the skilled attendance index: proposal for a new measure of skilled attendance at delivery

Abstract: Increasing the proportion of deliveries with skilled attendance is widely regarded as key toreducing maternal mortality and morbidity in developing countries. The percentage of deliverieswith a health professional is commonly used to assess skilled attendance, but measures only thepresence of an attendant, not the skills used or the enabling environment. To supplement currentlyavailable information on the presence of an attendant at delivery, a method to measure the extentof skilled attendance at delivery through use of clinical records was devised. Data were collectedfrom 416 delivery records in hospitals, government health centres and private non-hospitalmaternity facilities servicing Kintampo District, Ghana, using a case extraction form. Based onthe defined criteria, summary measures of skilled attendance were calculated. Between 32.6% and93.0% of the criteria for skilled attendance were met in the sample, with a mean of 65.5%. Nodelivery met all the criteria. A Skilled Attendance Index (SAI) was developed as a composite measureof delivery care. The SAI revealed that 26.9% of delivery records met at least three-quarters ofthe criteria for skilled attendance. Documentation of haemoglobin, current pregnancy complications,post-partum vital signs and completed partographs were amongst the criteria most poorly recorded.The purpose of applying these measures should be seen not as an end in itself but to advanceimprovements in delivery care. A 2004 Reproductive Health Matters. All rights reserved.

Keywords: safe motherhood, skilled attendance at birth, delivery care, Ghana

INCREASING the proportion of deliveries withskilled attendance is now being promotedas an important approach to reducing

maternal mortality and morbidity in developingcountries. This is reflected in the published

literature,1,2 international initiatives3 and safemotherhood programmes.4 Current knowledgeon the link between skilled attendance andmaternal mortality is documented, as well as thelimitations of the evidence.5 Skilled attendance isdefined as ‘‘the process by which a woman isprovided with adequate care during labour,delivery and the early post-partum period’’.6 Thisrequires a skilled person to attend the deliveryand an enabling environment, including ade-quate supplies, equipment, transport and drugs.

RESEARCH METHODOLOGY

The Skilled Attendance Index: Proposal for aNew Measure of Skilled Attendance at Delivery

Julia Hussein,a Jacqueline Bell,b Alex Nazzar,c Mercy Abbey,d Sam Adjei,e

Wendy Graham,f on behalf of the SAFE Study Sub-group*

a SAFE Project Manager, Dugald Baird Centre for Research on Women’s Health, University of Aberdeen,Aberdeen Maternity Hospital, Aberdeen, UK. E-mail: [email protected]

b Research Fellow and Epidemiologist, Dugald Baird Centre

c Senior Scientist, Ghana Health Service, Accra, Ghana

d Research Fellow, Ghana Health Service

e Deputy Director-General, Ghana Health Service

f Professor of Obstetric Epidemiology and Director, Dugald Baird Centre

*In addition to the authors, the SAFE study sub-group for

measurement of skilled attendance comprised: Dr Sylvia

Deganus, Tema General Hospital, Ghana; Dr Vanora

Hundley and Dr Birgit Jentsch, University of Aberdeen;

and Dr Gloria Quansah, Ghana Health Service.

www.rhmjournal.org.ukwww.rhm-elsevier.com

A 2004 Reproductive Health Matters.All rights reserved.

Reproductive Health Matters 2004;12(24):160–1700968-8080/04 $ – see front matterPII: S0968-8080 (04 )24136-2

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The indicator most commonly used to measureskilled attendance is the percentage of deliverieswith a health professional, the information usu-ally being obtained from community-based sur-veys by asking women to identify the attendantat each of their deliveries over the past three tofive years. Much importance is placed on thisindicator, and it is currently being used to mea-sure achievement of the international Millen-nium Development Goal on maternal health.7

Data for this indicator are widely regarded assimple to collect, but the indicator is only a proxymeasure of skilled attendance for several reasons.Firstly, only the presence of the health profes-sional is measured, not their skills, and it cannotbe assumed that all health professionals areskilled in delivery care.5 Secondly, despite accep-tance that skilled attendance incorporates boththe attendant and the enabling environment, theproportion of deliveries with a health professionaldoes not reflect the existence of an enablingenvironment. Finally, international comparisonsof this indicator across countries may be flawed,as the inclusion of different types of attendantswith different levels of training – doctors, nurses,multi-purpose health workers or maternal andchild health workers – varies across countries.Clarification by the World Health Organizationthat the term ‘‘skilled attendant’’ refers to ‘‘peoplewith midwifery skills who have been trained toproficiency in the skills necessary to managenormal deliveries and diagnose or refer obstetriccomplications’’,8 still leaves room for varyinginterpretations on a country-by-country basis.

To generate new knowledge and methods formeasuring skilled attendance at delivery, aninternational research partnership was formedcalled SAFE – Skilled Attendance For Everyone.9

This paper describes one SAFE study, the aimof which was to develop a means of measuringskilled attendance that could address someof the limitations of the indicator ‘‘percent-age of deliveries with a health professional’’.The method was to be suitable for routinemonitoring purposes by programme managersand clinicians, using health facility data.

MethodsPrinciples of rapid appraisal influenced methoddevelopment.10 This is because a means toroutinely monitor skilled care in a range of

health facilities and within a short time wasdesired. A schematic framework of skilled atten-dance at delivery (Figure 1) is used as the con-ceptual basis for determining the components ofskilled care.5 In this framework, the demand fordelivery by the community is met by the healthsystem, which is equated to the enabling envi-ronment for skilled attendance. Drugs, equip-ment, supplies and transportation are elementsof the enabling environment. Although notincluded in the framework, other features of thehealth system such as health sector policy orhuman resource management also comprise oraffect the enabling environment. The inner circlerepresents the health professionals who providedelivery care. The dotted lines indicate that skilledattendance may exist in the community and is notnecessarily confined to health facilities. The inner-most overlapping circles in the figure represent thedifferent levels of service provision. The arrowindicates referral of complicated cases from basicto comprehensive care.

A list of clinical procedures, interventions andcomponents necessary to provide care for nor-mal and complicated deliveries was developedusing standard obstetric texts, the CochraneLibrary and World Health Organization pub-lications. Refinements to this list were made byconsulting individuals experienced in obstetrics,

J Hussein et al / Reproductive Health Matters 2004;12(24):160–170

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midwifery and nursing in developing countries.They were asked to review the list and identifyitems most essential to measuring skilled careat delivery, using Figure 1 and focusing on theskills of the health professionals involved and keyaspects of the enabling environment. Fromthis refined list, a series of criteria were identifiedand reformulated into a case extraction formto collect data from delivery records. The caseextraction form was adapted from a study con-ducted in Ghana and Jamaica11,12 which assessedthe quality of emergency obstetric care throughcriterion-based clinical audit. However, the cri-teria used in our study on skilled attendance wereapplicable not only to emergency care, but also todelivery care in normal and complicated cases.

A pilot test of the case extraction form was firstcompleted. A panel of clinicians, programmemanagers and policymakers from Ghanareviewed the form to ensure congruence withlocal norms and policies of best practice. Minoralterations to the form were made and these werethen tested indeliveryunits from tertiary to primarylevel in urban and rural Ghana. Delivery records

could be traced in most facilities and sufficientinformation was available for case extraction.

The main study was conducted in deliveryunits of Kintampo District from June to August2001. Eleven health facilities serve KintampoDistrict. Surveillance data available for thedistrict estimated 3,460 deliveries in the year2000; 33.0% of these were in health facilities,of which 66.1% occurred in hospitals, 7.1% ingovernment health centres and 26.9% in privatenon-hospital maternity facilities. Five of the11 health facilities had less than one deliveryper month and were excluded from the study.

Data were retrospectively collected from 416delivery records, which were selected in propor-tion to the annual delivery rate of each facility.As there was no information available on exist-ing levels of skilled attendance, the sample sizerequired was based on an equipoise assumptionof this being true of 50% of cases. The samplesize allowed the resulting estimate of skilledattendance to fall within five percentage pointsof the true proportion with 90% confidence andaccounts for the need for sub-group analysis

Medecins sans Frontieres hospital, Cuito, Angola, 1997

JOHNVINK/M

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PHOTOS


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between normal and complicated deliveries andbetween different types of health facilities. Thesample was selected from the delivery register,identifying the most recent delivery records, untilthe required sample size was reached in eachfacility. This was taken as being a randomsample as it was likely that the facility deliveriesoccurred in a way that was representative offacility deliveries in the population as a whole.In hospitals, all delivery records comprised formalclinical case notes bound in a single file, with astandard format for the woman’s pregnancyhistory but unformatted pages for narration ofdelivery events. In non-hospital health facilities,these formal clinical notes were not available,so nursing notes (usually unformatted), deliveryregisters and partographs were used. Bothformatted and unformatted parts of the deliveryrecords were reviewed to extract data. If a deliv-ery record could not be traced, the next deliverylisted in the register was identified and thecorresponding record found.

The aim of the data analysis was to quantifyand summarise the level of skill provided atdelivery based on the records kept. Criteria onthe case extraction form were coded according towhether they indicated skilled attendance (coded‘‘1’’) or care falling short of skilled attendance(coded ‘‘0’’). For example, if the form indicatedthat a blood pressure measurement was takenand the value recorded was plausible, then thecriterion would be coded ‘‘1’’. If there was novalue recorded or it was implausible, then thatcriterion would be coded ‘‘0’’. Implausible valuesrefer to measurements that were out of scale(for example, a body temperature of 7jC in a

normal delivery). The complete coding scheduleis included with Table 1.

Section A of the case extraction form con-tains criteria of standard delivery care for allcases (with and without complications). SectionB was only filled in for deliveries with compli-cations, and four key criteria were selected asmarkers of skilled care common to most seriouscomplications. Our definition of cases with com-plications (Box 1) was based on the UNICEF/WHO/UNFPA Guidelines13 but adapted toinclude only the complications pertaining todelivery care, thereby excluding abortion com-plications and ectopic pregnancies.

Summary measures of skilled attendance werebased on responses to all the criteria in section Afor all deliveries, and including section B forcomplicated deliveries. A variable was createdequal to the sum of the codes for each record,resulting in a score that can be used as a summarymeasure of the skilled attendance recorded at eachdelivery. The score is reported as a percentage ofthe maximum possible score.

By pooling the data across deliveries, cumu-lative frequencies, mean and median percentagescores were produced. Mean percentage scoreswere stratified by type of attendant (doctor,midwife, midwife assistant) and place of deliv-ery (government hospital, mission hospital,government health centre and private maternityhome). The t-test was used to calculate statis-tical significance of differences observed.

Our basic analysis included all criteria as des-cribed above and listed in Table 1. This analysiswas termed Level 1. Unless stated otherwise,results are presented for this basic analysis of allcriteria. In addition, to make the scores morespecific to the immediate clinical needs during adelivery, two sub-groups of the criteria wereselected to produce scores indicating differentlevels of skilled attendance, identified as Levels2 and 3. The criteria included in each of theselevels are marked by a ‘‘+’’ sign in Table 1. Levels2 and 3 were formulated by a panel in Aberdeenmidway through the analysis. The levels areincluded as an illustration of ways in which thedata can be handled to allow for the relativeimportance of different criteria. Level 2 includedcriteria which the panel felt were relevant to theclinical welfare of the woman or her baby andexcluded criteria which were either administrativein nature (for example, registration number) or

Box 1. Definition of a complicated delivery13

For the purposes of this study, cases were definedas complicated if any of the following conditionswere recorded:

. Haemorrhage: antepartum or post-partum

. Prolonged or obstructed labour

. Post-partum sepsis

. Pre-eclampsia/eclampsia

. Retained placenta

. Retained products of conception post-partum

. Ruptured uterus


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which were unlikely to directly affect the medicalcondition of the woman or baby, such as recordingof the woman’s name, or the person who deliveredher placenta – even though recording of some ofthese items would normally be considered goodpractice. Level 3 further reduced the criteria toinclude only those deemed essential for clinicaldecision-making, such as mode of delivery,amount of blood loss or completion of partograph.

Results

Specific components of delivery careTable 1 illustrates the coding and criteriaincluded in the calculation of scores for Levels1, 2 and 3. This table also shows the frequenciesof specific criteria for Kintampo District. The leastwell recorded criteria were the date of recenthaemoglobin measurement (2.9%) and currentpregnancy complications (6.3%). Post-partumvital signs were also frequently not recorded. Afully completed partograph was available in only15.4% of delivery records. Monitoring of vitalsigns at the start of labour were met in 39.2% to51.7% of cases. Components more commonlyrecorded were Apgar score at delivery (76.9%),cervical dilatation (70.9%) and blood loss in94.0%. Examples of items recorded in over 90%of records include registration details, times anddates of delivery and admission, mode and placeof delivery, parity, estimated blood loss, andbaby’s discharge condition.

Summary measures of skilled attendanceTable 2 shows aggregated measures of skilledattendance for all deliveries and for complicateddeliveries. For all deliveries, 32.6% to 93.0% ofcriteria were met for ‘‘standard care’’ (defined bySection A criteria), with a mean of 65.5%. Nodelivery met all of the criteria. This range iswide and does not provide a picture of the typesof deliveries that fail to meet most criteria.Another way of expressing the summaryestimates was to determine the proportion ofrecords meeting a certain threshold of criteria,arbitrarily divided into quartiles and termed theSkilled Attendance Index (SAI). All records meta quarter of the criteria, 82.7% met half of thecriteria and 26.9% of records met at least three-quarters of the criteria for skilled attendance.

For complicated deliveries, the small num-bers available (n=16) allow only limited inter-pretation. In these deliveries, an average of70.9% of the criteria were met, and the SAIshows that 43.8% of records satisfied atleast three-quarters of the criteria for skilledattendance. This would suggest that 16.9%more deliveries with complications receivedskilled attendance than deliveries with nocomplications, although this difference is not


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statistically significant (p-value for the differ-ence in proportions = 0.14).

Table 3 presents summary measures stratifiedby attendant. Doctors, with a mean score of76.1%, appear to satisfy more criteria than mid-wives at 67.4%, who in turn satisfy more criteriathan assistant midwives, a non-professionalgrade of staff in private facilities in Ghana. Theassistant midwives satisfy only an average of36.0% of criteria. The differences between eachof these mean values are significant (p<0.001).

Stratification by place of delivery found mis-sion hospitals with the highest mean score of76.3% criteria met, compared to deliveries in thegovernment hospital at 68.6%. Other facilitieshad mean scores of less than 50%. Differencesbetween the means are statistically significant atp<0.001.

Table 4 shows how the summary measuresvary when different sub-groups of criteria areused. When the criteria are more focused onclinical parameters (Levels 2 and 3), the per-centage scores for skilled attendance are lower.There is a decrease in score with increasingfocus, with mean scores ranging from 65.5%for Level 1 to 58.2% for Level 3.

DiscussionOur study collected data on normal and compli-cated deliveries in both hospital and non-hospital

facilities and thus differs from other recordreviews.12,14 The study demonstrated the feasi-bility of collecting data from various types ofhealth facilities. Data could be extracted from10–12 records in an eight-hour working day.Forty days were required to complete the datacollection for the district by one person. Threedays were spent at each of the smaller healthfacilities with a delivery rate of less than 10 permonth, 16 days at the busiest hospital (50 deliv-eries per month). A nurse-midwife was recruitedfor data collection, although others have success-fully used non-medical personnel12 with advan-tages of greater objectivity of the data collectorand less disruption to clinical service provision.Other assessments of maternity care used severalinstruments, including structured observations,record review, inventories, patient flow studiesand interviews,15–19 rather than a single caseextraction form and are likely to require evenmore time and resource inputs.

Reliance on record review raises issues of biasand validity even though records are widelyused to assess quality of care.12,14,19 The methodpresupposes that what was recorded was per-formed and what was not recorded, not per-formed. Incomplete records (e.g. a missingpartograph in a set of clinical case notes) canresult in systematic errors. In this study, allincomplete records were included in the sample,and the missing criteria classified as not per-formed. If several primary data sources acrossdifferent types of health facilities are used, thesedifferent sources can be inconsistent with eachother. For instance, a partograph may recorda delivery as spontaneous and cephalic, whilethe same case is recorded in the nursing notes as abreech delivery. No such instances were identifiedin this study, but the problem could be overcomeby first identifying the most reliable type ofrecord. Missing records are another concern;clinical case notes of maternal deaths are some-times removed from the medical records officeand kept separately. The number of missingrecords was not documented in this study, butenquiries later revealed this to be rare.

The frequency of complications (3.9%) in thisstudy was much lower than the expected 15%.13

Possible reasons include exclusion of non-delivery complications from the sample, under-recording and under-reporting. Women withcomplications may also have gone directly to


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other hospitals, or were referred without the orig-inating facility recording events. However, thenearest hospitals not included in the sample werefour to five hours away by private vehicle andunlikely to be accessible to many. Another reasonfor the disparity could be that these facility-baseddata and the population-based, expected 15%complication rate are not comparable.

The study generates two main types of infor-mation. The first type, possibly of greater interestto clinicians, is the frequency of each clinicalaction comprising skilled attendance. Avail-ability of the enabling environment is partiallycaptured on the basis that if drugs and equip-ment are available, the related clinical actionsare more likely to be performed and recorded.

The second type of information is the summarymeasures. Alternative ways of describing theseinclude expression of a range or mean of criteriamet, or the SAI, which describes the proportion ofdeliveries meeting a pre-defined threshold. Themain advantage of summary measures is thecomputation of one single composite measurerather than a series of values for several indi-cators of performance used in other methods.18,19

The method also has a degree of flexibility andcan be computed in various ways, depending onthe type of information required. The binarynature of the analysis, however, results insimplification which cannot reflect qualitydimensions, for example when blood pressure istaken and recorded but incorrectly so. Also, theSAI does not inform on the interventions requiredto improve skilled attendance nor the reasonswhy care may be found to be inadequate, forinstance whether the partograph was not usedbecause of lack of training or lack of supplies.

Nevertheless, these summary measures arelikely to be of interest to programme managers,whose priorities are to monitor and achieve over-all improvements in practice. At programmelevel, progress could be monitored using one ofthe summary measures. In the event that skilledattendance is identified as sub-standard usingthis one indicator, then audit 11 or needs assess-ments19 can be used to find out how to correctthe problem. Once the necessary interventionsare put into place, continued monitoring usingthe summary measure should be sufficient toindicate changes over time. If the interventionsare appropriate and implemented well, the sum-mary measure should improve. If there is

no improvement, then further diagnosis will benecessary. Repeated collection of data with sev-eral instruments which generate many indicatorswill be unnecessary and reserved only for situa-tions where improvements are not occurring.

Use of the summary measures for monitoringraises the question of what ultimate target orstandard is required. Although the theoreticaltarget might be that all deliveries meet all criteria,the summary measures can also monitor changefrom a relative perspective as more deliveries meetmore criteria over time. Experience of using thesummary measures may reveal a feasible‘‘standard’’ of skilled attendance possible withincertain settings, for instance, a mean of 90% ofcriteria met might be expected in a tertiary facilitywhile in a rural health centre a mean of only 70%might be the best level achievable. Anotherexample of how the summary measure could beused is through comparison with other indicators.National figures from the 1998 Ghana Demo-graphic and Health Survey show that 44% ofdeliveries were attended by health professionals.20

The SAI of 26.9% of deliveries fulfilling three-quarters of criteria suggests that not all womenattended by a health professional will havereceived skilled care. This comparison betweenpopulation-based demographic survey dataand the facility-based SAI is justifiable in Ghana,as health professionals conduct very few deliveriesoutside health facilities. In countries where healthprofessionals practice in the community, this com-parison would be inappropriate. The method de-scribed in this study limits the assessment of skilledattendance to health facilities, but if communitypractitioners keep delivery records, a similarmethod may be used for community deliveries.

Stratification of the summary measures bytype of attendant, type of facility and ‘‘levels’’shows some controversial differences in skilledattendance, such as the disparity in care providedby midwives and doctors. These findings arepotentially damaging to the credibility of healthprofessionals and health services and because ofthe issues of validity and bias discussed, must beinterpreted carefully. It is possible that doctorsare trained to record events more frequently thanmidwives. In Ghana, doctors usually attend casesof complications where litigation is a threat,resulting in careful recording habits. Doctors tendto be employed in hospitals where resources andorganisation of systems are better with writing


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materials, standard forms and case notesavailable. Midwives often work in smaller, ruralfacilities where paper and copies of partographsare scarce. Midwives see more cases wherecomplications are not expected or do not occur,making recording of clinical actions seem lesscritical. It is therefore possible that midwivesprovide skilled care as or more often than doctorsbut are less likely to document it. Similar reasonsmay explain the differences observed in thisstudy between types of facilities.

Although such differences may be exposed ininitial measurements of skilled attendance, in thelonger term, if monitoring is continued and staffmade aware of the emphasis on record review,recording may improve and gradually reflectactual clinical actions more closely. Indeed, thesechanges in recording practice over timemay evenreverse the observed difference between doctorsand midwives, as other studies of skills andcompetence have shown that midwives do betterthan or as well as doctors.18

Another benefit in the longer term is that goodrecording is good clinical practice in itself. How-ever, better recording does not necessarily meanthat the actual care correspondingly improves.Even so, it can be argued that careful recordingcan encourage good practice, for example wherehealth workers are not well informed on goodpractice, analysis of the records will showup areas of deficiency which can be corrected.Even where knowledge levels are adequate,increased emphasis on recording could provideopportunities for self-reflection, analysis andtherefore improvements in care.

RecommendationsWith these benefits and constraints in mind, oursuggestions for future practical use of this tool areas follows. The method is put forward tentativelyas a means of measuring skilled attendance atdelivery. Further study of the method to addressquestions of validity and bias is necessary in thefirst instance. Validity of the proposed methodcould be established through triangulation withother means such as observational studies orinterviews, although other biases may result.Where the method is applied, careful considera-tion of how it might affect service provisionand provider practices is required. Given thetime constraints discussed, monitoring is likely

to be feasible only at yearly intervals and if staffcan be made available to collect data. Documen-tation of the effects of improved recording onclinical practice over time would be of interest.To provide information on how skilled attend-ance can be improved, other diagnostic toolsare available.12,16,18,19

Some key components of skilled care are notcaptured with this method, such as decision-making for referral and the practice of unneces-sary procedures like routine enema use prior todelivery and routine episiotomy.21,22 Anothercrucial aspect of skilled care not addressed isthe perspectives of women, which are describedin other SAFE studies.23

The proposed method can be used in bothhospital and non-hospital health facilities. Thepurpose of applying these measures of skilledattendance should be seen not as an end initself but to advance improvements in deliverycare. In contrast to clinical audits, which can bethreatening to health professionals who workwith little support and who may have lowself-esteem, the measures are presented in anaggregated form, preserving anonymity andresulting in non-punitive monitoring.12 TheSAI may seem complex for use in routinemonitoring, but it attempts to overcome thelimitations of a relatively simple indicator like‘‘percentage of skilled attendants or healthprofessionals’’ while reserving the need forrepeated use of other more cumbersome qualityassessment tools. To simplify application of theSAI, a field manual and computer analysisprogramme, which automatically computes theindices of skilled attendance, have been pro-duced and are available on the web.24

The study provides a new quantitative approachto measuring the extent of skilled attendance atdelivery in health facilities through one compositeindex, and contributes to greater understanding ofthe processes and measurement of skilled atten-dance. Although substantive conclusions cannotbe drawn from this single study, the method isproposed as an adjunct to existing indicators andtools for measuring skilled care. Refinements willbe required before it can be recommended as arigorous means to monitor skilled attendance, andlike many safe motherhood indicators, will needfurther study in order to establish its link withhealth outcomes and reductions in maternalmortality and morbidity.


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AcknowledgementsDr Colin Bullough, Dr Alice Kiger, Dr JosephTaylor and Dr Alex Quarshie commented onsampling and selection of criteria. Many individ-uals in the Ministry of Health, Ghana HealthService, Kintampo Health Research Centre, par-ticipating clinics and hospitals, and SAFE ProjectManagement Team andAdvisory Board made thisstudy possible. Caroline Reeves assisted with theliterature review and Lucia D’ambruoso provideda detailed synopsis of related methodologies. The

SAFE International Research Partnership isco-ordinated by the Dugald Baird Centre forResearch on Women’s Health, University ofAberdeen, Scotland. The European Commissionand the UK Department for International Devel-opment funded the SAFE study. The viewsexpressed in this article are solely the responsi-bility of the authors. Dr Paul Arthur (1956-2002), Director of the Kintampo Health ResearchCentre until his death, facilitated the conduct ofthis study and is remembered with great sadness.

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Attendance for Everyone.SAFE Resources. StrategyDevelopment Tool Module 4.At: <www.abdn.ac.uk/dugaldbairdcentre/safe/resources.hti>. Accessed28 February 2003.

ResumeAccroıtre la proportion d’accouchements pratiquespar un personnel qualifie est considere commeune mesure essentielle pour reduire la mortaliteet la morbidite maternelles dans les pays endeveloppement. Le pourcentage d’accouchementspratiques par un professionnel de la sante esthabituellement utilise pour evaluer la presenced’un personnel qualifie, mais il ne mesure que lapresence d’un personnel, et non les competencesutilisees ou l’environnement habilitant. Pourcompleter l’information disponible, on a mis aupoint une methode pour mesurer l’etendue desprestations assurees en utilisant les dossierscliniques. Les donnees ont ete recueillies a partirde 416 dossiers d’accouchements dans deshopitaux, des centres de sante gouvernementauxet des maternites privees non hospitalieres dudistrict de Kintampo, Ghana, en utilisant unformulaire d’extraction de cas. Selon les criteresdefinis, des mesures evaluant l’activite dupersonnel qualifie ont ete calculees. De 32,6% a93,0% des criteres definis etaient presents dansl’echantillon, avec une moyenne de 65,5%. Aucunaccouchement ne reunissait tous les criteres.Un indice d’assistance par un personnel qualifiea ete elabore comme mesure composite dessoins obstetriques. L’indice a revele que 26,9%des dossiers d’accouchements reunissaient aumoins les trois quarts des criteres de l’assistancepar un personnel qualifie. La verification del’hemoglobine, les complications de la grossesseen cours, les signes vitaux post-partum et unesurveillance complete au moyen du partographeetaient parmi les criteres laissant le plus a desirer.L’application de ces mesures ne devrait pasetre consideree comme une fin en elle-meme,mais comme un moyen de progresser dans lessoins obstetriques.

ResumenUna forma clave de disminuir la tasa demorbimortalidad materna en los paıses endesarrollo es aumentar la proporcion de partosque reciben atencion especializada. El porcentajede partos asistidos por un profesional de la saludse utiliza con frecuencia para evaluar la atencionespecializada, pero mide solo la presencia deun profesional de la salud en cada parto, y nolas habilidades empleadas o el ambiente enque se realiza. Con el fin de complementar lainformacion actualmente disponible sobre lapresencia de un profesional de la salud durante elparto, se creo un metodo para medir el nivel deatencion especializada durante el parto mediante larevision de las historias clınicas. Por medio de unformulario de extraccion de casos, se recolectarondatos de 416 historias clınicas correspondientesa partos atendidos en hospitales, centros desalud gubernamentales y servicios de maternidadparticulares extra-hospitalarios que brindancobertura de atencion a la poblacion del DistritoKintampo en Ghana. Conforme a los criteriosdefinidos, se calcularon las medidas sumarias dela atencion especializada prestada. En lamuestra secumplio entre el 32.6%y el 93.0%de los criterios dela atencion especializada, con un promedio de un65.5%. En la atencion de ninguno de los partosse cumplio con todos los criterios. Ademas, se creoun Indice de Atencion Especializada como unamedida compuesta de la atencion obstetrica.Dicho ındice revelo que el 26.9% de las historiasclınicas obstetricas cumplio por lo menos con trescuartas partes de los criterios de la atencionespecializada. Entre los criterios registrados conmenor exactitud figuran la documentacion de lacifra de hemoglobina, las complicaciones durante elembarazo actual, los signos vitales posparto y eldiligenciamiento completo de la ficha obstetricaperinatal. El proposito de aplicar estas medidasdebe considerarse no como un fin en sı sino comouna gestion para fomentar mejorıas en la calidadde la atencion obstetrica.


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the skilled attendance index: proposal for a new measure of skilled attendance at delivery

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