Effect of Shifting Policies on Traditional Birth Attendant Training

Skills and knowledge of midwives at free-standing birth centres and home birth: A meta-ethnography

PROBLEM

When midwives offer birth assistance at home birth and free-standing birth centres, they must adapt their skill set. Currently, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings.

BACKGROUND

Midwifery care at home birth and in free-standing birth centres requires context specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings.

AIM

To synthesise existing qualitative research that describes the skills and knowledge of certified midwives at home births and free-standing birth centres.

STUDY DESIGN

We conducted a systematic review that included searches on 5 databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the data set, and a line of argument synthesis was developed.

RESULTS

The search identified 13 papers, twelve papers from seven countries, and one paper that included five Nordic countries. Three overarching themes and seven sub-themes were developed: 'Building trustworthy connections,' 'Midwife as instrument,' and 'Creating an environment conducive to birth.'

CONCLUSION

The findings highlight that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centres. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of labouring women. Further research is needed to elicit how midwives develop these proficiencies.

Safe birth in cultural safety in southern Mexico: a pragmatic non-inferiority cluster-randomised controlled trial

BACKGROUND

Available research on the contribution of traditional midwifery to safe motherhood focuses on retraining and redefining traditional midwives, assuming cultural prominence of Western ways. Our objective was to test if supporting traditional midwives on their own terms increases cultural safety (respect of Indigenous traditions) without worsening maternal health outcomes.

METHODS

Pragmatic parallel-group cluster-randomised controlled non-inferiority trial in four municipalities in Guerrero State, southern Mexico, with Nahua, Na savi, Me'phaa and Nancue ñomndaa Indigenous groups. The study included all pregnant women in 80 communities and 30 traditional midwives in 40 intervention communities. Between July 2015 and April 2017, traditional midwives and their apprentices received a monthly stipend and support from a trained intercultural broker, and local official health personnel attended a workshop for improving attitudes towards traditional midwifery. Forty communities in two control municipalities continued with usual health services. Trained Indigenous female interviewers administered a baseline and follow-up household survey, interviewing all women who reported pregnancy or childbirth in all involved municipalities since January 2016. Primary outcomes included childbirth and neonatal complications, perinatal deaths, and postnatal complications, and secondary outcomes were traditional childbirth (at home, in vertical position, with traditional midwife and family), access and experience in Western healthcare, food intake, reduction of heavy work, and cost of health care.

RESULTS

Among 872 completed pregnancies, women in intervention communities had lower rates of primary outcomes (perinatal deaths or childbirth or neonatal complications) (RD -0.06 95%CI - 0.09 to - 0.02) and reported more traditional childbirths (RD 0.10 95%CI 0.02 to 0.18). Among institutional childbirths, women from intervention communities reported more traditional management of placenta (RD 0.34 95%CI 0.21 to 0.48) but also more non-traditional cold-water baths (RD 0.10 95%CI 0.02 to 0.19). Among home-based childbirths, women from intervention communities had fewer postpartum complications (RD -0.12 95%CI - 0.27 to 0.01).

CONCLUSIONS

Supporting traditional midwifery increased culturally safe childbirth without worsening health outcomes. The fixed population size restricted our confidence for inference of non-inferiority for mortality outcomes. Traditional midwifery could contribute to safer birth among Indigenous communities if, instead of attempting to replace traditional practices, health authorities promoted intercultural dialogue.

TRIAL REGISTRATION

Retrospectively registered ISRCTN12397283 . Trial status: concluded.

Maternal health and Indigenous traditional midwives in southern Mexico: contextualisation of a scoping review

OBJECTIVES

Collate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero.

DESIGN

Scoping review and stakeholder fuzzy cognitive mapping.

INCLUSION AND EXCLUSION

The scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico.

RESULTS

The initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature's map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases.

CONCLUSIONS

The literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

BACKGROUND

Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs).

METHODS

A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.

RESULTS

Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.

CONCLUSIONS

We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

Factors influencing maternal health in indigenous communities with presence of traditional midwifery in the Americas: protocol for a scoping review

INTRODUCTION

Indigenous mothers often receive culturally unsafe services that do not fully respond to their needs. The objective of this scoping review is to collate and assess evidence that identifies factors, including the role and influence of traditional midwives, that affect maternal health in indigenous communities in the Americas. The results will map Western perspectives reflected in published and unpublished literature to indicate the complex network of factors that influence maternal outcomes. These maps will allow for comparison with local stakeholder knowledge and discussion to identify what needs to change to promote culturally safe care.

METHODS AND ANALYSIS

A librarian will search studies with iterative and documented adjustments in CINAHL, Scopus, Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE, Embase and Google Scholar without any time restrictions, and use Google search engine for grey literature. Included studies will be empirical (quantitative, qualitative or mixed); address maternal health issues among indigenous communities in the Americas; and report on the role or influence of traditional midwives. Two researchers will independently screen and blindly select the included studies. The quality assessment of included manuscripts will rely on the Mixed Methods Appraisal Tool (MMAT). Two independent researchers will extract data on factors promoting or reducing maternal health in indigenous communities, including the role or influence of traditional midwives. Fuzzy cognitive mapping will summarise the findings as a list of relationships between identified factors and outcomes with weights indicating strength of the relationship and the evidence supporting this.

ETHICS AND DISSEMINATION

This review is part of a proposal approved by the ethics committees at McGill University and the Centro de Investigación de Enfermedades Tropicales in Guerrero. Participating indigenous communities in Guerrero State approved the study in 2015. The results of the scoping review will contribute to the field of cultural safety and intercultural dialogue for the promotion of maternal health in indigenous communities.

Traditional birth attendants' roles and homebirth choices in Ethiopia: A qualitative study

BACKGROUND

In Ethiopia, it is encouraged that labour and delivery care are performed under the observation of skilled/trained midwifery or medical professionals. However, 70% of all births occur outside the healthcare system under the care of unskilled birth attendants, family members, or without any assistance at all.

OBJECTIVE

This study aimed to assess the reasons for choosing homebirth and the role of traditional birth attendants in Arba Minch Health and Demographic Surveillance Site.

METHOD

A qualitative, exploratory study was carried out between May and June 2017. Twenty-nine semi-structured interviews were conducted with various respondent groups such as traditional birth attendants, pregnant women, skilled birth attendants, and health extension workers. Data were transcribed and for analysis, structured as per the participants' responses, sorted and categorized as per the topic guide, and presented in narrative form.

FINDINGS

The study revealed that traditional birth attendants are actively engaged in assisting homebirths in the selected area. It was also found that many women still prefer traditional birth attendants for childbirth assistance. Reasons for choosing homebirth included lack of transport to health care facilities, distance to health care facilities, lack of respectful care at health care facilities, and the friendliness of traditional birth attendants. Lack of formal partnerships between traditional birth attendants and the health system was also observed.

CONCLUSIONS

There is a need to incorporate traditional birth attendants as a link between healthcare facilities and pregnant women; thereby, improving respectful care at the healthcare facilities.

Socio-cultural contextual factors that contribute to the uptake of a mobile health intervention to enhance maternal health care in rural Senegal

BACKGROUND

Although considerable progress has been made in reducing maternal mortality over the past 25 years in Senegal, the national maternal mortality ratio (MMR), at 315 deaths per 100,000 live births, is still unacceptably high. In recent years a mobile health (mHealth) intervention to enhance maternal health care has been introduced in rural and remote areas of the country. CommCare is an application that runs on cell phones distributed to community health workers known as matrones who enroll and track women throughout pregnancy, birth and the post-partum, offering health information, moral support, appointment reminders, and referrals to formal health care providers.

METHODS

An ethnographic study of the CommCare intervention and the larger maternal health program into which it fits was conducted in order to identify key social and cultural contextual factors that contribute to the uptake and functioning of this mHealth intervention in Senegal. Ethnographic methods and semi-structured interviews were used with participants drawn from four categories: NGO field staff (n = 16), trained health care providers (including physicians, nurses, and midwives) (n = 19), community level health care providers (n = 13); and women belonging to a community intervention known as the Care Group (n = 14). Data were analyzed using interpretive analysis informed by critical medical anthropology theory.

RESULTS

The study identified five socio-cultural factors that work in concert to encourage the uptake and use of CommCare: convening women in the community Care Group; a cultural mechanism for enabling pregnancy disclosure; constituting authoritative knowledge amongst women; harnessing the roles of older women; and adding value to community health worker roles. We argue that, while CommCare is a powerful tool of information, clinical support, surveillance, and data collection, it is also a social technology that connects and motivates people, transforming relationships in ways that can optimize its potential to improve maternal health care.

CONCLUSIONS

In Senegal, mHealth has the potential not only to bridge the gaps of distance and expertise, but to engage local people productively in the goal of enhancing maternal health care. Successful mHealth interventions do not work as 'magic bullets' but are part of 'assemblages' - people and things that are brought together to accomplish particular goals. Attention to the social and cultural elements of the global health assemblage within which CommCare functions is critically important to understand and develop this mHealth technology to its full potential.

A qualitative exploration of the sociocultural determinants of exclusive breastfeeding practices among rural mothers, North West Nigeria

Background

Suboptimal breastfeeding is responsible for 96% of deaths among children under 12 months of age in developing countries. However, the exclusive breastfeeding rate in Nigeria from birth to 6 months is just 23%. The study explored the sociocultural factors that influence exclusive breastfeeding among rural mothers.

Methods

The social constructionism-interpretivist epistemological approach underpinned this qualitative study. Semi-structured interviews were conducted with 20 mothers aged 18–39 years, purposefully sampled from two Local Government Areas in Katsina State, Nigeria. Thematic content approach was utilised for analysis.

Results

Three major themes were developed from the analysis: (1) Breastfeeding initiation – the determinants of how soon a mother initiated breastfeeding included traditional new-born care practices, the birth attendant and place of delivery. (2) Exclusive breastfeeding - motivation to sustain exclusive breastfeeding was influenced by the conflict between the obligation to perform traditional rites, the mother’s awareness and family support. (3) Decision-making about infant feeding – the husband, grandmother, traditional birth attendant and the health workers all influenced participants’ decisions around infant feeding. Despite awareness of the benefits of exclusive breastfeeding among most mothers interviewed, they expressed concerns that they may not win their family’s support if their views were contrary to those held by other family members.

Conclusion

While mothers have limited powers to make decisions, the key role that grandmothers and husbands have in decisions about breastfeeding demonstrates the need to engage the support of partners and relatives through community-driven policies and integrated interventions that address social and cultural barriers throughout the prenatal and postnatal period.

Increasing health facility deliveries in Cambodia and its influence on child health

Background

A growing number of women in Cambodia are seeking support from health facilities during delivery, up from 8% in 2000 to 82% in 2014. This growth may be attributed to increased national level attention to incentivize hospital births and reduce potential barriers. This paper address three related questions regarding the impact of increased utilization of health care in Cambodia. First, did increasing health facility deliveries occur most among disadvantaged women? Second, as health facility utilization increased, did the benefit of delivery location on child health outcomes weaken? Finally, did socioeconomic disparities in child outcomes decline as a result of increased health facility deliveries?

Methods

Data is from the 2010 and 2014 Cambodian Demographic and health surveys. Regression models include logistic regression to predict utilization of a health facility, linear regression to predict child nutritional status and Cox regression to measure child survival. Propensity score matching was used to account for selectivity.

Results

Analysis shows that health facility delivery is associated with better nutritional status and survival and the effectiveness of a health center delivery remains with this rapidly increasing care. However, the largest increases in delivery at a health facility did not occur among less educated, less wealthy, and rural Cambodian women, and inequalities in child health outcomes remain.

Conclusions

Cambodian women have participated in a rapid increase in health center deliveries and those health facility deliveries remain beneficial for future child outcomes. However, initiatives to increase care are not addressing inequity in access to care among disadvantaged women. Additionally, disparities in children’s health outcomes remain, suggesting that health facility births are not sufficient in reducing disparities among children of disadvantaged mothers. Moving forward, current initiatives are rapidly increasing facility deliveries and maintaining their efficacy, but further efforts need to be placed on targeting disadvantaged women and their children.

Midwives' views of traditional birth attendants within formal healthcare in Nigeria

BACKGROUND

Discourses around the journey to motherhood in many poorly-resourced countries, particularly in the sub-Saharan African region, with no link to death and danger are limited. The custodians of traditional practices - the traditional birth attendants - are often blamed for the high maternal deaths in this region. Conventional institutional and international thinking about traditional birth attendants is that they are dangerous and therefore should no longer be allowed to practice.

AIM

To explore midwives' views of traditional birth attendants' place within formal healthcare settings in Nigeria.

METHODS

Hermeneutic phenomenological and poststructural feminist approaches were used. Seven midwives volunteered for semi-structured individual face to face interviews.

FINDINGS

The responses of the midwives were diverse and conflicting. Some midwives believe that the traditional birth attendants should be banned, arguing that they are responsible for low uptake of hospital-based maternity care by women which in turn leads to an increase in maternal deaths. Contrastingly, other midwives expressed a view that the traditional birth attendants 'cannot be phased out' due to their valid contributions, particularly in the rural areas where access to formal maternity care is limited by intractable structural problems.

CONCLUSION

Policy makers need to reconsider the role of traditional birth attendants. This should involve not only their integration into formal healthcare to work alongside formally trained maternity care providers, but also fostering a healthcare atmosphere where respect and recognition of each practitioner's skill is paramount.

Regulating Traditional Mexican Midwifery: Practices of Control, Strategies of Resistance

The institutionalization of Mexican midwifery has a long history. Despite global recommendations moving away from training traditional midwives, training courses still continue. Based on fieldwork in the State of Chiapas, I argue that while ongoing trainings offered to traditional midwives in Mexico aim at teaching them best practices, they also limit midwives' autonomy and keep poor women's reproductive behaviors under control. I demonstrate how midwives and medical personnel mobilize discourses of reproductive risk, women's rights and indigenous cultural rights to reinforce or contest mechanisms of reproductive governance.

Safe Birth and Cultural Safety in southern Mexico: study protocol for a randomised controlled trial

BACKGROUND

Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes. Living as they do at the very periphery of the Western health system, they often receive low-quality care from health services that lack human and financial resources. Traditional health systems remain active in indigenous communities where traditional midwives accompany women through motherhood. Several interventions have explored training birth attendants in Western birthing skills, but little research has focussed on supporting traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous groups and measures its impact on maternal health outcomes.

METHODS

The study includes four indigenous populations in the State of Guerrero (Nahua, Na savi/Mixteco, Me'phaa/Tlapaneco and Nancue ñomndaa/Amuzgo), covering approximately 8000 households. A parallel-group cluster-randomised controlled trial will compare communities receiving usual care with communities where traditional midwives received support in addition to the usual care. The intervention was defined in collaboration with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health staff in the intervention municipalities will participate in workshops to improve understanding and attitudes towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with traditional cultural activities (secondary outcomes). The project has ethical approval from the participating communities and the Universidad Autónoma de Guerrero.

DISCUSSION

Indigenous women at the periphery of Western health services do not benefit fully from the attenuated services which erode their own healthcare traditions. Western health service providers in indigenous communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of healthcare for indigenous families.

TRIAL REGISTRATION

ISRCTN12397283 . Retrospectively registered on 6 December 2016.

The role, practice and training of unregulated birth workers in Australia: A mixed methods study

BACKGROUND

In Australia, the provision of homebirth services by unregulated birthworkers (doulas, ex-registered midwives, traditional midwives and lay workers) has increased. Accessing a homebirth with a registered midwife via mainstream services is limited. Concern is growing that new legislation aimed at prohibiting unregulated birthworkers practice may result in homebirth going underground.

AIM

To explore the role, practice and training of unregulated birthworkers in Australian and establish what they would do if legislation prohibited their practice.

METHODS

This study used a mixed methods sequential exploratory design to explore the practice, training and role of unregulated birthworkers in Australia. In phase one, four unregulated birthworkers were interviewed in-depth and the findings informed the development of a survey in phase two. This was distributed nationally through two consumer websites, social media, Facebook and email. Data from both phases were integrated.

FINDINGS

Unregulated birthworkers in Australia provide homebirth services to women with high and low-risk pregnancies when this choice is unavailable or unacceptable within mainstream services. They operate covertly to protect their practice and avoid the scrutiny of authorities. Unregulated birthworkers can be experienced and trained in childbirth care and practice, much like a midwife working within a holistic paradigm of care.

CONCLUSION

Unregulated birthworkers believe they provide women with the homebirth service they want but cannot access. Mainstream service providers need to listen to consumer criticisms, as women seek answers outside the system. Change is needed to improve and align services with women's expectations of homebirth.

Changing the role of traditional birth attendants in Yirol West County, South Sudan

Effective from May 2014, community-based traditional birth attendants (TBAs) in Yirol West County, South Sudan, were directed to start referring all women in labour to health facilities for childbirth instead of assisting them in the villages. This study aimed to understand the degree of integration of TBAs in the health system, to reveal the factors influencing the integration, and to explore the perceived solutions to the challenges faced by TBAs. A qualitative study utilising 11 focus group discussions with TBAs, 6 focus group discussions with women, and 18 key informant interviews with members of village health committees, staff of health facilities, and staff of the County Health Department was conducted. Data were analysed using qualitative content analysis. The study found that many TBAs were referring women to health facilities for delivery, but some were still attending to deliveries at home. Facilitators of the adoption of the new role by TBAs were: acceptance of the new TBAs’ role by the community, women and TBAs, perceptions about institutional childbirth and risks of home childbirth, personal commitment and motivation by some TBAs, a good working relationship between community-based TBAs and health facility staff, availability of incentives for women at health facilities, and training of TBAs. Challenges of integrating TBAs in the health system included, among others, communication problems between TBAs and health care facilities, delays in seeking care by women, insecurity, lack of materials and supplies for TBAs, health system constraints, insufficient incentives for TBAs, long distances to health facilities and transportation problems. This study has revealed encouraging developments in TBAs’ integration in the formal health system in Yirol West. However, there is need to address the challenges faced by TBAs in assuming their new role in order to sustain the integration.

Reinforcing marginality? Maternal health interventions in rural Nicaragua

To achieve Millennium Development Goal 5 on maternal health, many countries have focused on marginalized women who lack access to care. Promoting facility-based deliveries to ensure skilled birth attendance and emergency obstetric care has become a main measure for preventing maternal deaths, so women who opt for home births are often considered 'marginal' and in need of targeted intervention. Drawing upon ethnographic data from Nicaragua, this paper critically examines the concept of marginality in the context of official efforts to increase institutional delivery amongst the rural poor, and discusses lack of access to health services among women living in peripheral areas as a process of marginalization. The promotion of facility birth as the new norm, in turn, generates a process of 're-marginalization', whereby public health officials morally disapprove of women who give birth at home, viewing them as non-compliers and a problem to the system. In rural Nicaragua, there is a discrepancy between the public health norm and women's own preferences and desires for home birth. These women live at the margins also in spatial and societal terms, and must relate to a health system they find incapable of providing good, appropriate care. Strong public pressure for institutional delivery makes them feel distressed and pressured. Paradoxically then, the aim of including marginal groups in maternal health programmes engenders resistance to facility birth.

Utilizing Task Shifting to Increase Access to Maternal and Infant Health Interventions: A Case Study of Midwives for Haiti

The shortage of health workers worldwide has been identified as a barrier to achieving targeted health goals. Task shifting has been recommended by the World Health Organization to increase access to trained and skilled birth attendants. One example of task shifting is the use of cadres of health care workers, such as nurses and auxiliary nurse-midwives, who can successfully deliver skilled care to women and infants in low-resource areas where women would otherwise lack access to critical health interventions during the childbearing years. Midwives for Haiti is an organization demonstrating the use of task shifting in its education program for auxiliary midwives. Graduates of the Midwives for Haiti education program are employed and working with women in hospitals, birth centers, and clinics across Haiti. This article reviews the Midwives for Haiti education program and presents successes and challenges in task shifting as a strategy to increase access to skilled maternal and newborn care and to meet international health goals to reduce maternal and infant mortality in a low-resource country.

Village midwives and their changing roles in Brunei Darussalam: A qualitative study

BACKGROUND

There are lay midwives worldwide, interchangeably and universally called traditional birth attendants or traditional midwives by organisations such as the World Health Organization and the International Confederation of Midwives.

AIM

This study aimed to explore the history of lay midwives (village midwives) in Brunei, describe the evolution from their previous to current roles and determine if they are still needed by women today.

METHODS

This qualitative, descriptive study included in-depth, semi-structured interviews with eight women who had received care from village midwives. Data analysis was based on the principles underpinning thematic analysis and used a constant comparative method.

FINDINGS

Village midwives have been popular in Brunei since the 1900s, with their major role being to assist women with childbirth. However, since the 1960s, their roles and practices have changed to focus on pre-conception, antenatal, postnatal and women's general healthcare. Traditional practices were influenced by religion, culture and the social context of and within Brunei.

DISCUSSION

The major changes in village midwives' roles and practices resulted from the enforcement of the Brunei Midwives' Act in 1956. Village midwives' traditional practices became juxtaposed with modern complementary alternative medicine practices, and they began charging a fee for their services.

CONCLUSION

Brunei village midwives are trusted by women, and their practices may still be widely accepted in Brunei. Further research is necessary to confirm their existence, determine the detailed scope and appropriateness of their practices and verify the feasibility of them working together with healthcare professionals.

Towards universal access to skilled birth attendance: the process of transforming the role of traditional birth attendants in Rural China

BACKGROUND

Institution-based childbirth, with the ultimate goal of universal access to skilled birth attendance (SBA), has been selected as a key strategy to reduce the maternal mortality rate in many developing countries. However, the question of how to engage traditional birth attendants (TBAs) in the advocacy campaign for SBA poses a number of challenges. This paper aims to demonstrate how TBAs in rural regions of China have been integrated into the health system under a policy of institutional delivery.

METHODS

Research was conducted through literature and document reviews and individual in-depth interviews with stakeholders of the safe motherhood program in rural Guangxi Zhuang Autonomous Region, China. A total of 33 individual interviews were conducted with regional and local politicians, policy makers, health managers, health providers, civil society members, village cadres for women affairs, former TBAs, village maternal health workers, mothers and their mother-in-laws.

RESULTS

Since 1998, TBA's traditional role of providing in-home care during childbirth has been restructured and their social role has been strengthened in rural Guangxi. TBAs were redesigned to function as the linkage between women and the health system. A new policy in 1999 shifted the role of TBAs to village maternal health workers whose responsibilities were mainly to promote perinatal care and institution-based delivery of pregnant women. This successful transformation involved engaging with government and other actors, training TBAs for their new role, and providing incentives and sanctions for human resources management.

CONCLUSIONS

The China experience of transforming the role of TBAs in Guangxi rural area is an example of successfully engaging TBAs in promoting institution-based childbirth.

Traditional birth attendants (TBAs) as potential agents in promoting male involvement in maternity preparedness: insights from a rural community in Uganda

Background

Since the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization’s Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context.

Methods

This study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes.

Results

Contrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives’ healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care.

Conclusion

In this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.

Community and provider perceptions of traditional and skilled birth attendants providing maternal health care for pastoralist communities in Kenya: a qualitative study

Background

Kenya has a high burden of maternal and newborn mortality. Consequently, the Government of Kenya introduced health system reforms to promote the availability of skilled birth attendants (SBAs) and proscribed deliveries by traditional birth attendants (TBAs). Despite these changes, only 10 % of women from pastoralist communities are delivered by an SBA in a health facility, and the majority are delivered by TBAs at home. The aim of this study is to better understand the practices and perceptions of TBAs and SBAs serving the remotely located, semi-nomadic, pastoralist communities of Laikipia and Samburu counties in Kenya, to inform the development of an SBA/TBA collaborative care model.

Methods

This descriptive qualitative study was undertaken in 2013–14. We conducted four focus group discussions (FGDs) with TBAs, three with community health workers, ten with community women, and three with community men. In-depth interviews were conducted with seven SBAs and eight key informants. Topic areas covered were: practices and perceptions of SBAs and TBAs; rewards and challenges; managing obstetric complications; and options for SBA/TBA collaboration. All data were translated, transcribed and thematically analysed.

Results

TBAs are valued and accessible members of their communities who adhere to traditional practices and provide practical and emotional support to women during pregnancy, delivery and post-partum. Some TBA practices are potentially harmful to women e.g., restricting food intake during pregnancy, and participants recognised that TBAs are unable to manage obstetric complications. SBAs are acknowledged as having valuable technical skills and resources that contribute to safe and clean deliveries, especially in the event of complications, but there is also a perception that SBAs mistreat women. Both TBAs and SBAs identified a range of challenges related to their work, and instances of mutual respect and informal collaborations between SBAs and TBAs were described.

Conclusions

These findings clearly indicate that an SBA/TBA collaborative model of care consistent with Kenyan Government policy is a viable proposition. The transition from traditional birth to skilled birth attendance among the pastoralist communities of Laikipia and Samburu is going to be a gradual one, and an interim collaborative model is likely to increase the proportion of SBA assisted deliveries, improve obstetric outcomes, and facilitate the transition.

Traditional and Skilled Birth Attendants in Zimbabwe: A Situational Analysis and Some Policy Considerations

The paper focuses on the situational analysis of traditional birth attendants (TBAs) and skilled birth attendants (SBAs) in Zimbabwe. Against a background of a frail health care system, characterised by a shortage in skilled professionals, increased cost of medical care, and geographic and economic inaccessibility of health care centres among others, TBAs have remained a life-line for especially many rural women in maternal health care provision. Moreover, TBAs have also found their way into the urban areas of Zimbabwe. The shift in international policy and health funding toward skilled birth attendants (i.e., an accredited health professional) has materialized into concerted government efforts to increase numbers of both midwifery training institutions and midwives themselves. The call for SBAs, though a worthy ideal, is out of touch with the lived realities of pregnant women in low resource settings such as Zimbabwe. The study is concerned with situational analysis of TBAs and SBAs in maternal health care service provision in Zimbabwe analysing and evaluating policy considerations.

"We have been working overnight without sleeping": traditional birth attendants' practices and perceptions of post-partum care services in rural Tanzania

BACKGROUND

In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs' practices and perceptions in post-partum care in rural Tanzania.

METHODS

Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data.

RESULTS

Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system.

CONCLUSIONS

This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA services.

Changing the role of the traditional birth attendant in Somaliland

OBJECTIVE

To explore the feasibility of changing the role of the traditional birth attendant (TBA) to act as birth companion and promoter of skilled birth attendance.

METHODS

Between 2008 and 2012, 75 TBAs received 3days of training and were paid US $5 for each patient brought to any of five healthcare facilities in Maroodi Jeex, Somaliland. Health facilities were upgraded (infrastructure, drugs and equipment, staff training, and incentivization). Eight key informant interviews (KIIs) and 10 focus group discussions (FGDs) involving 32 TBAs and 32 mothers were conducted. A framework approach was used for analysis.

RESULTS

TBAs adopted their new role easily; instead of conducting home births and referring women to a facility only at onset of complications, they accompanied or referred mothers to a nearby facility for delivery, prenatal care, or postnatal care. Both TBAs and mothers accepted this new role, resulting in increased deliveries at health facilities. Facilitating factors included the creation of an enabling environment at the health facility, acceptance of the TBA by health facility staff, and monetary incentivization.

CONCLUSION

Changing the role of the TBA to support facility-based delivery is feasible and acceptable. Further research is needed to see whether this is replicable and can be scaled-up.

Traditional Birth Attendants and Policy Ambivalence in Zimbabwe

This paper analyses the importance of the services rendered by traditional birth attendants (TBAs) to pregnant women in Zimbabwe. It argues that, though an integral part of the health system, the ambivalence in terms of policy on the part of the government leaves them in a predicament. Sociocultural values as well as tradition imbue TBAs power and authority to manage pregnancies and assist in child deliveries. On the other hand, government policies expounded through the Ministry of Health (MoH) programs and policies appear to be relegating them to the fringes of healthcare provision. However, in a country with a failing health system characterized by mass exodus of qualified personnel, availability of drugs, and understaffing of healthcare centres, among others, TBAs remain the lifeline for many women in the country. Instead of sidelining them in healthcare interventions, I argue that their integration, however, problematic and often noted to be with disastrous consequences for traditional medicine, presents the sole viable solution towards achieving MDGs 4 and 5. The government and MoH should capitalize on the availability of and standing working relations of TBAs with the grassroots for better/positive maternal health outcomes. In a country reeling with high maternal deaths, TBAs’ status and position in society make them the best intervention tools.

Stakeholder views on the incorporation of traditional birth attendants into the formal health systems of low-and middle-income countries: a qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums

Background

Health workforce shortages are key obstacles to the achievement of the health-related Millennium Development Goals. Task shifting is seen as a way to improve access to pregnancy and childbirth care. However, the role of traditional birth attendants (TBAs) within task shifting initiatives remains contested. The objective of this study was to explore stakeholder views and justifications regarding the incorporation of TBAs into formal health systems.

Methods

Data were drawn from messages submitted to the HIFA2015 and CHILD2015 email discussion forums. The forums focus on the healthcare information needs of frontline health workers and citizens in low - and middle-income countries, and how these needs can be met, and also include discussion of diverse aspects of health systems. Messages about TBAs submitted between 2007-2011 were analysed thematically.

Results

We identified 658 messages about TBAs from a total of 193 participants. Most participants supported the incorporation of trained TBAs into primary care systems to some degree, although their justifications for doing so varied. Participant viewpoints were influenced by the degree to which TBA involvement was seen as a long-term or short-term solution and by the tasks undertaken by TBAs.

Conclusions

Many forum members indicated that they were supportive of trained TBAs being involved in the provision of pregnancy care. Members noted that TBAs were already frequently used by women and that alternative options were lacking. However, a substantial minority regarded doing so as a threat to the quality and equity of healthcare. The extent of TBA involvement needs to be context-specific and should be based on evidence on effectiveness as well as evidence on need, acceptability and feasibility.

Safe Arrivals: Responding to the Local Context in a Training Program for Birth Attendants in Cambodia

The World Health Organization (WHO) recommends that every woman should have a skilled birth attendant (SBA) attend her birth; however, until this ideal is met, traditional birth attendants (TBA) continue to provide care to women, particularly in rural areas of countries such as Cambodia. The lack of congruence between an ideal and reality has caused difficulty for policy makers and governments. In 2007, The 2h Project, an Australian-based, nongovernment organization in partnership with a local Cambodian organization, “Smile of World,” commenced the “Safe Arrivals” project, providing annual training for SBAs and TBAs in the rural provinces of Cambodia. Following implementation of this project, feedback was collected through a questionnaire undertaken by interviews with participants. This was part of a quality assurance process to further develop training in line with WHO recommendations and to consider the cultural context and respond to local knowledge. Over a 2-year period, 240 birth attendants were interviewed regarding their role and practice. Specifically, through the responses to the questionnaires, several cultural practices were identified that have informed training focus and resource development. More broadly, it was evident that TBAs remain a valuable resource for women, acknowledging their social and cultural role in childbirth.

Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District

INTRODUCTION

Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries.

OBJECTIVES

This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services.

METHODS

157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required.

FINDINGS

Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents.

CONCLUSION

TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services.

Development of a community-based maternal, newborn and child emergency training package in South Sudan

OBJECTIVE

To develop an evidence-based maternal, newborn and child emergency training package for community-based frontline health workers (FHWs) in post-conflict South Sudan.

METHODS

In partnership with the new Republic of South Sudan, a multimodal needs assessment was conducted through purposive sampling, involving key informant interviews, focus group discussions, provider knowledge assessments and facility surveys. Data were analyzed using traditional qualitative techniques and compared with existing training programmes and curricula. These findings informed the development and implementation of the novel training approach.

RESULTS

The needs assessment involved 33 FHWs, eight diverse health facilities in Eastern Equatoria, and stakeholders within 18 governmental and non-governmental organizations. Significant consensus emerged regarding the need for greater capacity among previously untrained FHWs. A maternal, newborn and child health training package was developed that included: (1) a participatory training course taught through a 'training of trainers' approach; (2) nine different pictorial action-based checklists covering basic management and referral of maternal, newborn and child emergencies; and (3) essential setting-appropriate equipment.

CONCLUSION

A novel maternal, newborn and child survival package was developed for previously untrained and illiterate FHWs in South Sudan. It is hoped that this approach will build community-based capacity in resource-limited settings while greater capacity is being developed for facility-based deliveries by skilled birth attendants.

Lessons learned in Liberia: preliminary examination of the psychometric properties of trust and teamwork among maternal healthcare workers

BACKGROUND

Post-conflict Liberia has one of the fastest growing populations on the continent and one of the highest maternal mortality rates among the world. However, in the rural regions, less than half of all births are attended by a skilled birth attendant. There is a need to evaluate the relationship between trained traditional healthcare providers and skilled birth attendants to improve maternal health outcomes. This evaluation must also take into consideration the needs and desires of the patients. The purpose of this pilot study was to establish the validity and reliability of a survey tool to evaluate trust and teamwork in the working relationships between trained traditional midwives and certified midwives in a post-conflict country.

METHODS

A previously established scale, the Trust and Teambuilding Scale, was used with non- and low-literate trained traditional midwives (n=48) in rural Liberia to evaluate trust and teamwork with certified midwives in their communities. Initial results indicated that the scale and response keys were culturally inadequate for this population. A revised version of the scale, the Trust and Teamwork Scale - Liberia, was created and administered to an additional group of non- and low-literate, trained traditional midwives (n=42). Exploratory factor analysis using Mplus for dichotomous variables was used to determine the psychometric properties of the revised scale and was then confirmed with the full sample (n=90). Additional analyses included contrast validity, convergent validity, and Kuder-Richardson reliability.

RESULTS

Exploratory factor analysis revealed two factors in the revised Trust and Teamwork Scale - Liberia. These two factors, labeled trust and teamwork, included eleven of the original eighteen items used in the Trust and Teamwork Scale and demonstrated contrast and convergent validity and adequate reliability.

CONCLUSIONS

The revised scale is suitable for use with non- and low-literate, trained traditional midwives in rural Liberia. Continued cross-cultural validation of tools is essential to ensure scale adequacy across populations. Future work should continue to evaluate the use of the Trust and Teamwork Scale - Liberia across cultures and additional work is needed to confirm the factor structure.

The changing role of indigenous lay midwives in Guatemala: new frameworks for analysis

OBJECTIVES

to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general.

DESIGN/PARTICIPANTS

a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization.

SETTING

Kaqchikel Maya-speaking communities in the Guatemalan highlands.

FINDINGS

the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal-child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a high level.

CONCLUSIONS AND IMPLICATIONS

as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal-child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.

What is the role of informal healthcare providers in developing countries? A systematic review

Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.

Correlates of first dose of measles vaccination delivery and uptake in Indonesia

OBJECTIVE

To determine health systems-related, familial, and cultural factors which influence the delivery and uptake of measles vaccination in Indonesia.

METHODS

Logistic regression analysis of data collected during the 2007 Indonesian Demographic and Health Survey was undertaken by the authors to investigate these factors. The 2007 Indonesian Demographic and Health Survey dataset is a nationally representative, randomly sampled survey containing 15 065 children aged between 9 and 59 months.

RESULTS

72.8% of children had received the measles vaccine. Vaccination coverage was similar for males and females; however, coverage was higher amongst urban children, 80.1%, compared to 68.5% in rural areas. The key findings of the regression analysis were congruent with the results of previous research targeting vaccination coverage. After controlling for all other factors, maternal age, maternal education, wealth, the use of a skilled birth attendant, and postnatal check-ups were positively and significantly (P< 0.01) correlated with measles vaccination. The number of children per household was negatively correlated (P<0.01).

CONCLUSIONS

In order to enhance measles vaccination coverage in Indonesia, delivery to, and uptake by, rural and low socio-economic populations require substantial improvements. Mass health education and health systems improvements are also required.

Traditional Birth Attendants in Samoa: Integration With the Formal Health System

A traditional birth attendant (TBA) is a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other TBAs. In many parts of the world, TBAs continue to provide a significant proportion of maternity care during pregnancy, birth, and the postpartum period. In Samoa, TBAs are recognized part of both the formal and informal health care system. The aim of this research was to examine the contribution that TBAs made in the provision of maternity care in Samoa. A descriptive study was undertaken, and 100 TBAs who had attended more than 400 births a year were interviewed as part of a broader Safe Motherhood Needs Assessment.

The findings highlighted that although TBAs can work in collaboration with individual health providers or facilities or be integrated into the health system, TBAs were often practicing autonomously within their communities, independent of collaborative links. This study showed that formal recognition and registration of TBAs would improve the recording of births and augment their partnership to the formal health care system. This formal registration process has since been implemented to improve monitoring and evaluation and assist future research with this important group.

Re-examining authoritative knowledge in the design and content of a TBA training in India

Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India.

FINDINGS

The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme.

KEY CONCLUSIONS

The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.

Traditional birth attendant training and local birthing practices in India

Training birth attendants (TBAs) provide essential maternal and infant health care services during delivery and ongoing community care in developing countries. Despite inadequate evidence of relevance and effectiveness of TBA training programmes, there has been a policy shift since the 1990s in that many donor agencies funding TBA training programmes redirected funds to providing skilled attendants during delivery. This study aimed to assess the ways in which a TBA training programme in India has been successful in disseminating evidence-based knowledge on birthing practices. TBAs practicing within 16 villages targeted by training programme initiatives were administered with structured questionnaires. The post training birthing practices of trained (24) and untrained (14) TBAs was compared and birthing practices adopted by women assisted by trained (16) and untrained (9) TBAs was analysed. Positive post training practices were hand washing, use of a clean blade for cutting the cord, immediate breastfeeding and weighing of babies. Nevertheless, the training could be further improved with up to date and evidence-based information and more comprehensive instructions. The findings suggest an integration of local and evidence-based knowledge is needed to improve the training. Raising community awareness of public health measures related to maternal and child health is also recommended.

Home-based life-saving skills in Liberia: acquisition and retention of skills and knowledge

INTRODUCTION

In 2006, Home-Based Life-Saving Skills was introduced in three Liberian counties, in partnership with Africare-Liberia and the Liberian Ministry of Health and with funding by the United States Agency for International Development.

METHODS

Traditional midwives and trained traditional midwives (N = 412) underwent pre- and immediate posttesting on four topics. Three hundred eighty-nine (94%) of the original participants also completed 1-year follow-up posttesting.

RESULTS

Mean scores significantly improved between pre- and immediate posttests and knowledge improvement was stable at 1 year. Correct responses on individual steps for each of four topics significantly increased over the course of training. The data demonstrate a major change in the knowledge base of the traditional and trained traditional midwives acting as village guides.

DISCUSSION

Home-Based Life-Saving Skills is a viable means by which to improve community knowledge and decrease maternal and neonatal morbidity and mortality.

The effectiveness of continuing training for traditional birth attendants on their reproductive health-care knowledge and performance

OBJECTIVE

to evaluate the effectiveness of continuing training for traditional birth attendants (TBAs) on their reproductive knowledge and performance.

SETTING

Mzuzu Central Hospital in the northern region of Malawi. PARTICIPANTS AND ANALYSIS: a total of 81 TBAs trained during 2004 and 2006 in Mzuzu, Malawi received continuing training courses. Their reproductive knowledge was assessed by a structured questionnaire during 2004 and 2007. A multivariate generalised estimating equation (GEE) model was constructed to determine the associations between their reproductive knowledge scores and age, years of education, time since the last training course, test frequency and number of babies delivered.

FINDINGS

from July 2004 to June 2007, a total of 1984 pregnant women visited these trained TBAs. A total of 79 (4.0%) mothers were referred to health facilities before the birth due to first-born or difficult pregnancies. No maternal deaths occurred among the remaining mothers. There were 26 deaths among 1905 newborn babies, giving a perinatal mortality rate of 13.6 per 1000 live births. The GEE model demonstrated that knowledge scores of TBAs were significantly higher for TBAs under the age of 45 years, TBAs with more than five years of education, TBAs who had taken a training course within one year, and TBAs with a higher test frequency.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

continuing training courses are effective to maintain the reproductive knowledge and performance of trained TBAs. It is recommended that continuing training should be offered regularly, at least annually.

Birthing Practices of Traditional Birth Attendants in South Asia in the Context of Training Programmes

Traditional Birth Attendants (TBA) training has been an important component of public health policy interventions to improve maternal and child health in developing countries since the 1970s. More recently, since the 1990s, the TBA training strategy has been increasingly seen as irrelevant, ineffective or, on the whole, a failure due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Although, worldwide data show that, by choice or out of necessity, 47 percent of births in the developing world are assisted by TBAs and/or family members, funding for TBA training has been reduced and moved to providing skilled birth attendants for all births. Any shift in policy needs to be supported by appropriate evidence on TBA roles in providing maternal and infant health care service and effectiveness of the training programmes.

This article reviews literature on the characteristics and role of TBAs in South Asia with an emphasis on India. The aim was to assess the contribution of TBAs in providing maternal and infant health care service at different stages of pregnancy and after-delivery and birthing practices adopted in home births. The review of role revealed that apart from TBAs, there are various other people in the community also involved in making decisions about the welfare and health of the birthing mother and new born baby. However, TBAs have changing, localised but nonetheless significant roles in delivery, postnatal and infant care in India. Certain traditional birthing practices such as bathing babies immediately after birth, not weighing babies after birth and not feeding with colostrum are adopted in home births as well as health institutions in India. There is therefore a thin precarious balance between the application of biomedical and traditional knowledge. Customary rituals and perceptions essentially affect practices in home and institutional births and hence training of TBAs need to be implemented in conjunction with community awareness programmes.

Health literacy and the Millennium Development Goals: United Nations Economic and Social Council (ECOSOC) regional meeting background paper (abstracted)

This paper uses a health literacy "lens" to look at key global health challenges, including the achievement of health-related Millennium Development Goals (MDGs) and the reduction of disease burden due to non-communicable diseases (NCDs). Available global evidence is summarized related to: assessment of the impact of health literacy on health and development; identification of measures for reporting progress; exploring ways to strengthen multisectoral collaboration at the national, regional, and international levels to undertake joint actions for increasing health literacy; finding ways to promote better access and use of information through information and communication technology and empowerment; and building capacity for sustained action to increase health literacy. Key action messages are identified. Findings presented informed the 2009 ECOSOC Ministerial Declaration on Health Literacy.