Academic journal article Journal of Health Population and Nutrition

Where There Are (Few) Skilled Birth Attendants

Academic journal article Journal of Health Population and Nutrition

Where There Are (Few) Skilled Birth Attendants

Article excerpt


Recent efforts to reduce maternal mortality in developing countries have prioritized two key strategies: training and deploying skilled birth attendants (SBAs) and improving access to emergency obstetric care (EmOC) facilities. Both the strategies have repeatedly been shown to improve maternal and child-health outcomes for those who use these. However, these strategies are not sufficient. These do not address the safe-delivery needs of women living in remote communities, who are unlikely to be able to access either an SBA or EmOC. This flaw is critical because populations that should be at the centre of the discussion are out of reach of current interventions to reduce the maternal mortality ratio (MMR). By omitting traditional birth attendants (TBAs) and other lay birth attendants from the safe motherhood agenda, the families which rely solely on these attendants will continue to experience elevated maternal mortality and morbidity. The paper argues for the support of four community-based prevention interventions to reduce maternal mortality and morbidity in remote areas: (a) distribution of misoprostol for prevention of postpartum haemorrhage (PPH); (b) improved access to voluntary family planning; (c) simple tools to measure blood loss; and (d) better postpartum follow-up.


In 1986, the World Health Organization (WHO) estimated that over 500,000 women die from maternal causes annually, 99% occurring in developing countries. The latest inter-agency report on maternal mortality shows that the absolute numbers of maternal deaths in 2008 have declined to 358,000 but the ratio of 99% of deaths in developing countries (355,000 deaths) and only 1% of deaths in developed countries (3,000 deaths) has not changed since 1986. Regionally, sub-Saharan Africa and South Asia account for 87% of the world's maternal deaths (1). More effective strategies are required in countries where women remain at the highest risk.


To reduce mortality in areas where most women do not receive professional help during childbirth, macro-level barriers that jeopardize maternal health (i.e. low levels of awareness, high cost of services, and inequitable distribution of SBAs) must be addressed. Creative strategies (such as output-based assistance in East Africa and Southeast Asia, cash incentives for deliveries in hospitals in India, and training and deployment of community midwives in Afghanistan) demonstrate a considerable promise as a means to increase access to maternal health services for the poor (2-6). However, large regions exist without effective maternal mortality-reduction strategies in place, often as a result of weak infrastructure and limited political commitment. Until an adequate coverage of the most effective and appropriate strategies is achieved, community-based interventions could promote maternal health and avert unnecessary mortality by training and supporting active community-based birth attendants to provide the four aforementioned low-cost interventions.


Table 1 highlights four regions with high MMR, focusing on the 28 countries in which less than 50% of births are attended by SBAs. Each country contains large, underserved rural areas where women traditionally give birth in the home. The rural population of the 28 countries ranges from 44% to 90% (7). With high rates of poverty, great distances to facilities, and inadequate transportation, serious complications all too often lead to the death of a mother and/or the newborn. In poor countries, stark health inequities exist between urban and rural areas: the MMR estimate for urban areas is 447 per 100,000 livebirths [95% confidence interval (CI) 384-517] compared to 640 per 100,000 livebirths in rural areas (95% CI 590-630). In places such as Afghanistan, the difference is even more dramatic: the MMR in the capital city of Kabul is 418 per 100,000 livebirths compared to 6,507 per 100,000 livebirths in the remote rural district of Ragh (8). …

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