Intended for healthcare professionals

Head To Head

Are traditional birth attendants good for improving maternal and perinatal health? Yes

BMJ 2011; 342 doi: (Published 14 June 2011) Cite this as: BMJ 2011;342:d3310
  1. Joseph Ana, former commissioner for health, Cross River State, Nigeria
  1. 1Calabar, Nigeria
  1. jneana{at}

Joseph Ana argues that the shortage of skilled health workers means traditional birth attendants have a valuable place, but Kelsey A Harrison (doi:10.1136/bmj.d3308) believes they do more harm than good

The use of traditional birth attendants has generated a lot of heated debate over the decades, especially among health professionals. But the facts strongly support their use.

All over Africa, governments are introducing (or announcing) free healthcare for pregnant women and children under 5 years in the rush to meet the United Nation’s millennium development goals on reducing maternal and child mortality. Maternal mortality in sub-Saharan African countries varies widely, ranging from 800 to 2500 per 100 000 live births. Infant mortality ranges from 100 to 150 per 1000. Surely, all trained health hands must be on deck to deal with this emergency, including the hands of trained and monitored traditional birth attendants? Not to do so is unethical.

The causes of the poor health outcome for pregnant women and children are many, but the most important reason is the severe shortage of trained and skilled health workers. In some countries fewer than 20% of births are attended by skilled health workers.1 The problem is worsened by health workers being concentrated in cities and capitals when most of the developing world population resides in rural areas.

As governments have struggled to find staff to run their free healthcare schemes, managers of health facilities have tried local skill mix arrangements. In primary health centres community health workers conduct consultations and treatment, including deliveries. But unfortunately, these workers tend to shun home visits, preferring to practise like hospital based nurses and midwives. This lack of contact with the community leaves a vacuum that is filled by various groups, including traditional birth attendants, religious groups, herbalists, and native doctors.

Local value

Traditional birth attendants have no formal training and some are illiterate, but they are ubiquitous and accessible at all hours of the day and night. Every village has at least one, but most have several. Because traditional birth attendants are from the village, they understand the traditions, cultures, and languages of the women that they attend to, an obvious advantage during antenatal care and childbirth. They learn from their mothers or older women in the village, and therefore their practice is fraught with risks for the woman and newborn. However, in many places, they deliver more babies than the skilled midwives. And skilled midwives soon become deskilled because they stop regular delivery and concentrate more on administrative nursing duties as their careers progress. The village pregnant women and their families tend to trust traditional birth attendants and rely on their opinion.2

Some argue that traditional birth attendants should be prohibited from conducting any form of delivery, even when there is no skilled midwife around. Although WHO recognises that it is not ideal to allow untrained villagers to conduct deliveries, it points out that prohibiting or banning them is unwise and potentially dangerous. Maternal mortality rose after Malawi banned traditional birth attendants, who went underground and were lost to regulatory authority. This year, the country has reversed the ban and started training traditional birth attendants,3 and mortality seems to be falling again.

WHO suggests that until there are sufficient numbers of skilled midwives who are ready to live in the villages where their service is more in demand, the best policy is to identify traditional birth attendants, train them to recognise danger signs during pregnancy and labour, provide them with basic sterile delivery kits, and monitor and evaluate their practice.4 5 6

Benefits are proved

Such inclusive and pragmatic policy has reduced maternal mortality and perinatal and neonatal deaths and stillbirths.4 Trained attendants feel appreciated and follow protocols. In 2005, in Cross River State of Nigeria, the State Ministry of Health in collaboration with the Dr Bassey Kubiangha Education Foundation helped the traditional birth attendants to form an association.7 At the end of 2010 it had over 400 members. The association holds monthly meetings, at which skilled health practitioners are invited to lecture and train members. The association has also produced a training CD,7 which members are required to own, watch, and follow. Trained traditional birth attendants acknowledge their shortcomings and embrace change and new learning (even the illiterate ones). They submit to audit of their activities and help to monitor their fellow members.7

In Sierra Leone, the World Bank is funding a scheme that pays traditional birth attendants about £1 for every woman they bring to hospital. In one area, they were taken into the hospital with the pregnant women and invited to attend the caesarean sections to prove that there are other ways to safely deliver women.8

Where traditional birth attendants have been trained and integrated into existing health systems, they have not posed any threat to skilled midwives; rather, they have been seen as stakeholders in the effort to improve maternal health. They are very helpful as “counsellors,” comforting frightened rural women with complicated labour, often in the middle of night, in difficult to reach remote villages without electricity, water, or transport and no skilled health worker. In fact, it should be considered unethical to stop a lay person from assisting in such circumstances, especially one with many years’ experience.

As Shima Gyoh, professor of surgery at Benue State University, Nigeria, recently said, “It’s like forbidding a hospital attendant from applying first aid to victims of a road traffic accident, and insisting that they must wait for a doctor that might happen to come by.”9


Cite this as: BMJ 2011;342:d3310


  • Competing interests: Theauthor has completed the ICJME unified disclosure form at (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. JA is editor of BMJ West Africa.


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