Should Traditional Birth Attendants

Conduct Deliveries?Sheela Maru, MD

February 16th, 2011Resident Grand Rounds

Kutch, Gujarat, India

Kutch, Gujarat, India

Global Maternal Mortality Rates

Skilled Birth Attendance

WHO defines a skilled attendant as “an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”

“Traditional birth attendants, trained or not, are excluded from the category of skilled attendant at delivery”

Requires a high school education and family resources to get education; excludes most women in high-illiteracy areas

Skill Birth Attendance Worldwide

Rise and Fall of TBAs

1985

• Where is the M in MCH?

1987

• Safe Motherhood Conference

1990s

• Training TBAs to improve MCH

Rise and Fall of TBAs

1997

• Decade-long results disappointing; TBAs lose favor

2000

• 2000 Maternal Survival as MDG; focus on SBAs as a core strategy

2004

• WHO/FIGO/ICM issue formal statement against TBAs playing a role in deliveries

2010

• Despite policy shifts, TBAs continue to deliver >1/3 of deliveries worldwide

Should TBAs Conduct Deliveries?: Some Evidence

The Ghana Study

Cochrane Review (2007)

Most studies small with inconsistent/poor methods

Only 4 RCTs, 2 published (Pakistan and Malawi)

Conclusion: Not enough evidence to support or not

Pakistan Cluster RCT

Pakistan Cluster RCT

How to Gather the Evidence?

Rare outcome

Logistics

High variability across regions and cultures

Differences in infrastructure and referral systems

Should TBAs Conduct Deliveries?

YES: A Testable Hypothesis (contrary to what current global policy suggests)

Should TBAs Conduct Deliveries?

Exclusion of TBAs in birthing is probably unwarranted, and impractical

TBAs not effective without obstetric referral systems

Important advocates within their home communities

BUT: we have very little guidance as to how to utilize them effectively

Referral

Services

TBAs

community

IT’S A HEALTH SYSTEMS PROBLEM

Social SystemsHealth Systems

Need to conceptualize building health systems not upon a tabla rasa but within an existing, rich, and resourceful social fabric. But we still need DATA!

References

Proportion of births attended by a skilled health worker – 2008 updates. Geneva, World Health Organization, 2008 (http://www.who.int/reproductive_health/global_monitoring/data.html).

Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, World Health Organization, 2004 (http://www.who.int/making_pregnancy_safer/documents/92415916692/en/index.html).

Making Pregnancy Safer: The Critical Role of the Skilled Birth Attendant. http://whqlibdoc.who.int/publications/2004/9241591692.pdf

Smith, J. et al. The impact of traditional birth attendant training on delivery complications in Ghana. Health Policy and Planning, 15 (3) 326-331. Oxford University Press, 2000.

Jokhio, A. etal. An Intervention involving traditional birth attenants and perinatal and maternal mortality in Pakistan. New England Journal of Medicine, 352; 2005; 2091-9.

Starrs, AM, et al. Safe motherhood initiative: 20 years and counting. Lancet. 2006 Sep 30;368(9542):1130-2.

Acknowledgements

Dr. Eckardt

Members and leadership of Kutch Mahila Vikas Sangathan

Maru family