Maternal health is a critical and longstanding issue within global health. Though progress on maternal health outcomes since the Millennium Development Goals has been made, progress has been unequal within and between countries. Within the 73 countries accounting for the majority of global maternal deaths, only 4 are considered to have a suitable midwifery workforce to meet needs [1]. Progress within countries is also disparate, especially impacted by distances to urban centres [2]. This piece explores the impact of traditional birth attendants (TBAs) on outcomes, and the policy attitudes surrounding them, arguing that TBAs are unfairly scapegoated for maternal mortality rates.
A TBA is a person (usually a woman) who assists with births, but lacks formal biomedical training [3]. There is debate as to whether TBAs help or hinder maternal health outcomes, with the World Health Organization even running a campaign to eliminate their practice [4]. TBAs are perceived to be ignorant of correct, modern practices of midwifery, their lack of formal training leading to an assumption of inability [4]. Their practice is associated with home births, thus eliciting fears about unsanitary conditions and a lack of structured postpartum care [4]. Due to their lack of affiliation with the state’s health system, TBAs are harder to regulate, causing them to be perceived as an impediment to widespread policy implementation [3].
However, a wealth of evidence shows that the key causes of maternal mortality are due to lack of access to emergency services and tendencies towards blaming TBAs distracts from addressing inadequate health system resourcing [4]. Not only are government health centres often underequipped and unstaffed but their services are also more expensive than those of a TBA [4]. For rural populations, hospitals are often hours away, meaning that travel and long waiting times can prove fatal when women need timely, acute care, whereas a TBA is local and able to attend to the unpredictable nature of labour [4]. Furthermore, lacking formal training does not mean that a TBA is inexperienced, as many work for decades and successfully deliver births in the face of adverse conditions [4]. Conversely, research into WHO’s favoured alternative ‘Skilled Birth Attendants’ often indicates that their acclaimed training falls short in practice [4].
In conclusion, whilst TBAs are not a perfect solution for creating good maternal health outcomes, their positive contribution should not be discounted. Their service is invaluable for local women in rural communities, for whom formal services are often difficult to access. Instead of isolating them, it would be prudent to build links between their services and the broader health system, to improve overall outcomes and availability of resources [5]. This too should come in the context of fundamental improvements to national health systems to make them more accessible to the poorer rural communities who in many parts of the Global South, make up a considerable proportion of the total population.
Serena Bailey is the Director of Engagement at CORBIS and is a contributor to the ‘Social Justice, Health and Human Rights’ research stream. If you are interested in getting involved in this work or would like more information, get in touch with us at info@corbissussex.org
References
[1] Noyes et al, (2014), ‘Optimizing the world’s nursing and midwifery roles to meet the Millennium Development Goals for maternal and child health more effectively’, Journal of Advanced Nursing, Vol.70(12), pp.2699-2702, [online] Available at; http://onlinelibrary.wiley.com/doi/10.1111/jan.12491/epdf (Accessed 13/10/2017) [2] Ruhago et al, (2012), ‘Addressing inequity to achieve the maternal and child health millennium development goals: looking beyond averages’, BMC public health, 12(1119), p.1-7, [online] Available at; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543393/pdf/1471-2458-12-1119.pdf (Accessed 13/10/2017) [3] Copeland, M., (2011), ‘The Comadrona and Response to Obstetrical Emergencies: Maternal Mortality in Highland Guatemala’, PhD, University of California [online] Available at; https://search.proquest.com/docview/877551140 (Accessed 13/10/2017) [4] World Health Organisation, (2010), ‘WHO Technical Consultation on Postpartum and Postnatal Care’, Geneva: World Health Organisation Press, [online] Available at; http://apps.who.int/iris/bitstream/10665/70432/1/WHO_MPS_10.03_eng.pdf (Accessed 13/10/2017) [5] United Nations Population Fund (2014), ‘The State of the World’s Midwifery 2014: a Universal Pathway, a Woman’s Right to Health’ [online] Available at; http://www.unfpa.org/sites/default/files/pub-pdf/EN_SoWMy2014_complete.pdf (Accessed 13/10/2017)
