Objective 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. Methods 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). Findings 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%. Conclusion 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. Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward Introduction BackgroundEach year obstetric complications kill over 500 000 women worldwide. 1,2Skilled attendance during labour, delivery and in the early postpartum period could prevent many of these deaths, though establishing a causal link between skilled attendance and maternal survival remains problematic.2-6 Still, the proportion of deliveries assisted by a skilled birth attendant (SBA) has become an indicator for measuring maternal mortality reduction, including the 75% reduction called for by the fifth Millennium Development Goal (MDG-5). 7,8 WHO defines an SBA as someone "trained to proficiency in the skills needed to manage normal (uncomplicated) But are skilled birth attendants really skilled? Do the health personnel enumerated by household surveys fit WHO's definition? This question was the focus of our two-phase study. In Phase I, we developed and piloted evaluation instruments, then carried out small-scale competency assessments in four countries. In Phase II, shortcomings identified in Phase I were corrected and the revised instruments used to conduct a large...

The objective of the study described is to assess the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life-threatening obstetric complications--hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a "before and after" design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re-evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life-threatening complications occurring over 66 hospital-months; Review II included 342 complications over 42 hospital-months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion-based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life-threatening obstetric complications.

Peter Byass and colleagues raise questions about the recent, high-profile Global Burden of Disease estimates. Please see later in the article for the Editors' Summary

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ObjectiveTo field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women.MethodsA cross‐sectional study was conducted in Jamaica, Kenya, and Malawi (2015–2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD‐MM.ResultsA total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self‐reported exposure to violence.ConclusionNonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self‐reporting of exposure to violence, and mental health. Further validation is needed.

BackgroundWhile it is estimated that for every maternal death, 20–30 women suffer morbidity, these estimates are not based on standardized methods and measures. Lack of an agreed-upon definition, identification criteria, standardized assessment tools, and indicators has limited valid, routine, and comparable measurements of maternal morbidity. The World Health Organization (WHO) convened the Maternal Morbidity Working Group (MMWG) to develop standardized methods to improve estimates of maternal morbidity. To date, the MMWG has developed a definition and provided input into the development of a set of measurement tools. This protocol outlines the pilot test for measuring maternal morbidity in antenatal and postnatal clinical populations using these new tools.MethodsIn each setting, the tools will be piloted on approximately 250 women receiving antenatal care (ANC) (at least 28 weeks pregnant) and 250 women receiving postpartum care (PPC) (at least 6 weeks postpartum). The tools will be administered by trained health care workers. Each tool has three modules as follows:personal history – socio-economic information, and risk-factors (such as violence and substance abuse)patient symptoms – WHO Disability Assessment Schedule (WHODAS) 12-item, and mental health questionnaires, General Anxiety Disorder, 7-item (GAD-7) and Personal Health Questionnaire, 9-item (PHQ-9)physical examination – signs, laboratory tests and results.DiscussionThis pilot (planned for Jamaica, Kenya and Malawi) will allow for comparing the types of morbidities women experience between and across settings, and determine the feasibility, acceptability and utility of using a modified, streamlined tool for routine measurement and summary estimates of morbidity to inform resource allocation and service provision. As part of the post-2015 Sustainable Development Goals (SDGs) estimating and measuring maternal morbidity will be essential to ensure appropriate resources are allocated to address its impact and improve well-being.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0164-6) contains supplementary material, which is available to authorized users.

A wide gap exists between current evidence-based standards and current levels of provider competence.

A erobic exercise training in stroke has been shown to increase lower extremity strength, 1 improve aerobic capacity, 2 and functional abilities.3 Although these outcomes may impact health-related quality of life (HRQL), 4 the effect of aerobic exercise on HRQL has been much less investigated. Improvement in HRQL after combined aerobic and strengthening exercise has been reported, 5 whereas others have shown no effect. 6 Aerobic training alone was investigated in only 1 study with no effect. 7Previous studies used mainly treadmill and cycle ergometers, with none examining more accessible and less expensive modes of aerobic training such as overground walking. The purpose of this study was to determine the effect of a community-based, 12-week aerobic (walking) exercise program on functional status and HRQL in community-dwelling stroke survivors. Methods Design and SubjectsA single-blind randomized controlled trial was done. The study received ethics approval, and subjects gave written informed consent. Subjects were recruited from among those treated at 3 hospitals in the parishes of Kingston and St. Andrew. Persons included were: ≥40 years of age, community dwelling, 6 to 24 months after stroke, able to walk with or without an assistive device, not currently in a rehabilitation or regular exercise program, not having any disorder that would compromise exercise training, such as unstable cardiovascular diseases, and not having any cognitive deficits. ProceduresPotential candidates were screened for eligibility by a medical practitioner before baseline assessment, then block randomized to intervention and control groups. Reassessment was done at 6 weeks and 3 months (end of training). Participants were assessed by a physical therapist blinded to group assignment. InterventionSubjects were supervised by trained instructors to walk briskly along a prescribed course for 15 minutes, 3 times per week, for 12 weeks, initially, progressing by 5 minutes per week up to 30 minutes in their home or community. Target heart rate was 60% to 85% of agepredicted maximum heart rate (220-age). Training progression was also carried out by increasing speed.Background and Purpose-Little is known about the effects of community-based walking programs in persons with chronic stroke. The purpose of this study was to determine the effects of aerobic (walking) training on functional status and health-related quality of life in stroke survivors. Methods-A single-blind randomized controlled trial was conducted. The intervention group (n=64)