We read with interest the meta-analysis by Wilson et al.1 suggesting that traditional birth attendants (TBAs) is a cost effective resource for reducing perinatal and maternal mortality in developing countries. Even though these conclusions are in keeping with the WHO recommendation of implementing TBAS training programs in countries with low availability of obstetric care, still it seems to us that this meta-analysis does not allow any conclusion on the cost-benefit value of TBAs. Infact, none of the studies included in the meta-analysis allows to assess and discuss the long term effect of TBAs once the experimental period is over. In this regard, two studies have already documented that TBAS may have a long term positive effect on perinatal mortality only if a continuous retraining is granted2,3. Especially in low resource areas, preventive health interventions should be promoted only after assessment of their clinical and cost effectiveness in the course of time even beyond the experimental period.

References
1. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, MacArthur C, Coomarasamy A. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis. BMJ 2011;343:d7102.

2. Matendo R, Engmann C, Ditekemena J, Gado J, Tshefu A, Kinoshita R, McClure EM, Moore J, Wallace D, Carlo WA, Wright LL, Bose C. Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect. BMC Med. 2011;9:93.

3. Chen SC, Wang JD, Ward AL, Chan CC, Chen PC, Chiang HC, Kolola-Dzimadzi R, Nyasulu YM, Yu JK. The effectiveness of continuing training for traditional birth attendants on their reproductive health-care knowledge and performance. Midwifery. 2011;27(5):648-53.

Competing interests: None declared