Minim"m !tandards %or t,e Or#anisation o% /abo"r Wards0 London. 'andin%.o6o, A#, Larsson, .8, A7elsson, , K *all Lord, 0L ;AA?, Intrapartal care documented in a 'wedish maternity unit and considered in relation to 8orld *ealth ,rganisation recommendations for care in normal birth, Mid2i%ery, vol.;;, no <, pp. ;AC%;:C.

C; Thaddeus, ' K 0aine, ) :II=, RToo far to walk! maternal mortality in conte7t1, !o'ial !'ien'e and Medi'ine, vol.<D, pp. :AI:%::A. "&IC/5P8*,P"&5(A, :IIC, &"idelines %or monitorin# t,e availability and "se o% obstetri' servi'es, "nited &ations ChildrenQs 5und, &ew Fork. "&IC/5, 8orld *ealth ,rgani4ation and "&5(A. "nited &ations, :III, 1eport o% t,e d Ho' Committee o% t,e W,ole o% t,e -2enty*%irst !pe'ial !ession o% t,e &eneral ssembly. &ew Fork! "nited &ations, : July :III -3eneral Assembly document, &o. AP'%;:P>PAdd.:2. "nited &ations -"&2, ;AA>, -,e Millenni"m .evelopment &oals 1eport 200+. &ew Fork. "nited &ations -"&2, ;AAD, -,e Millenni"m .evelopment &oals 1eport 200?, iewed :: June ;AAI < http!PPwww.un.orgPmillenniumgoalsPpdfPtheE;Amillenium. "nited &ations (opulation 5und -"&5(A2, ;AA<, Maternal Mortality Update 20020 Emer#en'y Obstetri' Care. &ew Fork. "nited &ations (opulation 5und -"&5(A2, ;AA=a, Maternal mortality "pdate 200<: deliverin# into #ood ,ands0 &ew Fork. "nited &ations (opulation 5und -"&5(A2, ;AA=b, Into #ood ,ands: pro#ress report %rom t,e %ield. &ew Fork. "nited &ations (opulation 5und -"&5(A2, ;AA?, Investin# in mid2ives and ot,ers 2it, mid2i%ery s3ills to save t,e lives o% mot,ers and ne2borns and improve t,eir ,ealt,. A "&5(A%IC0 Joint Initiative to support the call for a )ecade of Action for *uman +esources for *ealth made at 8orld *ealth Assembly ;AA?. &ew Fork. ella, ;AA<, Maternal, perinatal and n"tritional 'onditions in B2a:"l"*Natal, The Fo'"s on

/pidemiology "nit #wa$ulu%&atal, )epartment of *ealth.

C< elaphi, ' K (attison, +C ;AAC, RAvoidable factors and causes of neonatal deaths from perinatal asphy7ia%hypo7ia in 'outh Africa! national perinatal survey1, nnals o% -ropi'al Paediatri's, vol. ;C, pp. II%:A?. oce, A' ;AA>, -,e development o% a distri't*based model o% intervention %or improvin# t,e ;"ality o% maternal ,ealt, 'are at primary level, Thesis, (h) "niversity of #wa$ulu%&atal, )urban. 8orld *ealth ,rganisation -8*,2, :II:, Essential elements o% obstetri' 'are at %irst re%erral level0 8*,, 3eneva. 8orld *ealth ,rgani4ation -8*,2 :II;. International !tatisti'al Classi%i'ation o% .iseases and 1elated Healt, Problems0 -ent, 1evision. 3eneva , 8orld *ealth ,rgani4ation, :II;. In! Abou4har and 8ardlaw, RMaternal mortality in 2000: estimates developed by WHO, UNICEF and UNFP . 8orld *ealth ,rganisation -8*,2, :II=, Mot,er*(aby Pa'3a#e: Implementin# !a%e mot,er,ood in 'o"ntries0 8*,P5*/P0'0'PI:.::. 8*,, 3eneva. 8*,P"&5(AP"&IC/5P8orld .ank, :III, 1ed"'tion in maternal mortality! 3eneva. 8*,P'/+A, ;AA;, Improvin# maternal s"rvival t,ro"#, s3illed 'are d"rin# ',ildbirt,: a revie2 o% t,e eviden'e, 8*,, 3eneva. 8*,PIC0P5I3,, ;AA=, Ma3in# pre#nan'y sa%er: t,e 'riti'al role o% s3illed attendants. A 6oint statement by 8*,PIC0P5I3,, 3eneva ;AA=. 8orld *ealth ,rgani4ation -8*,2, ;AA>, -,e World Healt, 1eport 200+: Ma3e Every Mot,er and C,ild Co"nt, 8*,, 3eneva. 8orld *ealth ,rgani4ation -8*,2, ;AA?, Neonatal and perinatal mortality 'o"ntry, 1e#ional and &lobal estimates, 8*,, 3eneva. $oint statement0

C= 8orld *ealth ,rganisation -8*,2 ;AAC, Maternal mortality in 200+: estimates developed by WHO, UNICEF, UNFP , and t,e World (an3. 3eneva. 8*,%,/C), ;AAD, Hosted dialo#"e on mi#ration and ot,er ,ealt, 2or3%or'e iss"es in a #lobal e'onomy, pp. ;A%;:, ,/C), 3eneva. 8orld *ealth ,rganisation -8*,2 ;AAD, Universal a''ess to sa%e blood trans%"sion0 )epartment of /ssential Technologies and .lood Transfusion 'afety "nit, 8*,, 3eneva0 Fesudian, (( ;AA=, RImpact of 8omen1s /mpowerment, Autonomy and Attitude on 0aternal *ealth Care "tili4ation in India1, International Instit"te o% Pop"lation !'ien'es, 5D%<;C, India.

C>

Appendices

C? Appendi? /& @etters ! appr (al and permissi n& Appendi? /& /- " stgraduate >ducati n 5 mmittee Appr (al&

CC Appendi? /& 2: ,i medical %esearch >thics 5 mmittee Appr (al&

CD Appendi? /& 6- "ermissi n !r m the "r (incial $ealth %esearch and Kn wledge Management Di(isi n&

CI Appendi? /& 8- $ spital permissi n2Supp rt @etters&

Solange Mianda University of Kwa !l! "atal #U$%&" #ear Solange

'o!r e(ail re)eived yesterday refers*

+er(ission is t,!s granted for yo! to )ond!)t yo!r resear), st!dy in t,is ,os-ital as re.!ested* /onditions will a--ly as -er t,e et,i)al g!idelines a--li)a0le on resear), st!dies a))ordingly1 and -lease 2ee- t,is offi)e -osted on t,e -ro-osed date of yo!r visit*
3,an2 yo!* 4*%*5U"#4& / 6 78 /%9

Mr0 /0(0 C"ndla C,ie% E8e'"tive O%%i'er Cat,erine (oot, Hospital -el: 0)+ * <A< ?<02 Fa8: 0)+ * <A< A@>< Cell: 0A? A?2)0 A<

DA

D:

D;

D<

D= Appendi? /& 7- @etter t M# ng lwane $ spital& 0rs. Jafta, 0bongolwane *ospital 0anager (P.ag G:;?, #wapett <D;A 5a7 number! A<>=C??<DA )ear 0rs Jafta 0y name is 'olange 0ianda. I am a 0aster of (ublic *ealth student at the "niversity of #wa$ulu%&atal. I am undertaking my final year research pro6ect on! Measuring skilled attendance at #irth in @e(el / $ spitals in the uThungulu District& I have attempted to contact you several times to obtain permission to conduct the study at 0bongolwane *ospital. I tried to contact you by e%mail -on ;;PA>P;AAD and ;=PA?P;AAD2 and also by facsimile -:<PA<P;AAD and A;PA?P;AAD2. I also have spoken personally to your secretary who gave me the assurance that you would revert to me. *owever to date I have not yet received your permission to go ahead with the study. I do not want to assume that 0bongolwane *ospital does not want to participate in the study. (lease sign the attached form and send to me either by mail -at somiangaXyahoo.fr2 or fa7 -A<: ;?A =;:: O for my attention2 to indicate whether you wish for 0bongolwane *ospital to participate in the study or not. If I do not hear from you by 0onday :<th ,ctober ;AAD I will assume that you do not wish for 0bongolwane *ospital to participate in the study. +est assured that if you do not wish for 0bongolwane *ospital to participate there will be no negative conse9uence, nor penalty involved, nor any loss of benefits to which the hospital may be entitled. #inds regard 'olange 0ianda

D>

Appendi? /& 9- *n! rmed 5 nsent ! rm&

3reeting! *ello 0y name is 'olange 0ianda I am a 0aster of (ublic *ealth student *ealth student at the "niversity of #wa$ulu%&atal. I am undertaking my final year research on! Measuring skilled attendance at #irth in @e(el / h spitals in the uThungulu District& Fou have been asked to participate in a research study involving you in responding to a multiple choice test and ,'C/ stations. Fou have been informed about the study by NNNNNNNNN. . Fou may contact 'olange at AC<<D==II> any time if you have 9uestions about the research or if you are in6ured as a result of the research. Fou may contact the ,i medical %esearch >thics B!!ice on 06/-290 8A9F r 290 /0A8 if you have 9uestions about your rights as a research participant. Four participation in this research is voluntary, and you will not be penali4ed or lose benefits if you refuse to participate or decide to stop at any time. If you agree to participate, you will be given a signed copy of this document and the participant information sheet which is a written summary of the research. The research study, including the above information, has been described to me orally. I understand what my involvement in the study means and I voluntarily agree to participate. I have been given an opportunity to ask any 9uestions that I might have about participation in the study. GGGGGGGGGGGGGGGGGGGG Signature ! "articipant GGGGGGGGGGGGGGGGGGGG Signature ! Hitness ;Hhere applica#le< GGGGGGGGGGGGGGGGGGGG Signature ! Translat r ;Hhere applica#le< GGGGGGGGGGGGGGGGGGGG Date GGGGGGGGGGGGGGGGGGGGG Date

GGGGGGGGGGGGGGGGGGGGG Date

D? Appendi? 2- "erinatal utc mes data e?tracti n ! rm S urce ! data E Maternit)2deli(er) register Name ! h spital! 4444444444444 Date ! data c llecti n- 444444444

@uly #004 2otal *eliveries 2otal births Cive births 5S. MS. 8""1 C.(

Aug #004

Sep #004

,ct #004

"ov #004

1ec #004

@an #00?

5eb #00?

Mar #00?

Apr #00?

May #00?

@une #00?

2otal

DC

Appendi? 6- MAT>%N*TI 5AS> %>5B%D %>.*>H :B%M& S urce ! data E Maternit) case rec rds Name ! h spital! 4444444444 Date ! data c llecti n- 44444&
I&'T+"CTI,&' : r each Ies answer, sc re / p int *! the item is inc mplete r missing, sc re 0 %ec rd the sc re n the summar) sheet ! rm Admissi n assessment ! rm :2 Is there evidence that the health worker has reviewed and summari4ed the A&C record and listed the maternal and fetal risk factorsJ ;2 Check the items on the admission form. Are all completedJ <2 At the end of the form, is there a decision on diagnosis and managementJ =2 8ere the admission findings checked and counter%signed by an Advanced 0idwife -or doctor or e7perienced midwife if no A)0 available2J @a# ur graph >2 Is the list of risk factors recorded at the top of the labour graphJ ?2 *as the fetal heart rate been recorded half%hourlyJ C2 *as the state of the li9uor -as recogni4ed by a pad check2 been recorded at least =%hrlyJ D2 *as the degree of moulding been recorded when a ( has been doneJ I2 *ave the contractions been recorded hourlyJ :A2 *as the cervical dilatation been recorded at least =%hourly during the latent phase and at least two%hourly in the active phaseJ ::2 *as the cervical dilatation been plotted in relation to the lines drawn for the latent and active phases, and for the alert and action linesJ :;2 *as the level of the head in relation to the brim of the pelvis been recorded at least =%hourly since admissionJ :<2 *ave the maternal .( and pulse been recorded at least hourlyJ :=2 *ave the maternal temperature and urinary output been recorded at least =%hourlyJ :>2 Is there a record of drugs and I fluids givenJ Management ! @a# ur ! rm ; n a separate page !r m the la# ur graph< :?2 Is this recorded after doing each vaginal e7amination, or at least =%hourlyJ :C2 Is the summary of fetal condition recordedJ :D2 Is the summary of labour progress recordedJ :I2 Is the summary of maternal condition recordedJ ;A2 Is the decision on further action recordedJ ;:2 Is the time of ne7t intended review statedJ ;;2 8ere these assessments checked =%hourly by an A)0 -or doctor or senior midwife2J Assessment ! the new# rn ;<2 Is the new born assessment form completed :inal summar) ;=2 Is there evidence of active management of the < rd stage of labourJ ;>2 Is the summary form completedJ

DD

DI Appendi? 8- Kn wledge Test& Data s urce Multiple-5h ice +uesti nnaire& (lease choose one, most correct answer to each 9uestion or statement and complete on the sheet provided. :. The latent phase of the first stage of labour is! a2 b2 c2 d2 The period of time the cervi7 takes to dilate from < cm to full dilatation. The period of time from the onset of labour to full cervical dilatation. The period of time from the onset of labour to < cm cervical dilatation. The period of time during which the cervi7 becomes effaced.

;. A patient presents in established labour with regular contractions and ruptured membranes. ,n vaginal e7amination the cervi7 is > cm dilated. 8here should her cervical dilatation be noted on the partographJ a2 ,n the alert line opposite > cm cervical dilatation. b2 At the beginning of the latent phase of labour opposite > cm cervical dilatation. c2 At the end of the latent phase of labour opposite > cm cervical dilatation. d2 ,n the vertical line at the beginning of the active phase of labour opposite > cm cervical dilatation. <. Fou should be satisfied with the progress of labour during the active phase when! a2 The cervical dilatation falls on or to left of the alert line together with progressive engagement of the head. b2 The cervi7 dilates at a rate of ; cm per hour. c2 Cervical dilatation falls on or to the left of the alert line together with improvement in the station of presenting part as assessed on vaginal e7amination. d2 There is progressive dilatation and effacement of the cervi7. =. 8hen does a patient have ade9uate and effective uterine contractionsJ a2 If she has ; or more contractions every :A minutes with each contraction lasting <A seconds or longer. b2 If she has < or more contractions every :A minutes with each contraction lasting ?A seconds or longer. c2 If she progresses normally in labour. d2 If she has pain with every contraction. >. A patient at term presents after having been in labour at home for some time. ,n admission <P> of the fetal head is palpable above the pelvic brim, and on vaginal e7amination <U moulding is detected, with cervical dilatation at :A cm. 8hat is the correct further management of this patientJ a2 An o7ytocin infusion should be started.

IA b2 A caesarean section should be done. c2 The patient should be given pethidine and hydro7y4ine -AT/+AG2. d2 The patient should be reassured that she will labour and deliver normally. ?. A patient presents in labour at term. 'he is having ; contractions of <> seconds each every :A minutes. The cervi7 is < cm dilated and the membranes have ruptured. *er cervical dilatation is plotted on the alert line. 5our hours later the cervi7 is = cm dilated and her other observations are unchanged. There are no signs of cephalopelvic disproportion. 8hat is the correct managementJ a2 b2 c2 d2 An o7ytocin infusion should be started. A caesarean section should be done. 'he should be given pethidine and hydro7y4ine -AT/+AG2. The doctor should be called to e7amine the patient.

C. 8hich of the following patient is at high risk of cord prolapseJ a2 A patient with a breech presentation. b2 A patient with cephalic presentation. c2 A patient with post term pregnancy. d2 A patient who ruptured her membranes when the fetal head is still palpable <P> above the pelvic brim. D. 8hat should be done first if a patient, who has a cervi7 ? cm dilated, presents with a prolapsed cordJ a2 Immediately replace the umbilical cord into the vagina and take steps to lift the presenting part off the cord. b2 An o7ytocin infusion should be started in order to deliver the infant as soon as possible. c2 3ive the patient ,7ygen by face mask in order to ensure that the fetus receives enough o7ygen. d2 The patient must be rushed to theatre for an emergency caesarean section. I. *ow many fifths of the fetal head will be palpable above the pelvic brim when engagement has taken placeJ a2 b2 c2 d2 >P> =P> <P> ;P>

:A. 8hat position should the patient adopt when she deliversJ a2 'he should lie on the back. b2 'he should lie on her side. c2 'he should s9uat upright. d2 'he should choose whichever position she prefers as long as it is practical under the clinical circumstances.

I:

::. 8hat is the correct management if there is no progress in the second stage of labour and there are signs of cephalopelvic disproportionJ a2 The patient must not bear down but should be evaluated by a doctor as a caesarean section is needed. b2 An episiotomy should be done to speed up delivery. c2 An o7ytocin infusion should be started to increase the strength of the contractions. d2 The patient should continue bearing down for <A minutes in a primigravida and => minutes in a multigravida before any further management is carried out. :;. 8hat should be the initial management of impacted shoulders -i.e. shoulder dystocia2J a. The patient buttocks should be moved to the end of the bed in order to allow good posterior contraction on the infant1s head. b. Arrangement must be made for an emergency caesarean section. c. An immediate attempt must be made to deliver the infant1s posterior arm. d. (ressure should be applied to the fundus of the uterus in order to deliver the infant 9uickly. :<. The third stage of labour starts when! a2 b2 c2 d2 The cervi7 is fully dilated. The anterior shoulder of the infant is delivered. The infant is born. The placenta is delivered.

:=. The active management of the third stage of labour includes! a2 3iving an o7ytocic drug, after a second twin has been e7cluded, and then waiting for the uterus to contract. b2 8aiting for signs of placental separation and then pulling on the umbilical cord while pushing the uterus upwards. c2 (ulling on the umbilical cord while pushing the uterus upwards immediately after the infant has been delivered. d2 3iving an o7ytocic drug, after the signs of placental separation have appeared and then pulling on the umbilical cord while pushing the uterus upwards. :>. 8hich of the following signs will confirm the diagnosis that the placenta has separatedJ a2 Lengthening of the umbilical cord. b2 The fundus of the uterus moves from below to above the umbilicus. c2 A sudden gush of blood runs out of the vagina. d2 'uprapubic pressure does not result in shortening of the umbilical cord when the uterus is pushed upwards. :?. 8hich of the following is a contra%indication to giving 'F&T,0/T+I&/ during the third stage of labourJ

I;

a2 b2 c2 d2

An atonic uterus *ypertension after delivery. Any of the hypertensive disorders of pregnancy. 5actors during pregnancy that result in a large uterus.

:C. 8hich ,7ytocic drug should be given if there is a contra%indication of the use of 'F&T,0/T+I&/J a2 b2 c2 d2 /rgometrine A combination of o7ytocin and ergometrine. ,7ytocin. (rostaglandin /;.

:D. 8hat is the advantage of using the active method of managing the third stage of labourJ a2 +etained placenta is uncommon. b2 An assistant is not needed. c2 As the o7ytocic drug is given after delivery of the placenta, complications with a second twin are avoided. d2 .lood loss during the third stage is reduced. :I. 8hat is the management of a retained placenta following the active management of the < rd stage of labourJ a2 (ethidine and dia4epam - alium2 must be given intravenously and manual removal of the placenta done in the labour ward. b2 An intravenous infusion with ;A units of o7ytocin should be started to ensure a well% contracted uterus and then the patient should be referred to hospital for manual removal under general anesthesia. c2 Allow a further <A minutes of observation before referring the patient. d2 Apply fundal pressure together with traction on the cord to deliver the placenta. ;A. 8hat should be the first step in the management of post%partum haemorrhage when the placenta has already been deliveredJ a2 b2 c2 d2 The uterus must immediately be rubbed up. A rapid intravenous infusion of ;A units of o7ytocin should be started. The patient1s bladder must be emptied. The cause of the bleeding must be looked for.

;:. 8hich signs suggest that the bleeding is caused by an atonic uterusJ a2 b2 c2 d2 The vaginal bleeding consists of a continuous stream of bright red blood. The membranes are not complete. The vaginal bleeding is intermittent and consists of dark red clots. &o uterus can be palpated on abdominal e7amination.

I< ;;. 8hich of the following is the most likely cause of post%partum haemorrhage due to an atonic uterusJ a2 b2 c2 d2 Abruptio placenta. The use of o7ytocin during the first stage of labour. 0ultiple pregnancy A uterus full of blood clots.

;<. *I in pregnancy is a2 b2 c2 d2 The commonest cause of mortality Is not prevented by the use of condoms after pregnancy, A cause of concern, as it affects up to =AE of A&C patients in the public sector +esponsible for the change in the midwifery practice

;=. In women who are *I positive, the membranes should! a2 b2 c2 d2 .e ruptured as soon as possible to speed up the labour. .e ruptured when the cervi7 reaches = cm dilated ,nly be ruptured when the cervi7 is D cm dilated. &ot be artificially ruptured unless there is good clinical indication.

;>. The following procedures may increase the risk of mother to child transmission of *I ! a2 /lective caesarean section b2 Active management of the third stage of labour. c2 aginal e7amination. d2 +outine episiotomy ;?. (regnancy induced hypertension a2 b2 c2 d2 Is associated with eclampsia if the diastolic pressure is above ::Amm *g. Is never causes convulsions when it is less than :>APIA mm *g. Is common in pregnancies less than ;A weeks gestation. Is associated with abruptio placenta.

;C. The management of eclampsia includes all the following e7cept! a2 b2 c2 d2 /nsuring clear airway, circulation and breathing. 0easuring urine output strictly every = hours. )elivery of the fetus within ? hours. (revention of further convulsions.

;D. The following are bad signs in eclampsia! a2 b2 c2 d2 Fellow diluted urine with yellow sclera. .leeding from ruptured sites. Convulsions in a very young woman. Convulsion in woman not in labour.

I=

;I. (uerperal sepsis may be caused by! a2 b2 c2 d2 (rolonged labour. +epeated internal e7aminations in labour. "rinary tract infection before labour. (neumonia.

<A. The management of severe endometritis post% delivery includes the following! a2 b2 c2 d2 Intravenous fluids. Intravenous antibiotics. "ltrasound e7amination only. /vacuation of the uterus using a manual vacuum e7tractor.

I> Multiple ch ice +uesti ns m del answer& $BS"*TA@ 5BD>DAT>- 44444444 $>A@T$ HB%K>% 5BD>- 44&44&&&&&&&&

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b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d

I? M'@T*"@> 5$B*5> J'>ST*BNS ANSH>% S$>>T $BS"*TA@ 5BD>7- K, L, M, N, O DAT>- 44444444 $>A@T$ HB%K>% 5BD>9,A- 44&44&&&&&&&& (lease mark with a cross the one most correct answer to each 9uestion or statement.

: ; < = > ? C D I :A :: :; :< := :> :? :C :D :I ;A ;: ;; ;< ;= ;> ;? ;C ;D ;I <A

a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a

b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d

> ?

'ymbols are used to identify hospitals &umbers are used to identify day shift health care workers C Letters are used to identify night shift health care workers

IC A"">ND*P 7- BS5> STAT*BNS

A"">ND*P 7& /- @A,B'% D%A"$ >P>%5*S> * DATA SB'%5> E BS5> STAT*BN $BS"*TA@ 5BD>DAT> B: ASS>SSM>NT$>A@T$ HB%K>% 5BD>B#Qecti(es- T assess health care w rker1s a#ilit) t interpret the la# ur graph Stati n design A writing station "resentati n % % % % )esk and chair 8riting paper Labour graph plotted from patient admitted in labour ward Container for answer sheets.

ID

*NST%'5T*BN I u are the midwi!e in charge ! la# ur ward& I u c me n dut) at 8 1 cl ck and !ind patient Z dwa in la# urStud) her la# ur graph care!ull) and tell the researcher the ! ll wing% % % The risk !act rs ) u ha(e identi!ied n the la# ur graph, I ur diagn sis, $ w ) u w uld manage the patient&

II

:AA @a# ur graph e?ercise * m del answer

%isk !act rs : ; < = > ? C D I :A :: :; :< 3rand multipara. )ecelerations of 5*. 0econium grade ;. Caput U. 0oulding = U. (ersistent ,( position. (oor rate of cervical dilatation. (oor descent of head. )ecreasing strength of contractions. +ising pulse and .(. (oor urinary output. #etonuria (yre7ia Diagn sis := 0aternal distress. :> C() due to persistent ,( position. *mmediate management :? /7plain the situation to the patient. :C Turn her on the left side. :D 3ive o7ygen by mask. :I (ut up I I -+inger1s Lactate2. ;A (ass 5oley catheter. ;: ,btain informed consent for CP'. ;; (repare for CP'. TBTA@ : : : : : ; : : : ; : : : : ; : : : : : : : 27

:A: @a# ur Draph Stati n * mark sheet $BS"*TA@ 5BD> DAT> B: ASS>SSM>NT$>A@T$ 5A%> HB%K>% 5BD>*nstructi n- /ach column represents the responses to 9uestions for each individual health workers. % %
06( 1 # $ % & E 4 ? : 10 11 1# 1$ 1% 1& 1E 14 1? 1: #0 #1 ## 2otal

)ay shift health workers are identified by numbers. &ight shift health workers are identified by letters.
1 # $ % & E 4 A .

:A; Appendi? 7& 2: LABOUR GRAP E!ERC"SE "" Data s urce E BS5> stati n $BS"*TA@ 5BD>- 44444444&& DAT> B: ASS>SSM>NT- 444444&& $>A@T$ HB%K>% 5BD>- 444444&

B#Qecti(es- T assess health care w rkers skills t pl t in! rmati n ! a patient n a la# ur graph Stati n design A writing station "resentati n % % % % )esk and chair (atient admitted in labour ward information /mpty labour graph Container for answer sheets

:A<
*NST%'5T*BNS

0s 0thembu <A year old (ara < 3ravida = admitted in the active phase of labour at A>hAA. .( ::APDA T<C (DA 5* :;= Cephalic presentation =P> 0oderate contractions < in :A mins Cervical dilatation =cm 0oulding! ,( U (( U Intact membranes "@>AS> %>5B%D $>% *N:B%MAT*BN BN T$> @A,B'% D%A"$ "%B.*D>D& 0Ah00 .( :;APCA Temp <C.; (ulse DA 5* :<A (resenting part =P> 0oderate contractions < in :A mins Cervical dilatation ?cm ,( UU (( U 0Fh00 .( :<APDA Temperature <C.A (ulse D= 5* :<; *ead (resenting part <P> 0oderate contractions ; in :A mins Cervi7 dilation Ccm ,( UU (( U //h00 .( :<APIA (ulse :AA Temperature <C.< "rine output =Amls 5* :=A 0'L *ead <P> 0oderate contractions < in :A minutes Cervical dilation Dcm Caput :U 0oulding ,(UUU ((UU /6h00 .( :<AP:AA T <C.C 5* :>A regular 0'L *ead ;P> 'trong contractions Cervical dilation Dcm Caput :U 0oulding ,(UUU ((UU /7h00 .( :<>PI> (ulse :AA Temperature <C.C 5* :?A *ead ;P> L,A 0oderate contractions < in :A minutes Cervical dilation Icm Caput ;U 0oulding ,(UUU ((UUU /Ah00 .( :=APIA (ulse ::A Temperature <C.D 5* :AA Li9uor not seen *ead ;P>J (osition 0ild contractions = in :A minutes Cervical dilation :Acm Caput <U )ifficult to feel moulding.

:A=

M del answer

:A>

LABOUR GRAP E!ERC"SE "" MAR#"NG GU"$E : 0aternal identity ; 5etal heart rate < 0oulding and li9uor = Caput > )escent of fetal head ? Cervical dilatation C 5etal position D "terine contractions I )rugs :A (ulse and .( :: Temperature :; "rine out put TBTA@ " ints > > ; > > : > = ; > > : 87

:A?
0A%K*ND S$>>T

$BS"*TA@ 5BD> DAT> B: ASS>SSM>NT$>A@T$ 5A%> HB%K>% 5BD>*nstructi n- /ach column represents the responses to 9uestions for each individual health workers. % % )ay shift health workers are identified by numbers. &ight shift health workers are identified by letters.
1 1 # $ % & E 4 ? : 10 11 1# 2otal # $ % & E 4 A .

:AC A"">ND*P 7& 6- ""$ STAT*BN

DATA SB'%5>

E BS5> STAT*BN

$BS"*TA@ 5BD>$>A@T$ HB%K>% 5BD>-

B#Qecti(es- T assess health care w rkers skills t diagn se and manage ""$ Stati n design Descripti n stati n "resentati n % Desk and chair % %ele(ant e+uipments

:AD

*NST%'5T*BNS :B% ""$ STAT*BN

A patient with pr l nged la# ur has Qust #een deli(ered in ) ur la# ur wardR 60 minutes a!ter placental separati n the patient has (aginal #leeding& Descri#e step #) step t the e?aminer h w ) u w uld manage this patient&

:AI

""$ stati n M del answer

/ 2 6 8 7 9 A 8 F /0 // /2 /6 /8 /7 /9 /A /8 /F Call for assistance )o not leave the patient alone Act 9uickly %esuscitati n 'end blood for cross match 'ite ; large bore intravenous canulae (ut +ingers Lactate or blood 0onitor vital signs, "rine output "lacenta deli(ered 'tep :! the uterus must be immediately rubbed up. 'tep ;! A rapid intravenous infusion of ;A units o7ytocin in a litre of intravenous fluids must be started. ,nce again, make sure the uterus is well contracted. 'tep <! the patient1s bladder must be emptied. If the uterus remains atonic, I or I0 A.> mgs of ergometrine, can be given if the patient is not hypertensive. 'tep =! 'uture any vaginal or perinatal tears that are bleeding. 'tep >! +eview the initial diagnosis of the causes of bleeding. Consider the possibility of retained product of conception. Intractable uterine atony. Cervical tears or uterine rupture. 'uspect coagulopathy secondary to massive haemorrhage. 'tep ?! Cross match e7tra blood and other fresh plasma. Assign the responsibility for resuscitation to one staff member who will also documents events 'tep C! Theatre T*TAL : : : : : : :

: : : : : : : : : : /F

::A

$BS"*TA@ 5BD>-4444444444& DAT> B: ASS>SSM>NT-44444444&& $>A@T$ HB%K>% 5BD>-44444444 *nstructi n- /ach column represents the responses to 9uestions for each individual health workers. % % )ay shift health workers are identified by numbers. &ight shift health workers are identified by letters.
1 1 # $ % & E 4 ? : 10 11 1# 1$ 1% 1& 1E 14 1? 1: 2otal # $ % & E 4 A .

:::

A"">ND*P 9- MAT>%N*TI 'N*T %>.*>H

DATA SB'%5> E MAT>%N*TI S>%.*5>
"eri d under re(iew*NST%'5T*BNS

% %

This form has been designed to assist with the collection of the availability of the enabling environment in the maternity unit of a level : hospital in the district This form has to be filled together with the unit manager

Name ! the re(iewer

Name ! the $ spitalDate ! Assessment

"r t c l ! management

5heck in the la# ur ward and tick the appr priate # ? Is a manual of protocols of obstetric management immediately accessible

Fes

&o

Ask the midwi!e in charge ! the la# ur ward If you have to refer an obstetric emergency how long does it take for the ambulance to arriveJ Ma?imum-444444 Minimum-44444&& 8hich is your referral hospitalJ *ow far is your referral hospital in -km2J %e!erral

::;

,l

5heck the a(aila#ilit) ! the ! ll wing items *tem A(aila#le Ies N (acked cells 5ree4e )ried (lasma

$ w man) unitsS

Kept whereS

5heck the a(aila#ilit) ! the ! ll wing drugs Drugs Ies N 5heck the la# ur ward ! r a(aila#ilit) and !uncti na#ilit) ! the ! ll wing items In6ectable Antibiotics *tem A(aila#le :uncti nal Ies N Ies N In6ectable Anticonvulsants. At least ; 'phygmoP)ynamaps At least ; CT3s In6ectable ,7ytocics. 'tethoscope 5etal stethoscope )op tone At least ; vacuum e7tractors &eonatal +esuscitation facility ,perating theatre Drugs

>+uipment

::<

5 mment n e+uipment-

Super(isi n sta!!

Ask the midwi!e in charge ! the la# ur ward n the a(aila#ilit) ! the ! ll wing

Fes
0idwife in charge of every shift in the labour ward in last month Advanced midwife in a supervisory capacity on day shift last month Advanced midwife in a supervisory capacity on night shift last month

&o

Sta!! and

Ask the midwi!e in charge ! the la# ur ward n the ! ll wing &umber of admission in the previous month &umber of deliveries in the previous month &umber of 0idwives on day duty U A)0 &umber of 0idwives on night duty U A)0

deli(er)