Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment

The components of the adapted WHO SMNA tool: facility assessment, SBA interviews, observations of labour and child birth and record reviews; were complementary and useful to provide a detailed synopsis of the strengths and weakness of the quality of care by SBAs in Mae La refugee camp. The most powerful part of the tool in this setting was the direct observation of SBAs providing care in labour and child birth. Incidents of substandard care and harmful practices conferred with previously reported studies in developing countries [22-24]. Importantly these incidents were observed during labour and child birth and could not be gleaned from record reviews or SBA interviews.

Infections rates of 15% of observed labour and births and 5% on record reviews were consistent with random and infrequent hand washing. Maternal and newborn health organizations have been promoting clean birth practices as the ‘six cleans’: clean hands of the SBA, clean perineum of the mother, a clean birth surface, a clean cord cutting instrument, a clean cord clamping device and clean cord care [25]. To their credit the observations of labour and birth showed full adherence of the SBAs to the last five ‘cleans’, but hand washing was substandard and strategies to improve compliance have been challenging even in resource rich settings [26]. High bladder catheterization rates can be harmful [27] and were confirmed in both record reviews and observations. Communication and kindness which can only be observed were also identified as an area for attention [28]. The low proportion of monitoring the blood pressure in labour differs because the SBAs measured the blood pressure two hourly according to the SMRU guideline which was based on a low staff to patient ratio, a particular consideration for quality of care in low resource settings [29]. Records were generally complete and consistent with observations of labour and child birth. Actively measuring and estimating the blood loss was introduced just prior to the observation period for this assessment, together with an obligatory item on the patient records to fill in the estimated blood loss, and this explains the major difference between the record reviews and the observations.

PPH is the most common complication in the SMRU birth room and SBAs always applied active management of the third stage of labour. In 20% of cases controlled cord traction was incorrectly applied which could be harmful and is pertinent following the recent publication that reported no benefit from this procedure [30]. SBA interviews and observation of child birth also identified differences between practice and knowledge: for example there was high awareness of the importance of the placenta being complete but carelessness was observed in confirming this. One of the most important observations was the difficulty in recognizing the severity of PPH and taking affirmative action. This will lead to delay and in the situation of PPH delay is associated with maternal mortality. Teaching speed for EmONC in the birth room is a challenge [31] and identifying how SBAs best acquire this skill has not been reported. In addition the SBAs in Mae La refugee camp who staff the birth centre are the people available from the population and this has its own constraints. In general record completion and competence in routine work such as correct use of the WHO partograph, monitoring the fetal heart beat in labour, and active management of the third stage of labour, were good, which is often difficult to achieve [22-24,32]. However when the situation deviated from normal, for example when the vital signs indicated that PPH was severe, or that the fetal heart beat was worrisome; a lack of depth of understanding started to emerge. Organizations cannot replace the vital years of schooling that is missing for an entire generation in protracted conflict situations so the pedagogy of how best to work within these constraints has to be developed [33].

Agreement between observed labours and births and record reviews for episiotomy rates was reassuring. In nulliparous women the rate of 49% falls between the average of routine episiotomy at 75% and of restrictive episiotomy at 28% [34]. During direct observation episiotomy was only applied for specified indications following the restrictive guidelines but it is unknown what influence the presence of the observers may have had. Support during labour was adequate and there is ample evidence of the beneficial influence of a supportive companion of the woman’s choice on her satisfaction and many aspects of the birth process [35,36]. Immediate neonatal care and initial assessment of the newborn was clean, efficient and appropriate. Postnatal monitoring was inadequate and needs improvement [7]. The low rate of antibiotic eye drops is correct according to local guidelines as observed STI and HIV rates are very low in the area [37]. Skin-to-skin contact, timing of first contact with the mother and timing of first breastfeeding have not been included in the observations, as these have been reported previously [38].

The birth unit did not suffer from lack of necessary equipment, medicines and infrastructure which were all available according to the facility assessment, contrary to the supply shortages previously described in nearby areas [12]. This creates an enabling environment for the SBAs to perform their tasks, which is important for the motivation of the staff and the perceived quality of the health care facility by the patients [39].

This study has several limitations. As the data collection was done during a short six week interval some less common problems may not have had an opportunity to be observed, nevertheless 20 observed labour and births provided plenty of points for quality improvement. Record reviews occurred prior (three months) to the observations and the interviews. Some aspects of practice were already in the process of improving by the time the observations were carried out, which explains some differences between record review and observation data: e.g. systematically recording post-partum blood loss. For the observations of labour and birth the language barrier may have been a limitation and some aspects of care may have been overlooked or interpreted or reported incorrectly. The observations themselves could have introduced bias in performances, such as the SBAs trying to do their very best. This Hawthorne effect where people may modify their behaviour because of being observed [40] has been demonstrated to influence the time interval until cesarean section [41]. The ability to generalize this study may be limited to birth centres where SBAs with similar background, level and responsibilities are the primary provider. However a recent systematic review and meta-analysis suggests that the level of the heath care provider is not significant in the effectiveness of care provided [29]. Lastly the initial data were collected in 2008 and while changes have taken place in the past six years these will be presented in a future publication to complete the audit cycle.

The WHO SMNA has been a useful tool to assess the quality of intrapartum care provided by SBAs in Mae La refugee camp. Adapting the tool for the setting and allowing local staff to apply the tool minimized the costs associated with the assessment. The strength of the tool lies in the combination of record reviews and direct observation and this has been reported in similar investigations using direct clinical observations [41,42].