Skilled maternity care throughout pregnancy, childbirth, and the postpartum period is globally recognized as one of the most promising strategies for reducing maternal mortality. Rates of skilled attendance at childbirth are being used as the main indicator to measure progress toward the Millennium Development Goal of reducing maternal mortality by three-fourths by the year 2015 (MDG 5).
Currently, almost half of women in developing countries go through childbirth without such care. Moreover, there has been little evidence-based research available to help guide efforts to increase skilled attendance rates. As Miller et al. note in their article, “Where is the E in MCH?” “There is no clear evidence on the best way to ensure appropriate care of women in developing countries who require life-saving interventions in the delivery and postpartum period”. 
In 2000, with support from the Bill & Melinda Gates Foundation, FCI launched the Skilled Care Initiative—a five-year operations research project in four rural, under-served districts in Burkina Faso, Kenya and Tanzania where the majority of women do not give birth with skilled providers. The SCI was developed in an effort to strengthen the evidence base for skilled care programming. The objective of the project was to test and evaluate strategies to increase skilled attendance at childbirth. Project strategies focused specifically on:
Improving the availability and quality of skilled maternity care through health system interventions;
Promoting utilization of maternity services through facility and community- level behavior change interventions.
SCI included a rigorous evaluation, using pre-test/post-test, quasi-experimental design with purposively selected comparison districts and included health facility and household surveys. Evaluation findings have shown that the intervention package led to significant improvements in the availability and quality of maternity care in all three settings, especially at mid-and lower-level health facilities, which were a major emphasis of the project, given their greater accessibility to women in rural communities. Impressive gains were also seen in women’s use of skilled care—even among the poorest women in some settings. Click here for an overview of the three-country results.
Reports on the full evaluation findings for each country can be accessed below.
A costing analysis, in partnership with Abt Associates, was also conducted in Kenya and Tanzania to determine the cost of the interventions, including the health systems component and community-focused BCC components. The primary objectives of this study were to determine the costs of implementing the SCI package in the intervention districts and the costs of replicating the intervention in other districts in Kenya and Tanzania. Click here to access this document.
 Miller, S. et al. “Where is the ‘E’ in MCH? The Need for an Evidence-Based Approach in Safe Motherhood.” Journal of Midwifery and Women’s Health 48, no. 1 (January/February 2003): 10-18.
Article shows out-of-pocket costs for maternity care in Africa
In an article “Out-of-pocket costs for facility-based maternity care in three African countries,” published in the journal Health Policy and Planning, FCI presents population-based household survey data on costs of maternity care in Kenya, Burkina Faso, Tanzania. The study showed that that the vast majority of women incur out-of-pocket expenses for maternity care, even where it is nominally free of charge. These costs generally represent a considerable portion of monthly household income. There was no difference in the out-of-pocket costs reported by the poorest women compared with women in the wealthiest quintiles, indicating that both user fee and nominally free services appeared to be equally regressive.
Skilled Care Initiative Delivers Impressive Results
Between 2003 and 2005, FCI worked with Ministries of Health in Burkina Faso, Kenya, and Tanzania to improve the quality and availability of maternity care, improving services for thousands of women. Through an ambitious research effort, FCI evaluated and documented key strategies for increasing skilled care during childbirth. Click here to download an overview of the results from all three countries.
Film about FCI's Work: “Changing Lives, Saving Lives.”
“I had months of bleeding with my first 6 deliveries—and 2 babies died—because I delivered at home. In the past, there were no drugs, no proper help from the doctors. But now I can go to this health facility with medicines and helpful doctors.”
Rangwe Health Centre in Kenya is one facility that has shown a remarkable change since the beginning of the Skilled Care Initiative.