OBJECTIVE: To assess the effect that a training intervention for traditional birth attendants (TBAs) in Guatemala had on the detection of obstetric complications, the referral of patients with complications to the formal health care system, and, ultimately, those patients' utilization of essential obstetric care services. METHODS: Using a quasi-experimental design, a surveillance system of births was implemented to collect population-based information from 3,518 women between 1990 and 1993. All women were interviewed postpartum by physicians. There were three key independent variables in our study: 1) geographical area (intervention community and non-intervention community), 2) time in relation to the training intervention (before or after), and 3) presence or absence of a TBA at the time of the complication. The key dependent variables for women interviewed were 1) development of an obstetric complication, 2) detection of the problem by the TBA, 3) referral to a health facility, 4) compliance with referral, and 5) use of services. RESULTS: The incidence of postpartum complications decreased after the intervention, controlling for intervention community. On the other hand, after the intervention TBAs were less likely to recognize most maternal complications, and referral rates did not increase significantly. The likelihood of using health care services increased six-fold among women who were not attended by TBAs, and no increase was observed among those who were attended by TBAs. CONCLUSION: Training TBAs may have had a positive effect on the rate, detection, and referral of postpartum complications. However, the evidence is less convincing for overall increases in the detection of complications, in referral to the formal health care system, and in the utilization of essential obstetric services among women attended by TBAs.
We report the findings of an evaluation of a programme in three districts in South Kalimantan, Indonesia, which consisted of the training, deployment and supervision of a large number of professional midwives in villages, an information, education and communication (IEC) strategy to increase use of village midwives for birth, and a district-based maternal and perinatal audit (MPA). Before the programme, the midwives had limited ability to manage obstetric complications, and 90% of births took place at home. Only 37% were attended by a skilled attendant. By 1998-99, 510 midwives were posted in the districts and skilled attendance at delivery had increased to 59%. Through in-service training, continuous supervision and participation in the audit system midwives also gained confidence and skills in the management of obstetric complications. Despite this, the proportion admitted to hospital for a caesarean section declined from 1.7 to 1.4% and the proportion admitted to hospital with a complication requiring a life-saving intervention declined from 1.1% to 0.7%. The strategy of a midwife in every village has dramatically increased skilled birth attendance, but does not yet provide specialized obstetric care for all women needing it. The high cost of emergency obstetric interventions may well be the most important obstacle to the use of hospital care.
OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.
OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.
BACKGROUND: As a result of war and periodic natural disasters, Angola has among the highest infant and maternal mortality rates in the world. In response to the acute health needs of the population, the International Medical Corps (IMC) developed a traditional birth attendant educational course designed to reduce the preventable causes of maternal and infant mortality. METHODS: From 1994 until 1998, Angolan traditional birth attendants (TBAs) participated in an intensive 38-hr training course on prenatal, delivery, and postnatal care. Following the birth of a child, the trained TBAs completed a registration form containing information regarding the health of the mother. Previous studies of Angolan maternal mortality served as historic comparisons. FINDINGS: Complete data including maternal mortality data were available for 19,666 deliveries (83% of total). Fifty five maternal deaths were recorded, which corresponds to a maternal mortality rate of 293 per 100,000 live births. The average historic maternal mortality rate for available comparison groups was 1241 per 100,000 live births. INTERPRETATION: The maternal mortality rate was reduced among women managed by IMC-trained TBAs when compared with historical control data.
A small-scale training programme for birth attendants in a remote area of Burkina Faso was evaluated two years after it had been started. The evaluation methods included interviews with trained birth attendants and the analysis of health service statistics and survey data. The findings showed that the programme had been moderately successful in imparting knowledge and overcoming cultural inhibitions about assisted deliveries. However, the effectiveness of the programme was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport. In deprived areas such as the Sahel, it is probably the health centre, the hospital and the referral system that should be the first priority for improvement, rather than grass-roots practices. This program evaluation pertains to a program initiated in 1990 for training of 18 traditional birth attendants (TBAs) from Fulani or Rimaibe villages in the department of Sebba in northern Burkina Faso. All were illiterate and most were another ethnic minority. Training was directed to performing safe birth procedures and the detection of high risk pregnancies. Techniques were taught for massaging the uterus in order to induce contractions, putting the baby to the breast immediately after delivery, and referral. Methods involved group discussions, practical demonstrations, and role playing. Pictorial cards were used for recording pregnancy information. TBAs received simple maternity kits. An ambulance was made available for emergency referral to the regional hospital. The area is served by two clinics and one medical center. Program evaluation occurred in 1992. Interviews were conducted among 17 TBAs, health service statistics were collected, and a health survey was conducted in the department (296 women of childbearing age from 21 villages). 397 deliveries occurred in the five years preceding the survey. 92% of deliveries were at either of the two clinics or at the Sebba medical center. 12% delivered without assistance. 39% had the assistance of a friend or relative. 24% had assistance from an older neighbor. 19% had assistance from untrained TBAs. 7% had health personnel assistance. TBAs were found to have retained most of the childbirth information, and 11 could correctly identify signs of high risk pregnancy. 14 correctly described hygienic practices. All 17 recognized chloroquine as an anti-malaria drug, and 12 knew the proper dosage of 3 tablets per week. Knowledge of postpartum hemorrhage was weak. The trained TBAs were seldom used in the two year period. Seven villages regularly used their services. Three correctly attended 35-50% of all births in their villages. 13 TBAs made a total of 36 referrals. Program success was not related to training activities or cultural obstacles. The entire health delivery system at the clinic level, the referral system, and health staff training rather than grass roots changes, were suggested improvements. Candidates for training should be selected more appropriately.
The Regionalization of Perinatal Care, an intervention study carried out in Tanjungsari, a subdistrict in rural West Java, aimed to develop a comprehensive maternal health program to improve maternal and perinatal health outcomes. The main inputs included training at all levels of the health care system (informal and formal) and the establishment of birthing homes in villages to make services more accessible. Special attention was given to referral, transportation, communication and appropriate case management, A social marketing program was conducted to inform people of the accessible birthing homes for clean delivery, located near the women, and with better transportation and communications to referral facilities should complications arise. The study design was longitudinal, following all pregnant women from early pregnancy until 42 days postpartum in an intervention and a comparison area. The population was +/- 90,000 in the intervention area and 40,000 in the comparison area. Inclusion criteria were all mother and infant units delivered between June 1st, 1992 and May 31st, 1993. Analysis showed the following results: Most women sought antenatal care (> 95%). In Tanjungsari, nearly 90% sought such care from professional providers as versus 75% in the control area of Cisalak. Most women with bleeding or bleeding and edema during pregnancy sought professional assistance in both the study and control areas. However, fever for more than 3 days received more attention in the study area versus control area (93 vs. 69%). Greater than 85% of deliveries in both areas were conducted by TBAs. However, in the study area, nearly one-third of those with intrapartum complications (17%) delivered in a health facility compared to one-tenth in the control area. This meant a hospital delivery, primarily with assistance of a doctor or doctor/midwife combination. Overall referral rates by TBAs were low -13% of women with complications in Tanjungsari and 6% in Cisalak. More women with intrapartum complications were referred in the study area than in the control, and more complied when referred. Women who suffered intrapartum complications were more likely to have a perinatal death. Perinatal deaths declined in Tanjungsari, but not significantly. However, the trend over the period of the intervention shows an improvement in the deliveries managed by TBAs with more deaths resulting in the hands of professionals. Either women were arriving too late or the quality of care could not meet the needs. There was no change in the levels or place of perinatal deaths in Cisalak.
To improve Maternal and Child Health services especially in the rural areas, a programme to train traditional birth attendants (Ungo Zoma) was established by the Sokoto State government of Nigeria in 1975. The impact of the training programme on the knowledge and practices of traditional birth attendants (TBAs) in a rural community in the state was studied. Seventy-four TBAs, consisting of 43 trained and 31 untrained attendants, were interviewed. Statistically significant differences were observed in the proportion of both groups of TBAs able to recognize high risk pregnancies and deliveries for referral to health institutions. In contrast to the trained attendants, none of the untrained TBAs offered any of the following Maternal and Child Health services: antenatal care, advice on immunization of children or their mothers during pregnancy, and family planning. Suggestions for improving the knowledge and practices of the TBAs in Sokoto as well as in other communities wishing to embark on similar programmes are offered. In Bodinga, a local government area of Sokoto State in Nigeria, a community medical doctor compared data on 43 trained traditional birth attendants (TBAs) with data on 31 untrained TBAs to evaluate Sokoto State's TBA training program by examining their knowledge and practices. Trained TBAs were more likely to identify high risk pregnant women for referral (p .001): pregnant women younger than 16 years old (74% vs. 19%) and older than 35 years old (63% vs. 16%), mothers who were of very short stature (72% vs. 0); women who had a history of antepartum or postpartum hemorrhage (77% vs. 13%), labor lasting for more than 24 hours (95% vs. 39%), abnormal lie (100% vs. 45%), and edema during pregnancy (67% vs. 19%). Even though trained TBAs were more likely to recognize high risk pregnancies, only 41% provided prenatal care. Similar proportions of both groups would refer women for postpartum hemorrhage after delivery, previous history of Cesarean section, disappearance of fetal movement during pregnancy, and retained placenta. None of the untrained TBAs provided any of the following maternal and child health services, while trained TBAs tended to do so (p .001): prenatal care, advice on immunization of mothers during pregnancy (91% of trained TBAs) and of children (82%), and advice on family planning (52%). Although trained TBAs were more likely to use new razor blades to cut the umbilical cord (58% vs. 32%), the difference was not significant. Yet, no trained or untrained TBA sterilized razor blades. 18% of trained TBAs did sterilize scissors, however, while no untrained TBA used sterilized scissors. These findings showed that the TBA training program contributed greatly to improved knowledge and practices, thereby supporting expansion and continued allocation of resources to the TBA training program.
Maternal mortality is high in most African countries, particularly in rural areas where access to formal health care is limited. The sociopolitical and economic environment complicates the medical factors directly responsible for this high rate. Since the 1970s many African countries have addressed this problem by training traditional birth attendants (TBAs) in health promotion and in the basics of safe delivery and referral. The Danfa Rural Health Project in Ghana has trained and supervised TBAs since 1973. It is located relatively close to the health services of the capital city of Accra, providing an ideal environment for the practice of trained TBAs. Thirty-seven trained TBAs currently practice in the area. Most provide patient education and encourage women to go to the health center for preventive services. However, many report routinely performing the high risk deliveries that they have been taught to refer to higher level care and that when they do refer, their patients may not go. Reasons for referral refusal frequently cited by TBAs include financial limitation or lack of transportation and the patients fear of disrespectful or painful treatment from medical personnel. In the rural environment, the trained TBA's greatest contribution to lower maternal mortality rates may lie in the area of health promotion rather than disease intervention.
The preliminary findings of a prospective study of perinatal, neonatal and maternal mortality carried out in a rural community of Sudan are reported. Out of 6275 deliveries monitored over a period of 3 years, 150 stillbirths, 167 neonatal deaths and 27 maternal deaths were observed. An intervention program to upgrade the skills of the village midwives started in the middle of the second year. There was a 25% reduction in the risk of unfavorable outcome of pregnancy (i.e. stillbirth and neonatal death) in the third year relative to the first 2 years. Peer review of the 40 village midwives who took part in the study revealed their tremendous potentials in mobilization of mothers as well as participation in primary health care. Their role in detection of high risk pregnancies and newborns cannot be overemphasized.
To assess the effect that a training intervention for traditional birth attendants (TBAs) in Guatemala had on the detection of obstetric complications, the referral of patients with complications to the formal health care system, and, ultimately, those patients' utilization of essential obstetric care services.
METHODS:
Using a quasi-experimental design, a surveillance system of births was implemented to collect population-based information from 3,518 women between 1990 and 1993. All women were interviewed postpartum by physicians. There were three key independent variables in our study: 1) geographical area (intervention community and non-intervention community), 2) time in relation to the training intervention (before or after), and 3) presence or absence of a TBA at the time of the complication. The key dependent variables for women interviewed were 1) development of an obstetric complication, 2) detection of the problem by the TBA, 3) referral to a health facility, 4) compliance with referral, and 5) use of services.
RESULTS:
The incidence of postpartum complications decreased after the intervention, controlling for intervention community. On the other hand, after the intervention TBAs were less likely to recognize most maternal complications, and referral rates did not increase significantly. The likelihood of using health care services increased six-fold among women who were not attended by TBAs, and no increase was observed among those who were attended by TBAs.
CONCLUSION:
Training TBAs may have had a positive effect on the rate, detection, and referral of postpartum complications. However, the evidence is less convincing for overall increases in the detection of complications, in referral to the formal health care system, and in the utilization of essential obstetric services among women attended by TBAs.
