Head To Head

Are traditional birth attendants good for improving maternal and perinatal health? No

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d3308 (Published 14 June 2011) Cite this as: BMJ 2011;342:d3308
  1. Kelsey A Harrison, retired gynaecologist and obstetrician
  1. 1Tuusula, Finland
  1. kelseyharrison50{at}gmail.com

Joseph Ana (doi:10.1136/bmj.d3310) argues that the shortage of skilled health workers means traditional birth attendants have a valuable place, but Kelsey A Harrison believes they do more harm than good

The concept of training traditional birth attendants to improve maternal and perinatal health in developing countries began over 100 years ago and was promoted by the World Health Organization, United Nations, and donor agencies during the 1970s-1990s as a strategy to reduce maternal and neonatal mortality. Since then, there have been repeated assessments to ascertain whether the strategy works. The latest Cochrane review based on four studies, including one from Malawi, concluded: “The potential of TBA [traditional birth attendant] training to decrease newborn death is promising, when combined with improved health services. The number of studies however, is insufficient to provide the necessary evidence for TBA training effectiveness.”1

Closer examination of the review shows that this conclusion is not fully supported by the results of the studies, and that the reverse might indeed be the case. Small sample size and the impossibility of pooling together the results of all four studies due to various weaknesses were important problems. But particularly telling were statements by the reviewers and researchers in referring to individual or groups of studies: “The observed improvement in the ability to correctly identify and to refer with the selected complication in a timely manner could not be attributed to TBA training,” “30% of TBA were untrainable,” “the accuracy of blood loss measurements by TBAs who were mostly illiterate or innumerate may be doubted.”

Fundamental change

The bedrock for achieving better maternal and perinatal health is a functioning healthcare service. But what constitutes a functioning health service? In the current sub-Saharan African context (high maternal and perinatal mortality and morbidity and high prevalences of obstetric fistula, and life threatening complications such as extreme anaemia, eclampsia, haemorrhage, puerperal infections and obstructed labour), and from my perspective as an obstetrician who worked in Nigeria for 38 years, a functional health service must be one that is able to reduce the maternal mortality rate to 40–200 per 100 000 total births and eliminate obstetric fistula. This figure for maternal mortality is what was achieved in a subgroup of Zaria women who received antenatal care and were healthy during pregnancy but not necessarily during labour2 and would meet the millennium development goal of a 75% reduction in the estimated maternal mortality in Nigeria from that in 1990 (870/100  000 live births).3

To achieve this general living standards must be good—nutrition and protection against childhood infections are important. Furthermore, all pregnant women must receive basic but professional and appropriate antenatal care. Measures must be put in place to ensure that pregnant women who develop life threatening complications get effective treatment, including operative intervention if required, before it is too late. Finally, records must be kept and reliable and compulsory registration of all births and deaths must be instituted. Success depends on overcoming the all-pervading chaos in people’s daily lives and inadequacies in the infrastructure.

What is the place of traditional birth attendants in this scheme of things? I believe they have little or no place. They are too old and therefore too set in their ways to adapt to modern healthcare methods. They are mainly responsible for the unbooked emergencies that have a high death rate, 2900 per 100 000 births in Zaria.2 They cannot treat any of the principal causes of maternal death. As most are illiterate, they cannot keep reliable records of their activities, and without such records, audit becomes impossible. When literacy becomes widespread, traditional birth attendants disappear. It is therefore difficult to justify investing in both public education and traditional birth attendants.4 5 6 Their use is a distraction in that it seeks to manage extreme poverty instead of working to eliminate it.

Most African countries are multiethnic—there are over 250 ethnic groups in Nigeria alone, each having its own language and culture. Implementation of a national policy requires that all those involved understand the national language—English in the case of Nigeria—which most traditional birth attendants cannot. From an equally practical standpoint, we should be worried by the fact that once something substandard gets entrenched it becomes difficult to replace it with something better in future.

I reiterate that in trying to reduce high maternal mortality, we need to treat the obstetric conditions and at the same time endeavour to remove the non-obstetric conditions especially mass illiteracy that create the unbooked emergencies.2

Initiatives that exclude traditional birth attendants have been shown to improve maternal health. The first was in the 1940s when maternal mortality in the Diocese of Niger in eastern Nigeria was reduced to less than 50 deaths per 100 000 live births.7 The second was in the 1970s when obstetric fistula was eliminated in the Zaria area.8

Within sub-Saharan Africa, where the middle class is already reaching 30% of the population9 there is growing realisation that things have got to change. In Nigeria, for example, people are seriously questioning why politicians send so called important people for treatment overseas instead of providing proper facilities locally for everybody.10 In time, these aspirations will be difficult to ignore. It stands to reason that decisions must be made with an eye to the future and not just with a mind for the present. Traditional birth attendants have no place in this future. Better management of the region’s abundant natural resources combined with a change in attitude towards the poor and women—helping rather than exploiting them—will surely work wonders.


Cite this as: BMJ 2011;342:d3308


  • Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.