Human resource shortages in the health services are widely acknowledged as a threat to the attainment of the healthrelated Millennium Development Goals (MDGs). Attempts to optimize the potential of the existing health workforce are therefore crucial. A more rational distribution of tasks and responsibilities among cadres of health workers is seen as a promising strategy for improving access and costeffectiveness within health systems. For example, access to care may be improved by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions that might otherwise be provided only by cadres with longer (and sometimes more specialized) training. Such task shifting strategies might be particularly attractive to countries that lack the means to improve access to care within short periods of time. Strategies to optimize tasks and roles for the implementation of effective interventions have achieved variable success. This is partly because the effects of these strategies are dependent on varying local health contexts and are shaped by a range of often very different social, political and cultural systems. However, the question of which health-care providers can deliver effective interventions is also linked to wider global discussions about whether health workers with lower levels of training can safely deliver key interventions. Within the arena of maternal and newborn health, for example, the implementation of contraceptive programmes and specific maternal health interventions (such as the use of uterotonics) is linked to wider debates about how task and role optimization can be achieved through task shifting. Consensus has emerged that there is a need to define which key interventions can safely and effectively be delivered by different cadres. Objectives These recommendations have been developed as part of the World Health Organization’s mandate to provide normative guidance to its member states. The objective of this guidance is to issue evidence-based recommendations to facilitate universal access to key, effective maternal and newborn interventions through the optimization of health worker roles. These recommendations are intended for health policymakers, managers and other stakeholders at a regional, national and international level. By providing this broad guidance internationally, the World Health Organization (WHO) assumes that countries will adapt and implement these recommendations while also considering the political system and health systems context in which they operate.
BACKGROUND: Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.
OBJECTIVE: We reviewed the content, impact, risk-benefit, and feasibility of interventions for obstetric complications with high population attributable risk of intrapartum-related hypoxic injury, as well as human resource, skill development, and technological innovations to improve obstetric care quality and availability.
RESULTS: Despite ecological associations of obstetric care with improved perinatal outcomes, there is limited evidence that intrapartum interventions reduce intrapartum-related neonatal mortality or morbidity. No interventions had high-quality evidence of impact on intrapartum-related outcomes in low-resource settings. While data from high-resource settings support planned cesarean for breech presentation and post-term induction, these interventions may be unavailable or less safe in low-resource settings and require risk-benefit assessment. Promising interventions include use of the partograph, symphysiotomy, amnioinfusion, therapeutic maneuvers for shoulder dystocia, improved management of intra-amniotic infections, and continuous labor support. Obstetric drills, checklists, and innovative low-cost devices could improve care quality. Task-shifting to alternative cadres may increase coverage of care.
CONCLUSIONS: While intrapartum care aims to avert intrapartum-related hypoxic injury, rigorous evidence is lacking, especially in the settings where most deaths occur. Effective care at birth could save hundreds of thousands of lives a year, with investment in health infrastructure, personnel, and research--both for innovation and to improve implementation.
Human resource shortages in the health services are widely acknowledged as a threat to the attainment of the healthrelated Millennium Development Goals (MDGs). Attempts to optimize the potential of the existing health workforce are therefore crucial. A more rational distribution of tasks and responsibilities among cadres of health workers is seen as a promising strategy for improving access and costeffectiveness within health systems. For example, access to care may be improved by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions that might otherwise be provided only by cadres with longer (and sometimes more specialized) training. Such task shifting strategies might be particularly attractive to countries that lack the means to improve access to care within short periods of time. Strategies to optimize tasks and roles for the implementation of effective interventions have achieved variable success. This is partly because the effects of these strategies are dependent on varying local health contexts and are shaped by a range of often very different social, political and cultural systems. However, the question of which health-care providers can deliver effective interventions is also linked to wider global discussions about whether health workers with lower levels of training can safely deliver key interventions. Within the arena of maternal and newborn health, for example, the implementation of contraceptive programmes and specific maternal health interventions (such as the use of uterotonics) is linked to wider debates about how task and role optimization can be achieved through task shifting. Consensus has emerged that there is a need to define which key interventions can safely and effectively be delivered by different cadres. Objectives These recommendations have been developed as part of the World Health Organization’s mandate to provide normative guidance to its member states. The objective of this guidance is to issue evidence-based recommendations to facilitate universal access to key, effective maternal and newborn interventions through the optimization of health worker roles. These recommendations are intended for health policymakers, managers and other stakeholders at a regional, national and international level. By providing this broad guidance internationally, the World Health Organization (WHO) assumes that countries will adapt and implement these recommendations while also considering the political system and health systems context in which they operate.
