Why retain traditional birth attendants?
Lancet 1(8318): 223-224
1983
ISSN/ISBN: 0140-6736 PMID: 6130253 Document Number: 199815
Although it is commonly agreed that the time has come to lessen the toll of maternal, fetal, and infant lives lost in childbearing in developing countries through improved perinatal care, there is little agreement on the specific measures that should be taken. An approach dating back to 1921 in The Sudan which calls for retraining of traditional birth attendants (TBAs), who conduct as many as 80% of deliveries in most developing countries, has attracted both supporters and detractors. Accounts of retraining programs of TBAs in 7 countries of Asia, Africa, and Latin America published by the World Health Organization demonstrate the problems involved. Almost without exception, the TBA retraining programs ran into difficulties. Although the core content of such problems was generally satisfactory, selection of trainees and teaching methodology often had shortcomings. Persistent shortages of teachers and supplies and lack of supervision for trained TBAs were other problems. With expansion of the retraining programs there were increases in the number of deliveries assisted by trained TBAs and in their case referrals for hospital care. Where reliable data or estimates of mortality rates were available, as in the Philippines, Sri Lanka, and parts of the Sudan, the reduction in overall infant mortality was linked to adoption of social welfare schemes rather than to activities of the trained TBAs. Problems of maternal and perinatal mortality should be viewed as political issues. TBAs as a group have little hope of increasing their influence because they are usually illiterate, females, and elderly, often with age-related handicaps such as poor vision. Experience suggests that TBAs are effective only when they are trained for a specific skill such as reducing neonatal tetanus or when their work is closely tied to highly professional systems of maternal and perinatal health care. TBAs cannot be expected to reduce overall maternal and infant mortality when the root causes lie in socioeconomic deprivation, in top managerial incompetence, and in mass illiteracy.