Maternal and Child Health Journal

, Volume 19, Issue 1, pp 155–169 | Cite as

Skilled Birth Attendants in Tanzania: A Descriptive Study of Cadres and Emergency Obstetric Care Signal Functions Performed

  • Etsuko Ueno
  • Adetoro A. Adegoke
  • Gileard Masenga
  • Janeth Fimbo
  • Sia E. Msuya


Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all the level of care. In the district, gaps existed between performance of EmOC signal functions by SBAs as expected by the MOHSW and the actual performance at health facilities. All basic EmOC facilities were not fully functional. Few health care providers performed all the basic EmOC signal functions. Competency-based in-service training of providers in EmOC and provision of enabling environment could improve performance of EmOC signal functions in the district.


Skilled birth attendant Emergency obstetric care Signal functions Tanzania Sub-Saharan Africa 



Assistant Clinical Officer


Assistant Medical Officer


Basic Emergency Obstetric Care


Comprehensive Emergency Obstetric Care


Clinical Officer


Emergency Obstetric Care


Enrolled Nurse/Midwife


Health care provider


Interquartile range


Kilimanjaro Christian Medical Centre


Kilimanjaro Christian Medical University College


Liverpool School of Tropical Medicine


Maternal and Child Health Aide


Millennium Development Goal


Maternal mortality ratio


Maternal and Newborn Health Unit


Ministry of Health and Social Welfare


Public Health Nurse


Reproductive and Child Health


Registered Nurse/Midwife


Skilled birth attendant


Standard deviation


Statistical Package for Social Science


United Nations Children’s Fund


World Health Organisation


  1. 1.
  2. 2.
    Ronsmans, C., & Graham, W. (2006). Maternal mortality: Who, when, where and why. Lancet, 368, 1189–1200.PubMedCrossRefGoogle Scholar
  3. 3.
    WHO, Unicef. (2010). Countdown to 2015 decade report (2000–2015): taking stock of maternal, newborn and child survival. Geneva, Switzerland: WHO and UNICEF. 2010.Google Scholar
  4. 4.
  5. 5.
    WHO (2009) Monitoring emergency obstetric care. A handbook. WHO, UNFPA, UNICEF & AMDD. Geneva, Switzerland: WHO press.
  6. 6.
    Campbell, O. M. R., & Graham, W. (2006). Strategies for reducing maternal mortality: Getting on with what works. Lancet, 368, 1284–1299.PubMedCrossRefGoogle Scholar
  7. 7.
    Bullough, C., Meda, N., Makowiecka, K., Ronsmans, C., Achadi, E. L., & Hussein, L. (2005). Current strategies for the reduction of maternal mortality. BJOG, 112(9), 1180–1188.PubMedCrossRefGoogle Scholar
  8. 8.
    Paxton, A., Bailey, P., Lobis, S., & Fry, D. (2006). Global patterns in availability of emergency obstetric care. International Journal of Gynaecology and Obstetrics, 93, 300–307.PubMedCrossRefGoogle Scholar
  9. 9.
    Van Lerberghe, W., & De Brouwere, V. (2001). Of blind alleys and things that have worked: History’s lessons on reducing maternal mortality. Studies in Health Services Organisation and Policy, 17, 7–33.Google Scholar
  10. 10.
    Paxton, A., Maine, D., Freedman, L., Fry, D., & Lobis, S. (2005). The evidence for emergency obstetric care. International Journal of Gynaecology and Obstetrics, 88, 181–193.PubMedCrossRefGoogle Scholar
  11. 11.
    WHO. (2004). Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, Switzerland: WHO press.Google Scholar
  12. 12.
    International Confederation of Midwives (ICM) (2010). Essential competencies for basic midwifery practice.
  13. 13.
    Bernis, L. D., Sherrat, D. R., AbouZahr, C., & Lerberghe, W. V. (2003). Skilled attendants for pregnancy, childbirth and postnatal care. British Medical Bulletin, 67, 39–57.PubMedCrossRefGoogle Scholar
  14. 14.
    Scott, S., & Ronsmans, C. (2009). The relationship between birth with a health professional and maternal mortality in observational studies: A review of literature. Tropical Medicine & International Health, 14(12), 1523–1533.CrossRefGoogle Scholar
  15. 15.
    National Bureau of Statistics (NBS). (2005). Tanzania Demographic and Health Survey 2004–2005. Dar -es- Salaam, Tanzania: NBS and ORC Macro.Google Scholar
  16. 16.
    National Bureau of Statistics (NBS). (2010). Tanzania Demographic and Health Survey 2010. Dar -es- Salaam, Tanzania: NBS and ORC Macro. 2011.Google Scholar
  17. 17.
    WHO (2011) World Health Statistics,
  18. 18.
    Ministry of Health and Social Welfare (2008) The national road map strategic plan to accelerate reduction of maternal, newborn and child health in Tanzania 2008–2015. http// Sector Documents/MNCH/One MNCH plan.pdf.Google Scholar
  19. 19.
    HSSE: Expectation of doctors and mid-level providers: alignment of regulation, training, and actual performance of emergency obstetric care by health care providers in Malawi and Tanzania 2009,
  20. 20.
    Adegoke, A., Utz, B., Msuya, S. E., & van den Broek, N. (2012). Skilled birth attendants: Who is who? A descriptive study of definitions and roles from nine Sub Saharan African countries. PLoS ONE, 7(7), e40220. doi:10.1371/journal.pone.0040220.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Lobis, S., Mbaruku, G., Kamwendo, F., & McAuliffe, E. (2011). Expected to deliver: alignment of regulation, training and actual performance of emergency obstetric care providers in Malawi and Tanzania. International Journal of Gynecology and Obstetrics, 115, 322–327.PubMedCrossRefGoogle Scholar
  22. 22.
    MOHSW. Staffing levels for Ministry of Health and Social Welfare Departments, health facilities and health training institutions. Dar es Salaam, Tanzania. 2012.Google Scholar
  23. 23.
    Report, Moshi Urban Annual. (2010). Ripoti ya mama na mtoto katika manispaa ya Moshi. Tanzania: Department of Health, Moshi Municipal Council.Google Scholar
  24. 24.
    Kruk, M. E., Wladis, A., Mbembati, N., Ndao-Brumblay, S., Hsia, R., Galukande, M., et al. (2010). Human resource and funding constraints for essential surgery in district hospitals in Africa: A retrospective cross-sectional survey. PLoS Medicine, 7(3), e1000242.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    WHO. (2006). The World Health Report 2006—Working together for health (p. 26). Geneva, Switzerland: WHO.Google Scholar
  26. 26.
    Ameh, C., Adegoke, A., et al. (2012). The impact of emergency obstetric care training in Somaliland, Somalia. International Journal of Gynaecology and Obstetrics, 117(3), 283–287.PubMedCrossRefGoogle Scholar
  27. 27.
    Pearson, L., & Shoo, R. (2005). Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda. International Journal of Gynecology and Obstetrics, 88(2), 208–215.PubMedCrossRefGoogle Scholar
  28. 28.
    Kongnyuy, E. J., Hofman, J., Mlava, G., Mhango, C., & van den Broek, N. (2009). Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi. Maternal and Child Health Journal, 13, 687–694.PubMedCrossRefGoogle Scholar
  29. 29.
    Ameh, C., Msuya, S. E., Hofman, J., Raven, J., Mathai, M., & Van den Broek, N. (2012). Status of emergency obstetric care in six developing countries 5 years before the MDG targets for maternal and newborn health. PLoS ONE, 7(12), e49938. doi:10.1371/journal.pone.0049938.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Ziraba, A. K., Mills, S., Madise, N., Saliku, T., & Fotso, J.-C. (2009). The state of emergency obstetric care services in Nairobi informal settlements and environs: Results from maternity health facility survey. BMC Health Service Research, 9, 46.CrossRefGoogle Scholar
  31. 31.
    van Lonkhuijzen, L., Dijkman, A., van Roosmalen, J., Zeeman, G., & Scherpbier, A. (2010). A systematic review of the effectiveness of training in emergency obstetric care in low-resource environments. BJOG: An International Journal of Obstetrics & Gynaecology, 117(7), 777–787.CrossRefGoogle Scholar
  32. 32.
    Kwast, B. E. (1998). Quality of care in reproductive health programmes: Education for quality improvement. Midwifery, 14, 131–136.PubMedCrossRefGoogle Scholar
  33. 33.
    Draycott, T., Sibanda, T., Owen, L., Akande, V., Winter, C., Reading, S., et al. (2006). Does training in obstetrics emergencies improve neonatal outcome? BJOG, 113, 177–182.PubMedCrossRefGoogle Scholar
  34. 34.
    Black, R. S., & Brocklehurst, P. (2003). A systematic review of training in acute obstetric emergencies. BJOG, 110, 837–841.PubMedCrossRefGoogle Scholar
  35. 35.
    Ijadunola, K. T., Fatusi, A. O., et al. (2007). Unavailability of essential obstetric care services in a local government area of south-west Nigeria. Journal of Health, Population and Nutrition, 25, 94–100.Google Scholar
  36. 36.
    Grady, K., Ameh, C., et al. (2011). Improving essential obstetric and newborn care in resource-poor countries. Journal of Obstetrics and Gynaecology, 31, 18–23.PubMedCrossRefGoogle Scholar
  37. 37.
    Sorensen, B. L., Rasch, V., et al. (2011). Advanced life support in obstetrics (ALSO) and post-partum hemorrhage: A prospective intervention study in Tanzania. Acta Obstetrica et Gynecological Scandinavica., 90, 609–614.CrossRefGoogle Scholar
  38. 38.
    Pereira, C., Mbaruku, G., et al. (2011). Emergency obstetric surgery by non-physician clinician in Tanzania. International Journal of Gynecology and Obstetrics, 114, 180–183.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Etsuko Ueno
    • 1
  • Adetoro A. Adegoke
    • 1
  • Gileard Masenga
    • 2
  • Janeth Fimbo
    • 3
  • Sia E. Msuya
    • 1
  1. 1.Liverpool School of Tropical MedicineLiverpoolUK
  2. 2.Department of Obstetrics and GynaecologyKCMC Hospital and KCMU CollegeMoshiTanzania
  3. 3.Reproductive and Child Health UnitMoshi Municipal CouncilMoshiTanzania

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