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Indicator 4: Health workforce adequate for caseload

This indicator is the proportion of facilities that have adequate staffing per shift for caseload.

Numerator:No. facilities meeting caseload-specific staffing recommendations per shift

Denominator:Total no. facilities assessed

× 100

Purpose

This indicator aims to capture whether facilities have the minimum number of health providers needed per shift to provide essential and emergency facility-based care to women and newborns through labor, birth and the immediate postnatal and newborn period. This indicator focuses on the staff who were actually present in the facility and not health providers who were formally posted or employed to provide services, but may not be present.

For the purposes of this indicator, we define "adequate staffing" as the minimum number of skilled health personnel,12 complete obstetric surgical and blood transfusion teams, and neonatal nurses (all categories are defined in Table 1 below), according to national qualification, that are needed to deliver high-quality essential and emergency care given the caseload and level of facility. Competency and authorization associated with the qualification of health providers is also a critical element of adequate staffing but it is not factored into this indicator. Competency and authorization can be assessed using various approaches; we provide one example under supplemental studies.

The minimum staffing levels recommended by the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood and Newborn Health Committee described by Stones et al (2019) for facilities with ±1000 annual deliveries is the foundation underpinning the skilled health personnel staffing recommendations for this indicator.34 We build on those recommendations by recognizing the importance of team work and interprofessional skills mix, including the critical complementary role played by nurses in delivering high quality essential maternal and newborn care. Specifically, this indicator adopts the principle that every birth should be attended by at least two trained health professionals: one to manage the woman giving birth and one with newborn skills to manage the newborn. The WHO-UNICEF Norms for Small and/or Sick Newborns in Level-2 Facilities are the basis for the staffing recommendations for inpatient newborn care units (in some countries called “special newborn care units” or SNCUs).56

This is a new indicator which can be used provisionally to ensure that this critical component of EmONC – the number of skilled health personnel and interprofessional teams adequate for caseload – is part of any assessment of the EmONC system and any planning for its future. The indicator has been used successfully in small pilot studies but has not yet been rigorously tested for reliability and validity. Its use should be monitored and evaluated.

Data collection and calculation

The staffing categories included in this indicator are defined in Table 1.

Table 1: Staffing categories for adequate staffing indicator

Category Definition Location (must be…)
Required in all EmONC facilities
Birth attendants (BAs) Birth attendants are able to provide all or most EmONC services and include cadres such as midwives, medical officers, obstetrician-gynecologist physicians, and others prepared and qualified at a national level, regardless of title, to provide EmONC. On the maternity unit* providing care through the shift
Complementary health professionals Nurses often serve an important complementary role supporting women and newborns, proactively screening for complications and providing some but not all EmONC services. Others with varying titles may also be prepared and qualified at a national level to serve in a complementary health professional role. On the maternity unit* providing care through the shift
Skilled health personnel (SHP) Those serving as BAs and in complementary health professional roles are all considered Skilled Health Personnel.
Required in CEmONC and IEmONC facilities
Obstetric surgical teams Each country is responsible for determining the component roles of an interprofessional obstetric surgical team in its context. An example obstetric surgical team might consist of a qualified surgical provider, surgical first assistant, surgical scrub nurse, nurse, midwife or technician (to receive the newborn), surgical circulating nurse, nurse midwife or technician (anesthetist assistant), anesthetist, and nurse or technician available to leave and return to the operating theater. Many of these roles in the operating theatre are performed by birth attendants and complementary health professionals in the maternity unit. Therefore, these individuals may also be counted as EmONC SHP (i.e., birth attendants and complementary health professionals). Immediately available
Blood transfusion teams Each country is responsible for determining the component roles of an interprofessional blood transfusion team in its context. An example blood transfusion team might consist of physicians, nurses and laboratory personnel required to order, type and crossmatch, and administer blood transfusion to women and newborns. In the facility
Neonatal nurses** Neonatal nurses are trained nurses (or midwives) with specialist skills in small and sick newborn care who provide most of the clinical hands-on care in the inpatient newborn care unit. A neonatal nurse specializes in care of newborns across the continuum including preterm, sick and at risk newborns to promote the best possible health outcomes. In the inpatient newborn care unit unless no sick or small newborns are receiving care, in which case they must be immediately available

* The maternity unit includes labor, delivery, and postpartum/postnatal rooms or wards.

** This indicator focuses on the presence of neonatal nurses as a core component of adequate staffing for inpatient newborn care units, but neonatal nurses should work within a multi-disciplinary team of adequately educated health-care providers with specialised skills, mostly nurses and paediatric and/or neonatal doctors, but also including (but not limited to) nutritionists, lactation specialists, speech and occupational therapists, physiotherapists, social workers and psychologists, as well as bio-medical engineers for maintenance of neonatal equipment. Special attention should be paid to adequate staff-patient ratios and skill mix.7 The family is also central to the care of the newborn, and should be involved and empowered as partners in care.8

The numerator for this indicator is the number of facilities that have adequate staffing per shift. The process for calculating this number, including sample data collection forms, can be found in Process to determine adequacy of the health workforce.

The denominator is the total number of facilities that are being assessed.

The indicator is typically expressed as a percentage of facilities that meet staffing recommendations.

To monitor whether facilities have adequate staffing per shift, this indicator can be calculated and analyzed by sub-national and/or national planners either for the entire quarter (if the required staffing data are already collected and easily available) or for the last month of every quarter (if the data need to be recorded for the purposes of calculating this indicator).

Analysis and interpretation

The benchmark for this indicator is 100%, such that all facilities should aim to have adequate staffing for their caseload.

This indicator can be calculated and analyzed both sub-nationally and nationally as well as by level of care (BEmONC/CEmONC/IEmONC), facility type, managing authority or urban/rural location of facility to identify where gaps in staffing adequacy are most pronounced. Sub-analyses that examine which health providers (birth attendants, complementary health professionals, obstetric surgical or blood transfusion teams, or neonatal nurses) are not meeting recommended levels may also be useful. Sub-analysis may also be useful in revealing variations of staffing in relation to time of day or day of the week. For example, skilled health personnel may be less likely to be available on night shifts, weekends or holidays.

Supplemental studies

Assess whether health providers are authorized and competent (or qualified in service - QIS)

Effective EmONC services are dependent on facilities having skilled health personnel9 and obstetric surgical, neonatal, and blood transfusion teams that are both legally authorized and competent in their role or “qualified in service” (QIS). While many countries have systems in place to ensure qualifications and to routinely assess and improve the quality of their health workforce (e.g., systems at a facility level; credentialing and supportive supervision; systems at the national level; licensing based on mandated pre-service preparation, continuing education and regular assessment of skills), Qualified in Service is an approach to assessing EmONC-related qualifications that can be considered for integration into countries’ existing practices.

Useful links

  1. World Health Organization. (2018). Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA (No. WHO/RHR/18.14). World Health Organization. ↩︎

  2. “Skilled health personnel, as referenced by SDG indicator 3.1.2, are competent maternal and newborn health (MNH) professionals educated, trained and regulated to national and international standards. They are competent to: (i) provide and promote evidence-based, human-rights based, quality, socioculturally sensitive and dignified care to women and newborns; (ii) facilitate physiological processes during labour and delivery to ensure a clean and positive childbirth experience; and (iii) identify and manage or refer women and/or newborns with complications. In addition, as part of an integrated team of MNH professionals (including midwives, nurses, obstetricians, paediatricians and anaesthetists), they perform all signal functions of emergency maternal and newborn care to optimize the health and well-being of women and newborns. Within an enabling environment, midwives trained to International Confederation of Midwives (ICM) standards can provide nearly all of the essential care needed for women and newborns. (In different countries, these competencies are held by professionals with varying occupational titles.)” (https://www.who.int/publications/i/item/WHO-RHR-18.14) ↩︎

  3. Stones W, Visser GHA, Theron G; FIGO Safe Motherhood and Newborn Health Committee. FIGO Statement: Staffing requirements for delivery care, with special reference to low- and middle-income countries. Int J Gynaecol Obstet. 2019;146(1):3-7. doi:10.1002/ijgo.12815 ↩︎

  4. Stones, W., & Nair, A. (2023). Metrics for maternity unit staffing in low resource settings: Scoping review and proposed core indicator. Frontiers in Global Women's Health, 4, 1028273 ↩︎

  5. Note that staffing recommendations for inpatient newborn care units will be further elaborated in forthcoming joint-UN implementation guidance documents. ↩︎

  6. WHO, UNICEF. Norms for care of small and sick newborns. Forthcoming. ↩︎

  7. World Health Organization, UNICEF. Survive and thrive: transforming care for every small and sick newborn. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. ↩︎

  8. Council of International Neonatal Nurses (COINN). (2024) What is a Neonatal Nurse Position Statement. Yardley, PA, USA: COINN. ↩︎

  9. World Health Organization. (2018). Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA (No. WHO/RHR/18.14). World Health Organization. ↩︎