|05. The Role of Traditional Birth Attendants in the Reduction of Maternal Mortality|
Access to essential obstetric care appears to be the crucial factor in reducing maternal mortality. In the Matlab region of Bangladesh, falls in maternal mortality in a MCH-FP intervention area were paralleled by falls in parts of the control area. The reductions in maternal mortality have been attributed to the presence of a referral hospital and transport links that were available to all areas (Ronsmans 1997, Maine 1996). A common finding in many studies of the effect of TBA training is the importance of referral to essential obstetric care facilities.
Many programmes have had a specific focus on training TBAs to refer emergency cases appropriately and some have also had major inputs into improving obstetric services, mechanisms for transport and the links between TBAs and professional health staff (Bullough 1989). In a peri-urban area in Brazil it has been shown that TBAs trained to recognise prenatal conditions and complications of pregnancy were successful in identifying them and in making referrals. TBAs were given a small maternity centre to work in and transport was available (Janovitz et al . 1988). TBAs in Burkina Faso have been successfully trained to refer seriously ill mothers (Wollast et al . 1993) and the MotherCare demonstration projects in Bolivia, Guatemala, Indonesia and Nigeria have shown that addressing issues of referral and emergency obstetric care improved quality of referrals and reduced perinatal mortality (Kwast 1996, Kwast 1995, Alisjahbana et al. 1995).
It is important to recognise that improvements in referrals may occur independently of TBA training. Hostility between TBAs and health staff has been found to act as a barrier to referrals (Okafor 1994). A study form Guatemala has demonstrated that hospital staff training can increase referrals from TBAs regardless of whether the TBAs are trained or untrained. Hospital staff were instructed in standards of care for managing obstetrical and neonatal patients and in the importance of being supportive and understanding of TBAs and of mothers referred by TBAs Referrals increased by over 200%. (O'Rourke 1995).
These findings and those from similar studies suggest that the crucial intervention for all domiciliary birth attendants is a reliable support system for emergencies with sufficient transport facilities available (Kwast 1992), and skilled, equipped and available support from professional midwives and other staff with life-saving skills (Fleming 1994).