For the past two weeks, I have been thinking about the kind of interventions needed when it comes to maternal and child health.

Common causes of maternal deaths may be preventable and treatable by access to emergency obstetric care, including going to skilled birth attendants.

The arguments about increase in facility-based deliveries being a proxy for “skilled attendance at delivery” is quickly being blown away by the lack of proportionate reduction in adverse maternal outcomes.

Who should assist women in childbirth? What should these attendants do or not do under various circumstances? And where should births take place? Policies regarding these questions have been debated for hundreds of years.

Measuring facility-based births and the presence of a birth attendant has been the main focus, not their skills and qualifications.

Skilled birth attendance appears to be reducing maternal mortality. Delivery at a facility is often seen as one way of ascertaining skilled delivery. However, this is not always the case. In a facility, you may encounter a trained midwife, a doctor or an auxiliary midwife, but you may also encounter someone with just a minimum, or no training at all.

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So we should ask: What qualifies a skilled birth attendant, and are all institutional birth attendants really skilled? We cannot presuppose that all birth attendants are skilled in delivery care. Qualifications on paper alone do not guarantee sufficient skills and competence, and we should not automatically assume that anyone with medical, nursing, or midwifery training meets the World Health Organisation definition of a “skilled attendant?.

There is also a discrepancy between being trained and feeling comfortable about skills, abilities and theoretical knowledge. Even trained personnel have gaps in their competence. This may result in feeling under-qualified and uncomfortable in performing the tasks expected according to the level of education.