Indian Journal of Public Health

: 2018  |  Volume : 62  |  Issue : 1  |  Page : 61--64

Evaluation of competency and skills of skilled birth attendants in Madhya Pradesh, central India

Surya Bali1, Venkatashiva B Reddy2,  
1 Additional Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Assistant Professor, Department of Community Medicine, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Pauri Garhwal, Uttarakhand, India

Correspondence Address:
Dr. Surya Bali
Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh


The National Health Mission tracks the proportion of women delivered by skilled birth attendants (SBAs). We assessed SBAs competence in Madhya Pradesh, India, using structured evaluation tools. It is a cross-sectional study conducted from 2014 to 2015. We evaluated 335 trained SBAs using multistage stratified random sampling. Of total, 335 skilled births attendant selected 41.8% were auxiliary nurse midwife, 47.8% were staff nurse, and 10.4% were lady health visitors. Grouping all provider and knowledge test versions, SBAs were correct on 75.4% of the questions. By topic, results ranged from 77.9% correct for the management of normal pregnancy and childbirth to 70.2% correct for intranatal care. The skill evaluation score was 88.1% of infection prevention practices to 74.3% for postnatal care. The present study found significant variations in knowledge and skill competency scores of the SBAs. There is a critical need to improve the training quality of skill birth attendants.

How to cite this article:
Bali S, Reddy VB. Evaluation of competency and skills of skilled birth attendants in Madhya Pradesh, central India.Indian J Public Health 2018;62:61-64

How to cite this URL:
Bali S, Reddy VB. Evaluation of competency and skills of skilled birth attendants in Madhya Pradesh, central India. Indian J Public Health [serial online] 2018 [cited 2020 Oct 24 ];62:61-64
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Achieving the maternal and child health are central to the achievement of National Health Goals under the National Health Mission (NHM).[1] Most pregnancies result in normal birth, but about 15% may develop unpredictable complications. These complications can be decreased by preventive care, skilled care at birth, appropriate, and timely management.[1] The major burden of maternal and child mortality is in developing countries. Approximately 800 women die every day from preventable causes related to pregnancy and childbirth.[2] In 2012, 40 million births in developing regions were not attended by skilled health personnel.[3] The current deficit of doctors, nurses, and midwives are about 7.2 million, and by 2035, it will grow to about 12.9 million. In Southeast Asia, there are only four trained health workers for every 1000 population. This is far short of what is needed to meet the health needs of mothers and children.[4]

A skilled birth attendant (SBA) is a midwife, physician, obstetrician, nurse, or other health-care professional who provides essential and emergency health-care services to women and their newborns during pregnancy, childbirth, and the postpartum period. The Government of India has committed under NHM to ensure universal coverage of all births in the presence of skilled person.[1] However, the availability of skilled human resources, coverage of deliveries by SBAs is of variable quality across states. In 2010, Madhya Pradesh has maternal mortality ratio 310, and infant mortality rate was 59.[1] Majority of the subcenters in Madhya Pradesh have at least one auxiliary nurse midwives. Little is known about their use of skill and knowledge at the delivery points. We assessed SBAs competence in Madhya Pradesh, Central India.

The present study is a cross-sectional study to evaluate SBA training, conducted from October 2014 to May 2015. The study was conducted at the individual health-care delivery points. Multistage stratified random sampling was used. Of the 51 districts in Madhya Pradesh, India, 10 districts were randomly selected in the first stage. In the second stage, all SBAs at the district hospital, at one community health center (randomly selected) and two primary health center (randomly selected) were included in the study. We evaluated 335 trained skill birth attendants. Inclusion criteria for SBAs were one who had completed at least one SBA training. Exclusion criteria were nonavailability after two consecutive visits or lack of written consent.

The competence level of SBAs was assessed using structured evaluation tools. We defined competence as possession of skills and knowledge sufficient to comply with predefined clinical standards. The competency was measured against NHM SBA guidelines for the training of skill birth attendants. A data collection tool was designed for the assessment of knowledge and skill of SBAs. Questionnaires, checklists, and interview schedules were developed after repeated validation and standardization. Digital monitoring through global positioning system was ensured, and data were collected online forms and in real time using ODK collect software which is an open-source data collection tool. Ethical clearance had been taken from All India Institute of Medical Sciences Bhopal’s Institutional Human Ethics Committee. Written informed consent has been taken from each participant before starting the study. Data were entered into Microsoft Excel spreadsheet and analyzed with IBM, SPSS version 21.0 (SPSS Inc., Chicago, IL, USA). Descriptive analysis was done. Test of significance was used with P < 0.05 as statistically significant.

Of total 335 SBA selected 140 (41.8%) were auxiliary nurse midwife (ANMs), 160 (47.8%) were staff nurse (SNs), and 35 (10.4%) were lady health visitors (LHVs). Mean age of the trained SBA was 32.01 years (standard definition 6.8).

Knowledge score: Grouping all provider categories and all knowledge test versions, skill birth attendants were correct on 75.4% of the test questions. By topic, results ranged from 77.9% correct for the management of normal pregnancy and childbirth to 70.2% correct for intranatal care. By cadre, SNs were correct on 86.3% of questions overall, auxiliary nurse midwife 78.9%, and LHV 78.8%. Detailed skill birth attendant knowledge, competency score by provider cadre, and topic are shown in [Table 1].{Table 1}

Skill score: The skill evaluation score was 88.1% of infection prevention practices to 74.3% for postnatal care. SNs and LHV performed similarly on the plot and interpretation of partograph 85.7% to 92.9%. Scores were lower 70.6% and 66.9%, respectively, for determining fetal lie and presentation. A difference of the overall skill score was not statistically significant among various SBA cadres. SNs, auxiliary nurse midwife, and LHV scored virtually identically on skill evaluation [Table 1]. Detailed skill birth attendant skill competency score by provider cadre and topic are shown in [Table 2].{Table 2}

The present study found significant variations in knowledge and skill competency scores of SBAs between different evaluation components and different cadres. The present study found appropriate training had not resulted in an acceptable level of knowledge and skill demonstrated in a practical situation. There is a critical need to improve the training system of skill birth attendant, to provide technically competent birth attendants rather than merely qualified.[5] This was comparable to a cross-sectional training site hospital-based study conducted in Chhattisgarh among 190 paramedical worker. A likely a clinic-based births evaluation in Benin, Ecuador, Jamaica, and Rwanda conducted to evaluate knowledge and skill of 166 participants using 49-question test covering seven clinical areas stated 55.8% providers had correct knowledge and 48.2% performed, skills steps correctly.[6]

We found lacunae in skills of SBAs to provide basic antenatal care and managing obstetric complication. Nevertheless, knowledge of active management of the third stage of labor was high in the present study. This was similar to another study conducted in Nicaragua, where skill birth attendants could identify active management of the third stage of labor components such as intramuscular oxytocin immediately after delivery of the fetus, controlled cord traction, and uterine massage.[5] In a study of Nepal sentinel scores for active management of the third stage of labor ranged from 13.2% to 71.2% among different maternal and child health worker cadre.[7]

We found skills for neonatal resuscitation was average among the studied SBAs. Similarly, a study from Cambodia, it was found the skill birth attendants lacked skills in neonatal resuscitation.[8] The knowledge and skill score neonatal resuscitation were higher in the present study compared to a study conducted in 2013, which evaluated 30 graduates from an SBA training program in Haiti using questionnaire. SBA was correct for 59% of the knowledge questions, near one-third SBA possesses the skill for neonatal resuscitation. This difference could be primarily due to the difference in sample size, study location, and study instrument.[9]

The present study revealed skill birth attendants had knowledge of partograph, but use was suboptimal. This was analogous to a study from maternity care settings of Cambodia conducted with a sample of 25 skill birth attendants.[8] Another cross-sectional descriptive study conducted on 140 midwives selected in the Tamale Metropolis of Ghana, in 2011 stated that study participants had knowledge of the supposed use of the partograph.[10] This could be primarily due to inadequate training of skill birth attendants. In addition, inadequate workforce or lack of logistics at health-care facility can be the contributing factors.

Skill birth attendant scored high on basic questions related to infection prevention in this study. On the contrary evaluation of 25 skill birth attendants from one provincial hospital, two district referral hospitals and two health centers of Cambodia found cleanliness during birth was lacking.[9] The prime reason could be adequate training of skill birth attendants for practices related to prevention of infection, emphasizing its importance.

There is no national standard framework to evaluate progress made in enhanced coverage with skilled birth attendance. There has been little emphasis on examining this issue in India. Therefore, the new policy should include the training and evaluation of skill birth attendant delivering services at health institutions. There is a strong need to focus on improving the current nursing and midwifery course curriculum. A special induction-training program should include 3 months attachments as part of preinduction training for SNs, ANMs, and LHVs to enable them to develop basic skills for providing maternal and newborn care. Develop skill birth attendant certification policy for private delivery points. Implementation of training methods that develop the confidence and competence to provide standard birth care is important for the effective functioning of skill birth attendants in government and private health facilities.

It is the first of its kind assessing the competence and satisfaction of skill birth attendant at the state level in India. On the intensive online-published literature search, there was a lack of similar articles.


This study was completed with efforts, contribution, guidance, and support of individuals and organizations. We would like to extend our sincere thanks and gratitude to all of them. We are thankful to National Rural Health Mission Madhya Pradesh for financial assistance to conduct this study. We would like to pay our sincere thanks to Principal Secretary Shri Praveen Krishna IAS, Health Commissioner Shri Pankaj Agarwal IAS, Mission Director Shri Faiz Ahmad Kidwai IAS, and Dr. Archana Mishra, Deputy Director Maternal Health, NHRM, for their continuous support and motivation to conduct this research.

Financial support and sponsorship

This study was financially supported by the National Rural Health Mission, Madhya Pradesh, India.

Conflicts of interest

There are no conflicts of interest.


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