Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis


Susan Munabi-Babigumira1, Claire Glenton1, Simon Lewin1,2, Atle Fretheim1,3, Harriet Nabudere4

1. Norwegian Institute of Public Health, Oslo, Norway
2. South African Medical Research Council, Health Systems Research Unit, Tygerberg, South Africa
3. University of Oslo, Institute of Health and Society, Oslo, Norway
4. Uganda National Health Research Organisation, Entebbe, Uganda

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD011558. DOI: 10.1002/14651858.CD011558.pub2.

Access the full-text article here: 10.1002/14651858.CD011558.pub2


What factors influence the delivery of care by skilled birth attendants in low- and middle-income countries?

Review aim

The aim of this Cochrane synthesis of qualitative evidence was to identify factors that influence the provision of care by skilled birth attendants. To answer this question, we searched for and analysed qualitative studies of skilled birth attendants’ views, experiences, and behaviour.

This synthesis complements another Cochrane Review assessing the effect of strategies to promote women’s use of healthcare facilities when giving birth.

Key messages

Many factors influence the care that skilled birth attendants provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork, trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to these factors.

What did we study in the synthesis?

In low- and middle-income countries, many mothers still die during childbirth. Women are encouraged to give birth in health facilities rather than at home so they can receive care from skilled birth attendants. A skilled birth attendant is a health worker such as a midwife, doctor, or nurse who is trained to manage a normal pregnancy and childbirth, and refer the mother and newborn when complications arise.

By exploring skilled birth attendants’ views, experiences, and behaviour, this synthesis aimed to identify factors that can influence their ability to provide quality care.

Main findings

We included 31 studies conducted in Africa, Asia, and Latin America. Participants were skilled birth attendants including doctors, midwives, nurses, auxiliary nurses and their managers.

Our synthesis pointed to several factors that affected skilled birth attendants’ provision of quality care. The following factors are based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they sometimes had insufficient training during their education or after they had begun work. Where facilities lacked staff, skilled birth attendants’ workloads could increase, it could become difficult to provide supervision, and mothers could receive poorer care. In addition, skilled birth attendants did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues could lead to stress and affect skilled birth attendants' family life. Some skilled birth attendants felt that managers lacked capacity and skills, and they felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages included problems with hiring and assigning health workers to health facilities; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of their work; these included good-quality housing, allowances for extra work, paid vacations, continued education, proper assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, drugs, and supplies; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce skilled birth attendants’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for skilled birth attendants to refer women to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

How up-to-date is this review?

We searched for studies published before November 2016.