Skip to main content

Main menu

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
      • The Challenge Initiative Platform
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search

User menu

  • My Alerts

Search

  • Advanced search
Global Health: Science and Practice
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search
  • My Alerts

Global Health: Science and Practice

Dedicated to what works in global health programs

Advanced Search

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Alerts
  • Visit GHSP on Facebook
  • Follow GHSP on Twitter
  • RSS
  • Find GHSP on LinkedIn
EDITORIAL
Open Access

Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?

Global Health: Science and Practice March 2016, 4(1):1-3; https://doi.org/10.9745/GHSP-D-16-00063
PreviousNext
  • Article
  • Info & Metrics
  • Comments
  • PDF
Loading

Peripheral-level birthing centers may be appropriate and effective in some circumstances if crucial systems requirements can be met. But promising models don’t necessarily scale well, so policy makers and program managers need to consider what requirements can and cannot be met feasibly at scale. Apparently successful components of the birthing center model, such as engagement of traditional birth attendants and use of frontline staff who speak the local language, appear conducive to use in other similar settings.

See related article by Stollak.

In this issue of Global Health: Science and Practice, Stollak et al.1 report a positive experience with maternal-newborn services for remote, primarily indigenous communities in Guatemala. The work was done by an NGO and included an important focus on community outreach and cultural sensitivity. Services were made more accessible by establishing birthing centers (Casas Maternas) in communities where such services hadn’t previously been available. They were staffed by skilled birth attendants (SBAs)—locally hired auxiliary nurses—who spoke the local language. The project also cultivated relationships with traditional birth attendants, who were made welcome to support women giving birth in the Casas Maternas. In addition, the project facilitated reliable transfer of complicated cases to higher-level care.

This case raises 2 important issues, one specific to maternal-newborn care and the other more broadly relevant to generalizability or transferability from small scale to large.

How Effective Are SBAs in This Particular Birthing Center Model?

Well into the 1990s, to the extent that the global health community gave attention to safe motherhood, the dominant model assumed that most births would take place at home without the assistance of an appropriately skilled professional. However, by the time of the 2006 Lancet Maternal Survival series,2 with the goal of ensuring as high as possible coverage of “skilled birth attendance,” the model of peripheral-level, midwife-staffed birthing centers had gained currency. Over the past decade, as various countries have made efforts to implement such services, doubts have emerged about the effectiveness of the peripheral-level birthing center model in reducing risk of death. To provide effective labor and delivery care for a population, clearly certain conditions need to be met. Unfortunately, if service providers in such settings are inadequately equipped to manage complications or if robust provision for timely transfer to higher-level care is lacking (which has commonly been the case for these services), it is hardly realistic to expect significantly improved outcomes.3

But, alternatively, if such crucial requirements can be met, this model of provision of care may be an appropriate part of the mix of services in some settings. It certainly is possible to ensure important aspects of routine, preventive care at this level, e.g., use of uterotonic drugs during the third stage of labor. Also, in principle health workers at this level can provide clean delivery and good thermal care of the newborn. Certainly, auxiliary nurses/midwives can be enabled to reliably and competently manage non-breathing newborns, at least to the point of bag-and-mask resuscitation. And with good coordination with higher-level facilities (facilitated by the now-widespread use of mobile phones) and robust provision for transportation, timely referrals can be made for complications that exceed the capabilities of the SBAs, and this care can include pre-referral stabilization and initiation of treatment, e.g., for eclampsia. But for each of these functions there are corresponding systems requirements: supply chain, infrastructure, staffing, equipment, transport and communication systems, etc. In the situation described in the Stollak paper,1 although the numbers are too small to ascertain mortality impact, it may well be that the conditions needed for effectiveness of a peripheral birthing center model have been met.

The important point here is that for any service delivery model, including peripheral-level birthing centers, it’s not a simple matter of whether a model does or doesn’t work; the key question is—in the particular setting—can the conditions required for effectiveness of an intervention or service delivery strategy be met?

This brings us to the second important issue arising from Stollak and colleagues …

Perils of Cookie-Cutter “Evidence-Based” Models

The field of global health suffers from a tendency to search for models that can be universally recommended. As long ago as the 1970s and earlier, inspiring examples of primary health care efforts implemented in remote areas and accomplishing major reductions in mortality prompted calls for replication at scale under government health services. Such overly simplistic response to evidence from what should have been seen as no more than proofs of concept—without careful consideration of what was required for effectiveness in varying contexts—resulted in widespread uptake and large-scale implementation of community health worker programs that in many cases were eventually found to perform poorly.4 The same pattern of concluding—on the basis of relatively intensively supported, small-scale experiences implemented by an NGO or research group—that similar impact can be reproduced at scale under government health services remains extremely widespread in global public health (e.g., Paul 20165).

Drawing Out Key Lessons: Avoiding Mechanical Replication

One possible conclusion arising from an experience such as described in the paper by Stollak and colleagues1 could be, “Based on this success, now the government should implement this model at scale.” Rather, we believe another response is needed; we should be asking: “What lessons can be drawn that can be applied for broader benefit, beyond this particular setting?” As described by Stollak et al., those involved in implementing this work have been actively discussing its implications with counterparts in government and the broader NGO community in Guatemala, and certain key features of the Casa Materna experience have been identified that point to needed changes in how the government approaches maternal-newborn health in remote indigenous communities.

A common pattern seen in other settings is for government to put in place a pale imitation of a successful (intensively supportive demonstration) model, a dysfunctional pattern that has been characterized as “isomorphic mimicry.”6 In this particular instance, the government of Guatemala is perhaps moving along a more promising track. It has identified certain key aspects of how the Casa Materna service has been delivered, which seem to be both important for effectiveness and feasible for government services, notably:

  • Upgrading existing health posts serving such communities to include 24/7 labor and delivery care

  • Ensuring that traditional birth attendants are welcome to accompany women coming to these centers

  • Ensuring availability of auxiliary nurses who speak the local language

  • Setting up local committees to provide for better support and accountability

What to take home from this? First, regardless of whether or not the model we’re implementing is globally recommended, we need to rigorously check to see—in the particular settings where we work—if it is actually producing its intended benefit. Are our “skilled birth attendants” actually effective in saving lives or reducing morbidity? Second, promising models can’t simply be replicated at scale; drawing lessons from such early positive experiences (implemented under rather special circumstances), we are then faced with the challenge of determining how the conditions needed for effectiveness can be met within the real-world constraints of health systems operating at large scale. –Global Health: Science and Practice

Notes

Cite this article as: Birthing centers staffed by skilled birth attendants: can they be effective ... at scale? Glob Health Sci Pract. 2016;4(1):1-3. http://dx.doi.org/10.9745/GHSP-D-16-00063

  • © Global Health: Science and Practice.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/10.9745/GHSP-D-16-00063.

REFERENCES

  1. ↵
    1. Stollak I,
    2. Valdez M,
    3. Rivas K,
    4. Perry H
    . Casas Maternas in the rural highlands of Guatemala: a mixed-methods case study of the introduction and utilization of birthing facilities by an indigenous population. Glob Health Sci Pract. 2016;4(1):114–131. doi:10.9745/GHSP-D-15-00266
    OpenUrlCrossRef
  2. ↵
    1. Koblinsky M,
    2. Matthews Z,
    3. Hussein J,
    4. Mavalankar D,
    5. Mridha MK,
    6. Anwar I,
    7. et al
    . Going to scale with professional skilled care. Lancet. 2006;368(9544): 1377–1386. doi:10.1016/S0140-6736(06)69382-3. pmid:17046470
    OpenUrlCrossRefPubMed
  3. ↵
    1. Morgan A,
    2. Jimenez Soto E,
    3. Bhandari G,
    4. Kermode M
    . Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal. Trop Med Int Health. 2014 Dec;19(12): 1457–65. doi:10.1111/tmi.12390 . pmid:25252172
    OpenUrlCrossRefPubMed
  4. ↵
    1. Walt G
    . CHWs: are national programmes in crisis? Health Policy Plan. 1988;3(1): 1–21. doi:10.1093/heapol/3.1.1
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Paul VK
    . Participatory women's groups: time for integration into programmes. Lancet Glob Health. 2016 Feb;4(2): e74–5. doi:10.1016/S2214-109X(16)00010-3. pmid:26823216
    OpenUrlCrossRefPubMed
  6. ↵
    1. Andrews M,
    2. Pritchett L,
    3. Woolcock M
    . Escaping capability traps through problem-driven iterative adaptation (PDIA). CGD Working Paper 299. Washington (DC): Center for Global Development; 2012. Available from: http://www.cgdev.org/content/publications/detail/1426292
PreviousNext
Back to top

In this issue

Global Health: Science and Practice: 4 (1)
Global Health: Science and Practice
Vol. 4, No. 1
March 21, 2016
  • Table of Contents
  • About the Cover
  • Index by Author
  • Complete Issue (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Global Health: Science and Practice.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?
(Your Name) has forwarded a page to you from Global Health: Science and Practice
(Your Name) thought you would like to see this page from the Global Health: Science and Practice web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?
Global Health: Science and Practice Mar 2016, 4 (1) 1-3; DOI: 10.9745/GHSP-D-16-00063

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?
Global Health: Science and Practice Mar 2016, 4 (1) 1-3; DOI: 10.9745/GHSP-D-16-00063
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Statistics from Altmetric.com

Jump to section

  • Article
    • How Effective Are SBAs in This Particular Birthing Center Model?
    • Perils of Cookie-Cutter “Evidence-Based” Models
    • Drawing Out Key Lessons: Avoiding Mechanical Replication
    • Notes
    • REFERENCES
  • Info & Metrics
  • Comments
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Strengthening Government Leadership in Family Planning Programming in Senegal: From Proof of Concept to Proof of Implementation in 2 Districts
  • Google Scholar

More in this TOC Section

  • Nurturing and Optimizing Networks of Care to Maximize Benefits to Patients, Health Workers, and Health Systems
  • Improving Maternity Care in India’s Private Hospitals: Quality Certification? Yes, but More Is Needed
  • Learning Health Systems to Bridge the Evidence-Policy-Practice Gap in Primary Health Care: Lessons From the African Health Initiative
Show more EDITORIAL

Similar Articles

Subjects

  • Health Topics
    • Maternal, Newborn, and Child Health
US AIDJohns Hopkins Center for Communication ProgramsUniversity of Alberta

Follow Us On

  • Twitter
  • Facebook
  • LinkedIn
  • RSS

Articles

  • Current Issue
  • Advance Access Articles
  • Past Issues
  • Topic Collections
  • Most Read Articles
  • Supplements

More Information

  • Submit a Paper
  • Instructions for Authors
  • Instructions for Reviewers
  • GH Journals Database

About

  • About GHSP
  • Advisory Board
  • FAQs
  • Privacy Policy
  • Contact Us

© 2023 Creative Commons Attribution 4.0 International License. ISSN: 2169-575X

Powered by HighWire