Maternal mortality, defined as the death of a woman during pregnancy or within 42 days of termination of pregnancy, remains a critical global health issue, particularly in developing countries. Although maternal deaths declined between 1990 and 2015, approximately 830 women still die each day from preventable pregnancy-related complications. Sub-Saharan Africa accounts for more than half of these deaths, with 99% of all maternal deaths occurring in low- and middle-income countries (World Health Organization, 2023).
Ensuring the presence of skilled birth attendants (SBA) and access to emergency obstetric care (EmOC) are two of the most effective strategies for reducing maternal mortality. This article explores the impact of SBA and EmOC, their effectiveness, the challenges to their implementation, and the necessary systemic improvements required to ensure better maternal health outcomes.
The Importance of Skilled Birth Attendants (SBA)
Skilled birth attendants (SBAs)—which include doctors, nurses, and midwives—play a critical role in ensuring safe deliveries and reducing maternal and neonatal mortality. These trained professionals manage normal pregnancies, childbirth, and postnatal care, while also identifying and responding to complications that may arise (World Health Organization, 2019).
Key Roles of Skilled Birth Attendants
- Managing normal deliveries: SBAs ensure safe childbirth practices and promote optimal maternal and newborn health.
- Identifying and managing complications: They detect and treat obstetric emergencies such as postpartum hemorrhage, obstructed labor, and eclampsia.
- Providing essential medical care: SBAs administer life-saving interventions including oxytocin to prevent postpartum hemorrhage, antibiotics to treat infections, and magnesium sulfate for pre-eclampsia (Sharrow et al., 2022).
- Ensuring hygienic practices: They implement infection control measures to prevent maternal sepsis caused by poor hygiene and unsafe birthing practices.
- Facilitating timely referrals: When necessary, SBAs refer mothers to higher-level health facilities for specialized obstetric care.
- Monitoring maternal and newborn health: They provide continuous care throughout pregnancy, labor, and the postpartum period.
The proportion of births attended by skilled health personnel is a key indicator of healthcare quality. While global SBA coverage increased from 79% in 2015 to 86% in 2023, Sub-Saharan Africa lags significantly behind with only 73% of births attended by skilled personnel. In contrast, Eastern and South-Eastern Asia have achieved 96% coverage, highlighting persistent inequities in maternal healthcare access (World Health Organization, 2023).
Emergency Obstetric Care (EmOC)
Emergency obstetric care (EmOC) is a critical component of maternal health services, designed to manage life-threatening pregnancy complications such as hemorrhage, obstructed labor, eclampsia, and infections. These complications account for nearly 75% of all maternal deaths (United Nations, 2024).
Key Components of EmOC
- Assisted vaginal delivery: Use of specialized tools to facilitate safe childbirth when fetal distress or prolonged labor occurs.
- Cesarean section: A life-saving surgical intervention for cases of obstructed labor, fetal distress, or high-risk pregnancies.
- Blood transfusions: Essential in severe hemorrhage cases, particularly postpartum hemorrhage, the leading cause of maternal deaths.
- Administration of critical medications: Includes uterotonics (e.g., oxytocin) to prevent postpartum hemorrhage, antibiotics for infections, and anticonvulsants for eclampsia.
- Referral systems: Efficient referral networks are required to transport women with complications to facilities capable of providing comprehensive care.
The World Health Organization recommends that there be at least five emergency obstetric care facilities, including one comprehensive facility, for every 500,000 people. However, many regions in Sub-Saharan Africa lack adequate infrastructure, staffing, and resources, leading to delays in accessing EmOC and increased maternal mortality risks (World Health Organization, 2019).
Effectiveness of Skilled Birth Attendants and Emergency Obstetric Care
Numerous studies confirm that SBA and EmOC significantly reduce maternal mortality rates. For example:
- A 1% increase in SBA coverage is associated with a 4.435 decrease in maternal deaths per 100,000 live births (Sharrow et al., 2022).
- A 1% increase in antenatal care visits correlates with a 5.225 decrease in maternal mortality per 100,000 live births (World Health Organization, 2019).
- The CLEVER Maternity Care Program in South Africa reduced birth asphyxia, meconium aspiration syndrome, and stillbirth rates while improving patient satisfaction in midwife-led obstetric units.
- Nigeria’s RICOM program, which targets indirect causes of maternal mortality such as diabetes, anemia, and hypertension, has enhanced healthcare service delivery, leading to reduced maternal deaths.
- The FOR M(om) program in Nigeria has invested over $400,000 in public and private healthcare facilities, addressing resource shortages and improving maternal health outcomes.
These interventions demonstrate that investing in SBA and EmOC leads to measurable improvements in maternal health.
Challenges in Implementation
Despite their effectiveness, numerous barriers hinder the implementation of SBA and EmOC, particularly in low-resource settings:
- Shortage of Skilled Health Workers:
- Sub-Saharan Africa has only 76 doctors per 100,000 people, with even fewer specializing in maternal and child health.
- This severe workforce shortage limits access to skilled birth attendants, especially in rural areas.
- Inadequate Infrastructure:
- Many healthcare facilities lack essential equipment, medications, and emergency supplies.
- Power outages and inadequate refrigeration hinder the storage of critical medications like uterotonics.
- Geographical Barriers:
- Women in remote areas often face long travel distances and unreliable transportation, delaying access to life-saving care.
- Financial Constraints:
- Insufficient healthcare funding leads to shortages in medicines, equipment, and skilled personnel.
- Many women cannot afford antenatal care, skilled birth attendance, or emergency procedures.
- Cultural and Social Barriers:
- Traditional beliefs often discourage facility-based deliveries, leading women to seek care from unskilled birth attendants.
- Gender inequality prevents some women from making independent healthcare decisions.
Strategies for Improving SBA and EmOC Access
To overcome these challenges, a multi-faceted approach is required:
- Investing in Healthcare Infrastructure: Expanding maternity facilities, transportation systems, and medical supply chains.
- Workforce Development: Training more midwives, obstetricians, and community health workers.
- Strengthening Referral Systems: Establishing emergency transport services to improve timely access to EmOC.
- Expanding Health Insurance Coverage: Reducing financial barriers to maternal healthcare services.
- Leveraging Digital Health Innovations: Using mobile health (mHealth) technologies to provide maternal health education and appointment reminders.
- Community Engagement: Partnering with traditional birth attendants and local leaders to promote SBA utilization.
Conclusion
Skilled birth attendance and emergency obstetric care are critical in reducing maternal mortality, particularly in Sub-Saharan Africa. While progress has been made, limited access to SBA and EmOC, workforce shortages, inadequate infrastructure, and socio-economic barriers continue to pose challenges. Strengthening healthcare systems, training more health professionals, and improving financial accessibility are crucial steps toward achieving the Sustainable Development Goal (SDG) target of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030.
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