The Debate Continues

In the international fora the debate has been and is still hot regarding the value and justification of training TBAs despite the lack of evidence as to their contribution to reduced maternal mortality (Sai & Measham 1992). TBAs have had many different roles in different cultures but they remain, even today, an important asset for a majority of the world’s rural pregnant women. It is beyond doubt that their impact is significant when it comes to empathy, cultural competence, and psychosocial support at birth although many women certainly seem willing to trade this for medical care once it is available (Jordan 1987).

There seems to be consensus that TBAs are generally not able to handle most potentially fatal complications and that many other factors are important, in particular the accessibility and quality of obstetric services. Some sources argue that any attention to less effective strategies diverts attention from development of professional midwifery and hospital delivery care (Maine 1993, De Brouwere et al . 1998). Others argue that a switch to the model of “professional midwifery for all” would not be immediately fruitful. They question whether an abandonment of traditional birth attendants is wise and they fear that “we are in danger of a wiping out the useful work along with the weaknesses, rather than building on strength and correcting shortcomings” (Walraven & Weeks 1999).

In an attempt to accommodate the conviction of need of training professional midwives and involving TBAs, Sibley and Armbruster have tried to develop an innovative, community-oriented strategy designed to reduce maternal mortality (Sibley & Armbruster 1997). This strategy targets women, families and TBAs and uses two mutually complementary training interventions, reflecting the idea that training of professional and paraprofessional health workers in emergency obstetric care is essential and that the education and mobilisation of families, communities and TBAs must complement it. It certainly seems to be the case that “the challenge for policy makers is to make the best use of this available human resource (TBAs) but simultaneously plan and implement a definite replacement strategy” (Kamal 1998).