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

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I appreciate the contribution of retired Professor Kelsey on the subject matter. However, his comment is not entirely correct and realistic in the light of the present day occurrences in some African countries. The various reports on the standard of living in African countries by WHO, World Bank, USAID and others still show indices of poverty, underdevelopment, deprivation, neglect of infrastructural development, inadequate attention and budget to the health and education sectors. More so, the issue of corruption in governance, instability due to ethnic, religious and political clashes in some Africa countries are not helping matters.In the light of all these, I will like to commend WHO initiative on better training and incorporation of the TBAs into the healthcare of developing nations towards achieving better health status for the populace.

Despite the increase urbanization of the African continent, majority of her people still leave in the rural areas, where good infrastructures such as good schools, well equipped hospitals, medical personnel, drugs and access to good road, availability of clean drinking water, reliable electricity supply are still dreams. The TBAs are therefore so entrenched in those societies where they live and are considered as a blessing as they are more readily available, with cheaper cost of services thou grossly ill equipped. As long as the government of such countries are not ready to make quick any meaningful progress towards the betterment of life for their people, the problem will persist and these TBAs, whether trained or untrained , equipped or ill equipped, will continue to be one of the ‘solutions’ to the maternal and infant healthcare need of those communities.

My suggestion is that there should be concerted effort towards compelling the various governments of African countries to embrace democracy, good governance and to fund infrastructural development in Africa. There should be strict penalties handed down to both the government officials and foreign countries of the world that encourage looting of African treasuries. Howbeit, the TBAs can also be modernized, with recruitment and training of younger generation in basic nursing care trainings (Community Health Officers) so that they can go back to those villages to replace the older untrained generation. By this, the various wrong practices will be eliminated, the maternal and infant healthcare need of the people will be met, and we will record a meaningful reduction in the mortality rates.

Competing interests: None declared

Funmileyi, Olubajo Awobajo, Lecturer and Researcher

University of Lagos

University of Lagos, Nigeria, Department of Physiology,

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The numerous efforts to train traditional birth attendants (TBAs) between 1970 and 1990 failed because, as Kelsey Harrison states correctly, TBAs could not "treat any of the principle causes of maternal death."(1) Curiously, both Harrison and Joseph Ana overlook the revolution in maternity care that is taking place with access to misoprostol. In every setting, postpartum haemorrhage (PPH) is the commonest single cause of maternal death and misoprostol is a powerful, heat stable, low cost, easy to use uterotonic.

No one disputes that in an ideal world all women would be attended by a skilled birth attendant within easy reach of emergency obstetric care. But 40 to 50 million do not live in an ideal world. In many low resource settings it is naive to believe that the number of women delivering without a skilled birth attendant is going to decline significantly in coming decades. Fortunately, there are a number of steps that can be taken to help such women, including the use of vouchers to reduce the cost of hospital delivery, training clinical officers to perform caesarean sections(2), and improving the pedagogic style of teaching TBAs(3). However, the most large scale, cost-effective strategy is to distribute misoprostol to control PPH, increase access to family planning and offer comprehensive abortion care(4). TBAs can responsibly and safely use misoprostol to treat PPH(5), or the drug can be given directly to the pregnant women to self-medicate immediately the baby is delivered(6).

As the highest maternal mortality ratios (MMR) are among women who deliver at home without a skilled birth attendant, it follows that some countries will not achieve the Millennium Developing Goal of reducing the MMR by two thirds between 1990 and 2015 without developing evidence- based policies to help these women, including the appropriate involvement of TBAs.

(1) Harrison KA, Ana J. Are traditional birth attendants good for improving maternal and perinatal health. BMJ. 2011. 342:1340 - 1343. BMJ 2011;342:d3310

(2) Prata N, Graff M, Graves S, Potts, M Avoidable maternal deaths: Three ways to help now. Global Public Health. 2009. 6: 575 - 587.

(3) Rowen T, Prata N, Passano P, Evaluation of a traditional birth attendant training programme in Bangladesh. Midwifery (in press).

(4) Prata N, Sreenivas A, Greig F, Walsh J, Potts M. Setting priorities for safe motherhood interventions in resource-scarce settings. Health Policy. 2010. 94:1-13.

(5) Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia f. Controlling postpartum haemorrhage after home births in Tanzania. Internat J Gynec Obstet. 2005. 90:51--55.

(6) Sanghvi H, Ansari N, Prata N, Gibson H, Ehsan A, Smith J. Prevention of postpartum haemorrhage at home birth in Afghanistan. Internat J Gynec and Obstet. 108: 276-281. 2010.

Competing interests: None declared

Malcolm Potts, Professor, Public Health

University of California, Berkeley, CA 94720 USA

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The debate on the role of traditional birth attendants in improving maternal and perinatal health(1) is germane particularly in the context of the millennium development goal of reducing child and maternal mortality by 2015. It refocuses on the measure of the proportion of deliveries assisted by skilled competent attendants. Uneducated mothers tended to have traditional birth attendants(2); care and delivery in medical institutions promote child survival and reduces the risk of maternal morbidity and mortality(3) With reported incidences of 6.9% HIV prevalence in the antenatal population(4) in parts of Nigeria, it is salutary to consider wider adoption of institutional delivery to maximise prevention of mother-to- child transmission and appropriate care for the HIV infected mother and her partner(s). This is a role that cannot be filled by traditional birth attendants ; it needs political will in implementation of the National Health Bill of Nigeria currently awaiting Presidential assent(5) and participation of the significant Nigerian healthcare workers in Diaspora in enabling and maintaining capacity for institutional delivery.

References

(1) Harrison KA. Are traditional birth attendants good for improving maternal and perinatal health? No. BMJ 2011; 342.

(2) Wanjira C, Mwangi M, Mathenge E, Mbugua G, Ng'ang'a Z. Delivery Practices and Associated Factors among Mothers Seeking Child Welfare Services in Selected Health Facilities in Nyandarua South District, Kenya. BMC Public Health 2011; 11:360.

(3) Pardeshi GS, Dalvi SS, Pergulwar CR, Gite RN, Wanje SD. Trends in choosing place of delivery and assistance during delivery in Nanded district, Maharashtra, India. J Health Popul Nutr 2011; 29(1):71-76.

(4) Okeudo C, B U E, Ojiyi EC. Maternal HIV positive sero-prevalence at delivery at a tertiary hospital in South-Eastern nigeria. Niger J Med 2010; 19(4):471-474.

(5) Hope for health in Nigeria. Lancet 2011; 377(9781):1891.

Competing interests: None declared

Tubonye C Harry, Honorary Senior Clinical Lecturer in Medicine

University of East Anglia, Norwich NR4 7TJ

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Author's reply

Gill CJ, Phiri-Mazala et al of Lufwanyama Neonatal Project took me to task for failing to cite their work. No offence was meant. I concentrated on Cochrane reviews because they are regarded as the highest level of evidence.

The rest of the reactions from Gill CJ et al illustrate two things: first is the failure to look far back into relevant past literature when there is the need to do so. The second is the failure to grasp what lies at the heart of the issue of the continuing high maternal mortality in parts of sub Saharan Africa including Nigeria.

It has been known for a long time that traditional birth attendants can be effective in contributing positively towards the improvement of neonatal outcome especially in neonatal tetanus prevention(1). But that is not the issue of my article. The thrust is on high maternal mortality and obstetric fistula. The persistence of high maternal mortality despite all our efforts is because we are looking at the wrong end of the problem. Dead and damaged mothers and infants make up a cluster of conditions resulting from one thing, very poor obstetric care. But then, very poor obstetric care is one result of the chaotic socio-economic and political system, which is the major underlying disease. It is this disease or chaos that must be treated. Pouring resources (projects) to a single symptom in this case high maternal mortality is pointless when the root causes lie elsewhere (1).

Examined in this way, the issue of traditional birth attendants in the scheme of things is scarcely relevant. We have to device strategies that will ensure the transformation of our society from one where scarcely anything works properly into one where most things work to the benefit of the society as a whole. Clearly, the solution is largely political. Of the strategies we need to device to deal with the underlying disease, the most fundamental is quality universal and basic formal education because of the social, economic, political, demographic, and health benefits it confers (2). Indeed, Lyndon Johnson, the former President of United States of America put it best and I quote "At the desk where I sit, I have learnt one great truth. The answer for all our national problems - the answer for all the problems of the world - come to a single word. That word is education". Instead of committing scarce resources towards the retraining of elderly illiterate women, we should concentrate on educating the young.

Meanwhile, in Nigeria, health wise, things have started moving in the right direction towards the setting up of a functioning health care system. This is through the passage of the country's National Health bill(3) and the establishment of Midwives Services Scheme (4), whereby thousands of trained midwives are being deployed in rural areas.

For the avoidance of doubt about my identity, I am a male Nigerian.

References.

1.Editorial. Why retrain traditional birth attendants? Lancet 1988; 321: 223-224.

2.Harrison KA. Sowing the seeds of safe motherhood in sub Saharan Africa. Adonis and Abbey Publishers London . First edition reprint pages 459-460.

3. Editorial. Hope for health in Nigeria. Lancet 2011; 377: 1891.

4.www.who.int/workforcealliance/forum/2011/hrhawards/en (cited 19 June 2011)

Competing interests: None declared

Kelsey A. Harrison, Retired Obstetrician and Gynaecologist

None

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Dr. Kelsey Harrison cites a 2007 Cochrane review in her criticism of the strategy of using traditional birth attendants (TBAs) to improve neonatal and maternal outcomes in low resource settings. As she notes, the evidence in the review was scant: studies were few and small, and limited by poor study designs. From this she concluded that TBAs are not useful and possibly harmful.

However, in response to this knowledge gap, we conducted a methodologically rigorous, randomized and controlled effectiveness trial: the Lufwanyama Neonatal Survival Project (LUNESP)(BMJ Feb 2011)(1), which Dr. Harrison did not cite. In LUNESP, from analysis of outcomes from over 3500 deliveries, we showed conclusively that training TBAs in techniques targeting the principle causes of neonatal mortality (asphyxia, hypothermia, sepsis) led to a highly statistically significant 45% reduction in all cause mortality - and a 63% reduction in birth asphyxia deaths. A meta-analysis is only as good as the studies it includes, and the Cochrane review from 2007 was prior to our study and that of Carlo et al, which showed that a package of essential newborn care interventions was highly effective in the hands of TBAs(2).

The truth is that similar arguments against TBAs have been voiced many times before. 'TBAs are too illiterate to be trained'; 'TBAs practice unorthodox medicine'; 'TBAs are just not effective'. Our experience in LUNESP showed otherwise. So why are these sentiments so persistent?

One of the most common arguments is that previously there was little published evidence that TBAs can meaningfully impact maternal and infant outcomes. While technically true, this is actually quite misleading since the range of services required of the TBAs was limited to supportive interventions, such as breast feeding counseling, antenatal support, and family planning counseling, none of which would be expected to register much of an effect in terms of maternal or infant morbidity/mortality. In other words, because so little had been asked of TBAs, it is no surprise that their effectiveness appeared so marginal. In LUNESP, by asking more of the TBAs we got more.

In fact, given that TBAs proved so remarkably effective in LUNESP at reducing neonatal mortality, we think the question now becomes: what more could TBAs do to care for mothers? For example, it would seem well within their capacity for TBAs to administer post-partum misoprostol, or antibiotics for suspected puerperal sepsis. Well-designed intervention studies could - and should - be conducted to address TBA's effectiveness in delivering these services.

We suspect that underlying the concerns voiced by Dr. Harrison is whether allowing TBAs to conduct home deliveries may discourage mothers from delivering at facilities. In our view this misses the point. For many mothers, delivering at a facility is simply not an option. TBAs exist because they fill an unmet public health need. For women who cannot access health facilities, their choices are to deliver with a trained traditional birth attendant, to deliver with an untrained birth attendant, or to deliver alone. To us, the choice seems clear.

1. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, Macleod WB, et al. Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. Bmj 2011;342:d346.

2. Carlo WA, Goudar SS, Jehan I, Chomba E, Tshefu A, Garces A, et al. Newborn-care training and perinatal mortality in developing countries. N Engl J Med 2010;362(7):614-23.

Competing interests: None declared

Christopher J Gill, Clinician researcher; Principle Investigator of LUNESP study

Anna B Knapp and Davidson H. Hamer

Boston University School of Public Health

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