Who is Assisting Women to Deliver Babies within Health Facilities? An Analysis of Deliveries in Four Provinces in Zambia

Skilled birth attendance (SBA) has been shown to reduce maternal mortality and improve birth outcomes. Because skilled professionals are supposed to be present in health facilities, increasing facility deliveries is expected to increase SBA. However, in a country with a critical shortage of skilled health personnel, is this always the case? We present data from three studies conducted in Zambia to understand SBA and delivery practices in health facilities. In each of the studies, women were asked where and with whom they delivered their youngest child. We calculated the proportion of all deliveries that occurred at health facilities, and proportion of SBAs at health facilities. Across all three studies, 62.5% of 39,419 were facility deliveries. Of 39,078 deliveries where data were available for the person assisting, SBA was 54.1%; non-SBA was 45.9%. TBAs assisted 18.5% of all deliveries, but of all non-SBAs, TBAs delivered 40.3%. Among 24,254 health facility deliveries where data were available for person assisting, SBA was 86.3%; non-SBA was 13.7%; TBAs assisted 10% of all facility deliveries. Of all non-SBA deliveries within health facilities, 70.9% were assisted by TBAs. Our studies revealed that unskilled personnel attended 14% of deliveries occurring within health facilities and TBAs assisted 71% of these. In a country with a critical shortage of skilled health personnel, facility deliveries may not directly translate into SBA. We recommend equipping TBAs with stronger skills to conduct deliveries and manage delivery-associated complications in addition to emphasizing the need to refer to health facilities.