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The vast majority of the 4 million neonatal and 500,000 maternal deaths each year occur in resource-poor countries where traditional birth attendants (TBAs) participate in 43% of deliveries. In rural areas, the proportion is even higher.(1) Lack of affordable, easily accessible health care facilities with well-trained and adequately equipped staff are major reasons for women?s heavy reliance on TBAs. In recent years, the worldwide shortage of midlevel health care workers in resource-poor countries has become critical. Dr. Lee Jong-Wook, director of the World Health Organization (WHO), has warned, "There is a serious shortfall of health care workers in the parts of the world most seriously affected by HIV and AIDS. Sub-Saharan Africa has merely 600,000 health care workers for a population of 682 million people."(2) As a result of these shortages, policy makers have long considered the use of trained birth attendants and community health workers to bring the most basic antenatal, intrapartum, and postnatal care to women who lack it. International recognition of the importance of training TBAs was a central component of the Safe Motherhood initiative organized by the WHO, the United Nations Children's Fund, United Nations Population Fund, the World Bank, and other international organizations.(3,4)
However, increased training and support of TBAs over several decades did not decrease global maternal mortality (as measured in 1990). This has been interpreted by many international organizations and national health care programs as evidence that training TBAs is an ineffective intervention. Others have countered that measures of maternal mortality changed significantly during the observation period and that increased training of TBAs was not accompanied by a comparable increase in access to quality referral care.(4) The fact that there have been no controlled studies to evaluate the impact of training TBAs on perinatal and maternal mortality rates complicates discussions about incorporating TBAs into maternal and child health (MCH) programs.(1,4,5) These uncertainties have delayed widespread training of TBAs and their inclusion into MCH programs in general and prevention of mother-to-child transmission (PMTCT) programs in particular.
The study by Jokhio et al, abstracted above, therefore provides a timely contribution to an important discussion. The article reports the results of a randomized controlled trial conducted in 4 provinces in Pakistan, a country with high perinatal and maternal mortality rates, which are in the middle range of those found in other resource-poor countries. Pregnant women in the study were recruited into either a control arm or an intervention arm. Those in the intervention arm were cared for by TBAs who received a 3-day training course on basic antenatal, intrapartum, and postpartum care; clean delivery; care for the newborn; and referral of women to health care facilities. The TBAs in the intervention arm were supplied with and trained in the use of delivery kits consisting of sterile disposable gloves, soap, gauze, cotton balls, antiseptic solution, an umbilical cord clamp, and a surgical blade. The TBAs in the control group did not receive any additional training and were not supplied with delivery kits.
In Pakistan, a recent government initiative involves training community care providers called Lady Health Workers to deliver many primary health care services, including MCH services. The Lady Health Workers generally are relatively well educated (most have approximately 10 years of schooling) but have no medical or nursing degree. In addition, they receive 3 to 6 months of training in primary health care and family planning. In the Jokhio study, these women supported TBAs in the intervention arm and were responsible for data collection. The TBAs were asked to visit each pregnant woman a minimum of 3 times during the pregnancy--at 3, 6, and 9 months--to check for signs of complications such as bleeding or eclampsia, and to encourage women with such signs to seek emergency obstetrical care.
Researchers found a significant reduction in both perinatal and maternal mortality in the intervention group: perinatal mortality in the intervention group was 84.8 per 1,000 live births compared with 120 per 1,000 in the control group; the maternal mortality rate in the intervention group was 260 per 100,000 pregnancies and 360 per 100,000 pregnancies in the control group. In addition, the intervention group had significantly lower rates of puerperal sepsis and hemorrhage as a complication of pregnancy. A similar but uncontrolled study in Nepal also showed a reduction (30%) in neonatal mortality and a reduction (78%) in maternal mortality.(6) The possession of the delivery kit improved the standing of the TBAs among their clients and, because they were delivered at primary care facilities, improved the linkage between TBAs and these facilities.
An additional observation in the Jokhio study was that women in the intervention group were more likely than those in the control group to be referred to emergency obstetrical care for treatment. This is an especially interesting observation, as many skilled and trained health care workers argue that increasing training and responsibility of TBAs will decrease referrals to more advanced health care facilities.
This is an important study, providing statistical evidence from a controlled trial that TBAs can assume greater responsibility for MCH services. Implementation of PMTCT activities often are hampered by a lack of trained health care workers and by the fact that many women do not give birth in health care facilities. As antiretroviral drugs for PMTCT increasingly become available, the lack of trained health care workers is emerging as the major obstacle to achieving PMTCT goals. The results of this study, which demonstrate a substantial improvement in maternal and perinatal outcomes using TBAs within existing infrastructure, suggest that incorporating TBAs into PMTCT activities should be considered. The study also points to the factors that may be crucial for the success of TBA interventions--not only training and providing supplies, but also close supervisory support from trained community health workers and linkages to functional referral facilities.
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