Academic journal article Journal of Health Population and Nutrition

Training Traditional Birth Attendants on the Use of Misoprostol and a Blood Measurement Tool to Prevent Postpartum Haemorrhage: Lessons Learnt from Bangladesh

Academic journal article Journal of Health Population and Nutrition

Training Traditional Birth Attendants on the Use of Misoprostol and a Blood Measurement Tool to Prevent Postpartum Haemorrhage: Lessons Learnt from Bangladesh

Article excerpt

INTRODUCTION

The World Health Organization (WHO) defines a traditional birth attendant (TBA) as "a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through an apprenticeship to other TBAs" (1). Beginning in the 1970s, the WHO advocated for the training of TBAs as a strategy to reducing the maternal and neonatal mortality and morbidity occurring in low-resource settings during home deliveries. However, in the 30 years following the WHO's recommendation, the majority of reviews on the impact of TBA training did not find compelling evidence to promote it as a strategy to reducing maternal mortality (2).

In light of these studies, a consensus emerged in the late 1990s among leaders in global maternal health that TBAs should no longer be trained in delivery skills and should instead be incorporated into the skilled birth attendant strategy as promoters of facility-based care (3). The safe motherhood initiative began advocating for skilled birth attendants (SBAs) at every birth and increased access to emergency obstetric care (EmOC) in low-resource settings. Unlike most TBAs, the SBAs receive formal medical training and are better equipped to manage complications. However, since inequities in the distribution of SBAs are pervasive and resources to train them are limited in many developing countries, these goals remained unattainable (4). Worldwide, 34% of births still occur without an SBA present (5). To mitigate the effects of the shortage of healthcare workforce, many low-resource countries have continued to invest in the training of TBAs and other cadres who practise in their own communities. Appropriate technologies, for example misoprostol to prevent PPH and blood loss measurement tools to measure blood loss, create new opportunities for reevaluating the role of TBAs at delivery.

In Bangladesh, more than 70% of women deliver at home and only 32% of births are attended by a medically-trained provider (6). Bangladesh has an extensive rural health infrastructure but the challenge of making SBAs available to all women who need them has been insurmountable to date (7). Acknowledgeing that most women are still choosing to deliver at home, the Government launched a programme to train two additional cadres of community health workers to be SBAs. However, implementation was challenging, and in the five years following the community SBA initiative, the new cadres had conducted only 0.1% of all deliveries (8). Rates of skilled attendance at birth have steadily increased over the last decade but with a very low baseline, the complete transition to facility-based delivery will take decades (Figure) (6,8); the majority of births (63%) are still attended by TBAs, trained or untrained (6).

Qualitative research has demonstrated that some women prefer being assisted by a TBA compared to an SBA, particularly if the SBA is young, unmarried, and without children (9). Because TBAs live and work within the social and cultural matrix of the community, they often understand women's needs and are better positioned to influence women to choose safer options in pregnancy (9,10). In addition to advice and information, TBAs are often well-situated to coordinate referrals to health facilities (10). Previous work has shown that incorporating TBAs into the formal healthcare system can increase skilled birth attendance and utilization of services (11). Additionally, researchers working in Zimbabwe determined that TBAs serve as the bridge between biomedical and traditional medicine, providing women with greater re-assurance of positive outcomes than what is available to them in standard antenatal care (ANC) (12). With better coordination, TBA integration could leverage TBAs' unique position within the community to link women with the formal healthcare system (11). Merely training TBAs in safe motherhood interventions without the necessary technologies, infrastructure, and support cannot make TBAs effective (12-15). …

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