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The vast majority of the 4 million neonatal and 500,000 maternal
deaths each year occur in resource-poor countries where traditional
birth attendants (TBAs) participate in 43% of deliveries. In rural
areas, the proportion is even higher.(1) Lack of affordable, easily
accessible health care facilities with well-trained and adequately
equipped staff are major reasons for women?s heavy reliance on TBAs. In
recent years, the worldwide shortage of midlevel health care workers in
resource-poor countries has become critical. Dr. Lee Jong-Wook,
director of the World Health Organization (WHO), has warned,
"There is a serious shortfall of health care workers in the parts
of the world most seriously affected by HIV and AIDS. Sub-Saharan
Africa has merely 600,000 health care workers for a population of 682
million people."(2) As a result of these shortages, policy makers
have long considered the use of trained birth attendants and community
health workers to bring the most basic antenatal, intrapartum, and
postnatal care to women who lack it. International recognition of the
importance of training TBAs was a central component of the Safe
Motherhood initiative organized by the WHO, the United Nations
Children's Fund, United Nations Population Fund, the World Bank, and
other international organizations.(3,4)
However, increased training and support of TBAs over several decades
did not decrease global maternal mortality (as measured in 1990). This
has been interpreted by many international organizations and national
health care programs as evidence that training TBAs is an ineffective
intervention. Others have countered that measures of maternal mortality
changed significantly during the observation period and that increased
training of TBAs was not accompanied by a comparable increase in access
to quality referral care.(4) The fact that there have been no
controlled studies to evaluate the impact of training TBAs on perinatal
and maternal mortality rates complicates discussions about
incorporating TBAs into maternal and child health (MCH)
programs.(1,4,5) These uncertainties have delayed widespread training
of TBAs and their inclusion into MCH programs in general and prevention
of mother-to-child transmission (PMTCT) programs in particular.
The study by Jokhio et al, abstracted above, therefore provides a
timely contribution to an important discussion. The article reports the
results of a randomized controlled trial conducted in 4 provinces in
Pakistan, a country with high perinatal and maternal mortality rates,
which are in the middle range of those found in other resource-poor
countries. Pregnant women in the study were recruited into either a
control arm or an intervention arm. Those in the intervention arm were
cared for by TBAs who received a 3-day training course on basic antenatal,
intrapartum, and postpartum care; clean delivery; care for the newborn;
and referral of women to health care facilities. The TBAs in the
intervention arm were supplied with and trained in the use of delivery
kits consisting of sterile disposable gloves, soap, gauze, cotton
balls, antiseptic solution, an umbilical cord clamp, and a surgical
blade. The TBAs in the control group did not receive any additional
training and were not supplied with delivery kits.
In Pakistan, a recent government initiative involves training
community care providers called Lady Health Workers to deliver many
primary health care services, including MCH services. The Lady Health
Workers generally are relatively well educated (most have approximately
10 years of schooling) but have no medical or nursing degree. In
addition, they receive 3 to 6 months of training in primary health care
and family planning. In the Jokhio study, these women supported TBAs in
the intervention arm and were responsible for data collection. The TBAs
were asked to visit each pregnant woman a minimum of 3 times during the
pregnancy--at 3, 6, and 9 months--to check for signs of complications
such as bleeding or eclampsia, and to encourage women with such signs
to seek emergency obstetrical care.
Researchers found a significant reduction in both perinatal and
maternal mortality in the intervention group: perinatal mortality in
the intervention group was 84.8 per 1,000 live births compared with 120
per 1,000 in the control group; the maternal mortality rate in the
intervention group was 260 per 100,000 pregnancies and 360 per 100,000
pregnancies in the control group. In addition, the intervention group
had significantly lower rates of puerperal sepsis and hemorrhage as a
complication of pregnancy. A similar but uncontrolled study in Nepal
also showed a reduction (30%) in neonatal mortality and a reduction
(78%) in maternal mortality.(6) The possession of the delivery kit
improved the standing of the TBAs among their clients and, because they
were delivered at primary care facilities, improved the linkage between
TBAs and these facilities.
An additional observation in the Jokhio study was that women in the
intervention group were more likely than those in the control group to
be referred to emergency obstetrical care for treatment. This is an
especially interesting observation, as many skilled and trained health
care workers argue that increasing training and responsibility of TBAs
will decrease referrals to more advanced health care facilities.
This is an important study, providing statistical evidence from a
controlled trial that TBAs can assume greater responsibility for MCH
services. Implementation of PMTCT activities often are hampered by a
lack of trained health care workers and by the fact that many women do
not give birth in health care facilities. As antiretroviral drugs for
PMTCT increasingly become available, the lack of trained health care
workers is emerging as the major obstacle to achieving PMTCT goals. The
results of this study, which demonstrate a substantial improvement in
maternal and perinatal outcomes using TBAs within existing
infrastructure, suggest that incorporating TBAs into PMTCT activities
should be considered. The study also points to the factors that may be
crucial for the success of TBA interventions--not only training and
providing supplies, but also close supervisory support from trained
community health workers and linkages to functional referral
facilities.
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