Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?

Peripheral-level birthing centers may be appropriate and effective in some circumstances if crucial systems requirements can be met. But promising models don't necessarily scale well, so policy makers and program managers need to consider what requirements can and cannot be met feasibly at scale. Apparently successful components of the birthing center model, such as engagement of traditional birth attendants and use of frontline staff who speak the local language, appear conducive to use in other similar settings. I n this issue of Global Health: Science and Practice, Stollak et al. 1 report a positive experience with maternal-newborn services for remote, primarily indigenous communities in Guatemala. The work was done by an NGO and included an important focus on community outreach and cultural sensitivity. Services were made more accessible by establishing birthing centers (Casas Maternas) in communities where such services hadn't previously been available. They were staffed by skilled birth attendants (SBAs)—locally hired auxiliary nurses—who spoke the local language. The project also cultivated relationships with traditional birth attendants, who were made welcome to support women giving birth in the Casas Maternas. In addition, the project facilitated reliable transfer of complicated cases to higher-level care. This case raises 2 important issues, one specific to maternal-newborn care and the other more broadly relevant to generalizability or transferability from small scale to large. Well into the 1990s, to the extent that the global health community gave attention to safe motherhood, the dominant model assumed that most births would take place at home without the assistance of an appropriately skilled professional. However, by the time of the 2006 Lancet Maternal Survival series, 2 with the goal of ensuring as high as possible coverage of ''skilled birth attendance,'' the model of peripheral-level, midwife-staffed birthing centers had gained currency. Over the past decade, as various countries have made efforts to implement such services, doubts have emerged about the effectiveness of the peripheral-level birthing center model in reducing risk of death. To provide effective labor and delivery care for a population, clearly certain conditions need to be met. Unfortunately, if service providers in such settings are inadequately equipped to manage complications or if robust provision for timely transfer to higher-level care is lacking (which has commonly been the case for these services), it is hardly realistic to expect significantly improved outcomes. 3 But, alternatively, if such crucial requirements can be met, this model of provision of care may …