Evaluating skilled care at delivery in Burkina Faso: principles and practice.

There are strong expectations of what could be achieved by skilled care at delivery for maternal and newborn survival and health. Meeting these expectations involves the translation of the concepts and principles of skilled attendance into the reality of routine programmes. This process of translation brings to light some of the tensions which lie behind the consensus on the ideal package and particularly the alternative configurations of provider and place necessary in the immediate term. Lessons learnt from the implementation of specific projects and initiatives have a crucial role to play in informing scaling-up and the achievement of universal coverage. The Skilled Care Initiative implemented in Burkina Faso by Family Care International, evaluated and reported here, provides many lessons for moving from concepts to practice. Firstly, there is the crucial issue of local contextual adaptation, as no one-size-fits-all for skilled attendance. Secondly, interventions to achieve skilled care require and imply different levels of intensity of implementation, depending on the functionality of the wider health system in the intervention area. Thirdly, there is the crucial issue of the balance and sequencing of supply- and demand-side interventions. Finally, the concept of skilled attendance at delivery does not exist in a vacuum in space or time, and concurrent health initiatives and cross-sectoral developments, such as transport and road improvements, can strongly influence outcomes. This not only presents challenges for the implementation of specific interventions within health institutions and communities, but also for the evaluation of their effects.