Review article Does training TBAs prevent neonatal tetanus?

Training traditional birth attendants (TBAs) has been promoted as a way to prevent neonatal tetanus in areas of the developing world where TBAs are widespread. The evidence for the effectiveness of this strategy is reviewed. It is concluded that the evidence that training TBAs prevents neonatal tetanus is much weaker than that for vaccination of women with tetanus toxoid either before or during their pregnancy. Vaccination is the method of choice for prevention of neonatal tetanus wherever it is economically practicable. Where TBAs are trained, their tasks should include promotion of tetanus toxoid vaccination coverage. Neonatal tetanus and infant mortality Neonatal tetanus is one of the major causes of perinatal mortality: it has been estimated to cause from 160 0001 to 900 0002 deaths in the world each year. However, these deaths are distributed very unevenly between world re-gions, countries and even within one country. Neonatal tetanus has virtually been eliminated in all the countries of Western Europe and North America. In contrast, local community surveys have reported rates as high as 260 deaths per 1000 live births,3 though 5 to 80 per 1000 births are more usual rates in rural areas of developing countries (Table 1). Recent retrospective sample surveys using a standard questionnaire have been conducted by the World Health Organization (WHO) in 15 countries in Asia, the Middle East and Africa. These have reported tetanus-specific neonatal mortality rates ranging from 3 to 67 per 1000 live births in rural populations (Table 2). In those surveys which included rural areas shown in Table 2, the proportion of the total neonatal mortality caused by tetanus ranged from 8 % to 72%, with most estimates in the range from 20 % to 60%. These proportions are similar to those found in other surveys in rura