Harvey Steven A, Blandón Yudy Carla Wong, McCaw-Binns Affette, Sandino Ivette, Urbina Luis, Rodríguez César, Gómez Ivonne, Ayabaca Patricio, Djibrina Sabou
Quality Assurance Project, University Research Co LLC, Bethesda, MD 20814, USA.
Bull World Health Organ. 2007 Oct;85(10):783-90. doi: 10.2471/blt.06.038455.
Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement.
The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II).
On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%.
There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.
由熟练的助产士接生是全球在降低孕产妇死亡率（千年发展目标的第五项）方面取得进展的一个指标。虽然世界卫生组织追踪由熟练助产士接生的妇女比例，但我们对她们处理常见的危及生命的产科并发症的能力了解甚少。我们评估了五个孕产妇死亡率高的地区熟练助产士的能力，以此作为启动质量改进工作的基础。
世界卫生组织的《妊娠和分娩综合管理》（IMPAC）指南作为我们的能力标准。评估包括书面知识测试、产程图（用于记录分娩妇女的所有观察情况）案例研究以及在五个技能站对解剖模型上演示的操作进行评估。我们在贝宁、厄瓜多尔、牙买加和卢旺达对166名熟练助产士进行了有目的抽样测试（第一阶段）。这些初步结果用于完善评估工具，然后用于评估尼加拉瓜各地的1358名熟练助产士（第二阶段）。
平均而言，第一阶段的参与者知识问题答对率为56%，技能步骤答对率为48%。第二阶段的参与者知识问题答对率为62%。她们各领域的平均技能得分如下：第三产程的积极管理——46%；徒手剥离胎盘——52%；双手压迫子宫——46%；新生儿即时护理——71%；新生儿复苏——55%。
当前基于证据的标准与医疗服务提供者处理特定产科和新生儿并发症的能力之间存在很大差距。我们讨论了这一差距的重要性，提出了缩小差距的方法，并简要介绍了厄瓜多尔、尼加拉瓜和尼日尔目前为此所做的努力。
