should traditional birth attendants conduct deliveries?
DESCRIPTION
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.TRANSCRIPT
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