The Challenges and Potential Roles of Birth Attendants in the Provision of Maternal and Neonatal Health Services Within the Developing World

Objectives: The main objectives of this literature search and paper are to review and discuss the existing issues surrounding and affecting Traditional Birth Attendants (TBAs) in their role as a provider of community-based maternal and neonatal health services, and to suggest potential health system roles that trained TBAs could fill in developing countries. Background: Due to a lack of trained professional health care workers (HCWs) around the world, including doctors and midwives, 60-80% of births in the world are attended by TBAs with even more attended by untrained family members (Fleming, 1994). Although TBAs are highly varied in their training, education, and acceptance, in the developing world they remain an integral part of the maternal and child health care process, whether formally integrated, or in some cases, formally rejected by the public health care sector. An abundance of information exists that describes birth attendants, their training, and the benefits and detriments of their work related to the provision of clean and safe home delivery. Much of this information is not easily accessible as many groups who have reported on this theme have not published their findings in peer-reviewed journals. Methods: This paper makes use of available information gathered from searching public databases, combined with information gathered as part of an MPH practicum experience with the Christian Children‟s Fund (CCF). The author conducted a systematic search of the Public Medicine Database (http://www.ncbi.nlm.nih.gov/pubmed), from the inception of individual journals through May 2008, using TBA-related search terms. A targeted search of publicly accessible websites for many international health organizations was also conducted. Manuscripts from these two sources were supplemented with internal documents obtained from the CCF pertaining to its Maternal and Neonatal Project in the Americas that incorporates trained TBAs as part of their health care delivery strategy (Vargas, 2008). Results: Major issues identified during this literature review include: 1) The need for consistency in the definition and nomenclature regarding birth attendants. 2) The standardization of training with defined, minimum competency requirements. This training should include a component that addresses regional or cultural issues as well as general practice skills, including the management of complications during pregnancy and birth, linked to an established referral system. 3) Standardized training should serve to transition more TBAs into an accepted role of Skilled Birth Attendant. 4) Continuing education will help not only TBAs who receive this training, but other potential birth attendants and HCWs. 5) Ancillary training and refresher courses can be used as a vehicle for the incorporation of education and training on related health topics, such as infant vaccinations and diarrhea prevention. Conclusions: The author concludes that three recommendations will greatly influence the ability for birth attendants to positively contribute to maternal and child health issues in the developing world. First, a standardization of nomenclature surrounding the various types of birth attendants must be implemented. Second, trained TBAs are a safe and effective means of addressing many community-based maternal and child health issues in the developing world. Trained TBAs have the ability to provide perinatal services to large numbers of women and families who have no access to, or in many cases, experience substantial perceived barriers to formal health care services. The better prepared and educated a TBA is, the more effective s/he will be (Carlough, 2005; Jokhio, 2005). Third, developing countries should create well defined transition strategies that allow trained TBAs to receive updated training and support, to permit a workable timeframe for an eventual shift toward the use of professionally trained and certified Skilled Birth Attendants (SBAs). The mode of training recommended to accomplish this follows a proven WHO format (Halim, 2003).Master of Public Healt