Millennium Development Goal 5 (MDG-5) which aimed to reduce maternal mortality by 75% by 2015 has been extremely important in increasing government attention and resources for maternal health in low- and middle-income countries (LMICs) over the last two decades. The maternal mortality ratio (MMR) and proportion of births attended by skilled health personnel were identified as the two indicators to monitor progress towards MDG-5. Indeed, increasing skilled birth attendance (SBA) has become a key maternal health strategy in most LMICs, as efforts have intensified to achieve the MDG-5 target of 90% coverage of SBA by 2015.

 

After significant global consultation and debate, the post-2015 development agenda have recently been formulated in the Sustainable Development Goals (SDGs). The health SDG (SDG-3) is expressed more broadly as “ensuring healthy lives and promoting wellbeing for all at all ages”. However, the proposed health subgoal 1 is to reduce the global average MMR to less than 70 per 100,000 births by 2030, with no country to have an MMR greater than 140. There appears to be somewhat less focus on SBA in achieving the maternal health target although it is listed as a possible coverage indicator for health subgoal 8 which is concerned with universal health coverage (UHC).

 

Skilled birth attendance requires both a skilled attendant (registered nurse, midwife or doctor) and an enabling environment (adequate medicines, equipment, referral system and policies). The rationale for the SBA strategy over the last 20 years was based on:

 The demonstrated failure of traditional birth attendant (TBA) programmes to significantly improve maternal mortality;

 Ecological evidence of a relationship between increased SBA and lower MMRs; and

 Historical evidence of the link between skilled birth attendance and declines in maternal mortality in many high-income countries in the early 20th Century, as well as more recently from countries such as Sri Lanka, Malaysia, Thailand, Egypt, Honduras and Bangladesh.

 

      Source: Adegoke & van den Broek, 2009

 

As the global maternal health community begins to prioritise and plan for achieving the maternal health SDG targets it would be important to critically evaluate the contribution of the SBA strategy. On the one hand, there is still a significant proportion of women in LMICs without access to SBA. For example, Crowe et al (2012) estimate that over 12 million women in sub-Saharan Africa will deliver without a health professional in 2015. However, on the other hand, although skilled birth attendance may be necessary for decreasing the MMR below 140 per 100,000 births it may not be sufficient. 

 

The recent experiences with maternal health in South Africa may support this argument in that the MMR remains above 300 despite a national SBA coverage of over 90%. A number of factors contribute to this discrepancy:

 The contribution of HIV/AIDS to maternal mortality although this is likely to decline as anti-retroviral access improves;

 Persistent inequalities in SBA coverage, in particular areas and for particular groups of women, despite the high national average;

 Deficiencies in the quality of skilled attendance being provided both in terms of the competence of health professionals and the adequacy of the enabling environment; and

 Significant problems with the management of obstetric emergencies and the systems required to support this.

 

It is important to emphasise that the strategies that were helpful in reducing the global MMR from 800 to 200 may not be effective in further decreasing it to 70 per 100,000. National responses in the post-2015 era will have to extend beyond achieving universal SBA coverage. New strategies should be tailored to the local context but, in general, will need to focus more on improving the quality and equity of both routine and emergency obstetric care. Better process indicators will also be required to monitor progress towards the maternal health SDG targets. For some time, the United Nations agencies have promoted additional process indicators for measuring access to emergency obstetric care but these are seldom used routinely in most LMICs, and have, in any case, been criticised for being too crude. However, surprisingly little progress has been made to date in identifying the new strategies and indicators required to supplement skilled birth attendance in the global post-2015 maternal health agenda.      

 

Adegoke, A. A. and N. van den Broek (2009). "Skilled birth attendance-lessons learnt." BJOG: An International Journal of Obstetrics & Gynaecology 116: 33-40.

Crowe, S., M. Utley, A. Costello and C. Pagel (2012). "How many births in sub-Saharan Africa and South Asia will not be attended by a skilled birth attendant between 2011 and 2015?" BMC Pregnancy and Childbirth 12(1): 4.

Gabrysch, S., P. Zanger and O. M. R. Campbell (2012). "Emergency obstetric care availability: a critical assessment of the current indicator." Tropical Medicine & International Health 17(1): 2-8.

Sustainable Development Solutions Network (2015). Indicators and a Monitoring Framework for the Sustainable Development Goals. Launching a data revolution for the SDGs. A report by the Leadership Council of the Sustainable Development Solutions Network. Revised working draft (Version 7) March 20, 2015. Geneva, Sustainable Development Solutions Network.

World Health Organization (2015). Towards a monitoring framework with targets and indicators for the health goals of the post-2015 Sustainable Development Goals. Geneva, World Health Organization.