Talk given by Nyaya member Dr. Sheela Maru at Boston Medical Center's Obstetrics-Gynecology Resident Grand Rounds in February, 16, 2011. She discusses her experiences with traditional bith attendants in rural Kutch, Gujarat, some of the evidence for their roles in safe deliveries, and the implications for global policy in places like Kutch and Achham.
6. 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
12. 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
15. How to Gather the Evidence? Rare outcome Logistics High variability across regions and cultures Differences in infrastructure and referral systems
16. Should TBAs Conduct Deliveries? YES: A Testable Hypothesis (contrary to what current global policy suggests)
17. 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 IT’S A HEALTH SYSTEMS PROBLEM
18. 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!
19. 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.
Worldwide: 400 per 100,000 to 260 per 100,000 from 19902008. But only 75% of the way towards the MDGhttp://gamapserver.who.int/gho/static_graphs/MDG5_MM_trends.pngFor example the maternal mortality rate in Africa is more than 600 per 100,000 which is about 100x higher than at BMC.
One of the ways that global health policy makers have identified as a strategy to reduce maternal mortality is to promote skilled birth attendance at all deliveries.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, accessed 14 August 2008). 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, accessed 14 August 2008).
<50% in many parts of the worldCurrent global health policy consensus is that a primary strategy in reducing maternal mortality is to increase the number of deliveries conducted by a skilled Birth attendant. This is to the direct exclusion of TBAs in conducting deliveries. 20 years ago, the global consensus was very different. What happened? WHOHealth services coverage statisticshttp://www.who.int/healthinfo/statistics/09.whostat2005graph_birthsattended.jpg
1985: Where is the M in MCH- A Rosenfield and D Maine point out that MCH programs in developing countries focus almost exclusively on the health of the child, not considering factors that contribute to maternal M&M. WHO announces that 500,000 women die each yr of obstetric complications.1987: UNFPA, World Bank and WHO sponsor the Safe Motherhood Conference in Kenya, raise awareness and challenge the world to do something1990s: Safe Motherhood Interagency Group formed- focus is antenatal care with risk stratification and training of TBAs, with goal of reducing maternal mortality by 50% by yr 2000
1997: antenatal screening not effective because every pregnancy faces risksEnsure skilled attendance at delivery (excluding trained TBAs)2000: Millenium Development Goals2004: TBAs can play a role in achieving the goal of skilled birth attendance at every delivery by encouraging women to seek delivery care by an SBA, by providing health education, and by serving a doula-type role.TBAs should NOT, however, be called upon to perform the role they have played historically in their communities: deliver babies.
There were several small studies that contributed to this global policy consensus. I would like to take a moment to review one of the more widely cited studies as a representation of these data.
1989 Ghana National TBA training program: 2 wk curriculum. This is a cross-sectional household survey of TBA clients in 2 districts (one proxy for poor referral services and one proxy for good referral services- 2 hospitals). Within the districts, all areas with at least 1 trained an 1 untrained TBA were eligible for inclusion in the study. Looked at process outcomes, not mortality, because they could not support the sample size that would have been required and they only surveyed survivors. Training protective against intrapartum fever and retained placenta. However training associated with longer labor. (Trained TBAs try to manage prolonged labor longer? Or trained TBAs are called when a mother’s labor is not progressing normally?). Limitations: diffusion of innovation from trained to untrained TBAs in same area. Underreporting of adverse events.Authors of this study concluded, that some effect of training on outcome were evident, but magnitudes were small. In many respects, the shift away from focusing on TBAswas probably more representative of a political and policy environment in which the Safe Motherhood maternal mortality goals were not being met and in which the TBAs were an obvious target, even if there was little evidence.
I’ll
The two studies I have reviewed here highlight the challenges and pitfalls of studying interventions aimed at reducing maternal mortality.
FINAL SLIDE. The question aboutTBAs is not WHETHER– communities themselves have already decided– but HOW. Different approach to development which integrates and utilizes existing structures. Community driven initiatives, such as in Kutch, advocate for the role of TBAs.
Making Pregnancy Safer: The Critical Role of the Skilled Birth Attendant. http://whqlibdoc.who.int/publications/2004/9241591692.pdf- Allocation of cost- trying to distribute a small amount of resources
WHODepartment of Reproductive Health and Research Proportion of births attended by a skilled health worker 2008 updates http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/2008_skilled_attendant.pdf
