Making Skilled Care a Reality

Making Skilled Care a Reality:
Areas of Intervention

Skilled care encompasses a continuum of maternal and newborn services, including care throughout pregnancy, childbirth, and the immediate postpartum period. It includes both routine care and care for emergency complications.

Making skilled care a reality for women involves:

  • Training maternity care providers in essential clinical, interpersonal, and decision-making skills for providing high-quality maternity care and managing obstetric complications;
  • Strengthening health systems and creating an enabling working environment that includes essential equipment, supplies, infrastructure, and supervision;
  • Improving emergency communications and transport systems to facilitate prompt referral of complicated cases to advanced levels of care;
  • Educating and mobilizing communities to ensure that women seek skilled care and can reach appropriate health facilities in time;
  • Establishing strong national policies, programs, and guidelines in support of skilled care.
Below are some highlights of the Skilled Care Initiative (SCI) interventions. For a more detailed description of the interventions in each country, please see the full reports [Burkina (in French), Kenya, Tanzania].


1. Upgrading Providers' Skills and Improving Performance
Through SCI, maternity care providers in the intervention districts received intensive training in life-saving obstetric skills. For many midwives, this training was the first update they had had since completing their basic training as much as 20 years earlier.
Practical and hands-on in nature, the training sessions focused on essential clinical and cognitive skills, such as infection prevention, monitoring labor, preventing and controlling hemorrhage, and management of obstetric complications. Training was also provided in interpersonal communication and counseling, with an emphasis on compassionate treatment of clients and counseling women and their families about making preparations for childbirth. To reinforce the training, regular follow-up visits were conducted with trained staff to provide on-the-job guidance and support in adopting new skills and practices. FCI also worked with the Ministry of Health in each country to develop visual aids and clinical reference tools on obstetric care help providers retain and maintain new skills.
Which Childbirth Attendants are Skilled?: Issues and Strategies in Assessing Provider Skills highlights baseline findings related to provider skills and competencies, and the unique methodological challenges of conducting such assessments in the field of maternal health. English
Strengthening Provider Competencies and Performance in Skilled Care discusses the interventions to strengthen providers’ clinical and inter-personal skills. English
Compassionate Maternity Care: Provider Communication and Counseling Skills provides a more detailed look at interventions to promote caring behaviors and train providers in compassionate maternity care. English 
See Training and Capacity Building page for a full list of the training tools.
2. Strengthening Health Systems and Creating an Enabling Environment for Skilled Care
A major focus of FCI’s Skilled Care Initiative was on upgrading the health infrastructure and strengthening maternal health service delivery in each district.
Special emphasis was placed on rural health centers and dispensaries, which are most accessible to the majority of women. Solar equipment and water tanks were installed at facilities with inadequate power and water supplies. In addition, FCI provided a range of obstetric equipment (e.g. blood pressure gauges, weighing scales, delivery kits, delivery beds, autoclaves for instrument sterilization, examination lamps, incubators, etc.) to ensure that health staff could perform routine procedures and emergency interventions when needed. The project also strengthened referral systems through the provision of communications equipment (e.g. radio call systems and telephones) and the purchase or repair of ambulances in the project districts. Finally, to address chronic shortages of essential supplies and drugs, FCI worked with district health managers to strengthen logistics systems.
The Enabling Environment for Skilled Care: A Health Systems Approach, discusses interventions at the facility level to create an enabling work environment for maternal health services. English
3. Strengthening Supervision and Health Service Management
FCI introduced a range of interventions to strengthen health service management at health facilities and in the project districts overall.  As record books were found to be inadequate and in some cases almost non-existent, FCI developed standard registers for maternal health service delivery. In addition, to encourage a supportive, problem-solving approach, district health managers received training and on-the-job support in areas such as annual planning and budgeting, accounting and financial management, and conducting supervisory visits to health facilities.
To foster a similar problem-solving approach among facility managers and staff, FCI adapted EngenderHealth's COPE ® quality-improvement tool for use at maternal health facilities. The tool was introduced at selected facilities in each country to involve health facility staff in ongoing processes of identifying and addressing issues that compromise the quality of care. For example, through the COPE® exercises, staff implemented practical steps to ensure continuity of supplies and improve communication with clients.
COPE® for Maternal Health Services: Experiences from the Field describes the Skilled Care Initiative experience implementing the COPE® method to improve the quality of maternity services.
4. Mobilizing Communities and Promoting Behavior Change for Safe Motherhood
To complement health systems improvements, FCI launched intensive behavior change and mobilization efforts to encourage health-seeking behaviors and to work with communities to overcome barriers to skilled care.
Community interventions were specifically designed to promote birth preparedness and planning for delivery, recognition of and response to obstetric complications at household and community levels, and the use of skilled care throughout pregnancy, childbirth, and the postpartum period. Targeting women, as well as key household and community-level decision-makers, behavior change activities as well as included the use of traditional health education tools (e.g. printed pamphlets, flipcharts, and posters) grassroots outreach strategies, such as participatory drama and performing arts, and community discussion and dialogue.
Behavior Change and Community Mobilization for Skilled Care gives an overview of project activities at the district level to mobilize communities for skilled care and increase skilled care-related behaviors. English

5. Monitoring Progress and Documenting Results
One of the most unique aspects of FCI's Skilled Care Initiative was its emphasis on evaluation and its focus on generating evidence and tools to guide safe motherhood programming.
The Initiative had a pre-test/post-test design with in-depth facility assessments and a representative household survey in each of the project districts. Evaluating the Skilled Care Initiative describes FCI's extensive research at the outset of the project that served to inform the design of project interventions, and also to gather in-depth baseline data so that the impact of project activities could be assessed. English
Post-intervention research provided solid data on the impact of the skilled care approach in resource-constrained settings in Africa. Specifically, FCI assessed whether the "package" of facility-based interventions being implemented had a measurable impact on the capacity of health facilities at various levels to provide quality maternity care during pregnancy, delivery, and the postpartum period. It also assessed whether the project's multi-faceted interventions had a significant impact on utilization of skilled care, as well as on the pregnancy-related knowledge, attitudes, and intentions of people in the community (see Overview of Three-Country Results).


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The Skilled Care Initiative
SCI in Burkina Faso
SCI in Kenya
SCI in Tanzania
Making Skilled Care a Reality
Monitoring and Evaluating SCI
                            Training and Capacity Building

Skilled Care Initiative Delivers Impressive Results

Between 2003 and 2005, FCI worked with Ministries of Health in Burkina Faso, Kenya, and Tanzania to improve the quality and availability of maternity care, improving services for thousands of women. Through an ambitious research effort, FCI evaluated and documented key strategies for increasing skilled care during childbirth. Click here to download an overview of the results from all three countries.

Safe Motherhood In The Community: A Flipchart

AA05, AF09
This flipchart focuses on care during pregnancy, delivery, and the post-partum period.

Visit our Publications section to view our complete online catalogue of training and informational materials.

'Changing Lives, Saving Lives'

"Changing Lives, Saving Lives"

In the past, women in Rangwe, Kenya did not receive health care and many died as a result. Today the local health facility has staff and equipment that is making all the difference to save women’s lives. The facility is featured in this short film.

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