SPECIAL COMMUNICATION Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement S.A. Harvey a, * , P. Ayabaca b , M. Bucagu c , S. Djibrina d , W.N. Edson a , S. Gbangbade e , A. McCaw-Binns f , B.R. Burkhalter a a Quality Assurance Project, University Research Co., LLC, Bethesda, MD 20814, USA b Quality Assurance Project, University Research Co., LLC, Quito, Ecuador c School of Public Health/National University of Rwanda, Butare, Rwanda d Quality Assurance Project, University Research Co., LLC, Niamey, Niger e Averting Maternal Death and Disability Project, Cotonou, Benin f Department of Community Health and Psychiatry, University of the West Indies, Jamaica Received 27 April 2004; received in revised form 30 June 2004; accepted 30 June 2004 Abstract Objectives: Percentage of deliveries assisted by a skilled birth attendant (SBA) has become a proxy indicator for reducing maternal mortality in developing countries, but there is little data on SBA competence. Our objective was to evaluate the competence of health professionals who typically attend hospital and clinic-based births in Benin, Ecuador, Jamaica, and Rwanda. Methods: We measured competence against World Health Organization’s (WHO) Integrated Management of Pregnancy and Childbirth guidelines. To evaluate knowledge, we used a 49-question multiple-choice test covering seven clinical areas. To evaluate skill, we had participants perform five different procedures on anatomical models. The 166 participants came from facilities at all levels of care in their respective countries. Results: On average, providers answered 55.8% of the knowledge questions correctly and performed 48.2% of the skills steps correctly. Scores differed somewhat bycountry, provider type, and subtopic. Conclusion: A wide gap exists between current evidence-based standards and current levels of provider competence. D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 0020-7292/$ - see front matter D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.06.017 * Corresponding author. Tel.: +1 301 941 8441; fax: +1 301 941 8427. E-mail address: sharvey@urc-chs.com (S.A. Harvey). KEYWORDS Skilled birth attendant; Skilled attendance at delivery; Clinical competence/ standards; Maternal mortality; Maternal health services/standards; Pregnancy complications/ mortality/prevention and control International Journal of Gynecology and Obstetrics (2004) 87, 203–210 www.elsevier.com/locate/ijgo