The Rationale for TBA Training

Three quarters of maternal deaths in developing countries are attributable to direct obstetric causes such as postpartum haemorrhage, postpartum sepsis, eclampsia, obstructed labour, and complications of unsafe abortion (WHO 1996). For many years it has been recognised that the presence of an attendant with professional midwifery skills, who can either provide or ensure access to essential obstetric care, has an important role in preventing maternal deaths from these causes (IAG 2000).

Historical data from currently affluent countries support this view. The marked decline in maternal mortality in Sweden during the period 1750-1900 parallels the development of midwifery as a profession and the increasing use of professional midwives by women in childbirth (De Brouwere et al . 1998).⁴ Analysis of contemporary data from demographic health surveys (DHS) reinforces this observation. At national level there is a clear negative correlation between the proportion of deliveries attended by a skilled attendant (midwife, nurse or doctor) and the maternal mortality ratio (Stanton et al . 1997). There are a few exceptions, but almost all countries where skilled attendance is more than 80% have MMRs below 200 (World Bank 1999). It is in recognition of this relationship, as well as difficulties in measuring maternal mortality, that the proportion of birth with skilled attendance has been adopted as an additional IDT⁵.

Clearly, universal skilled attendance at delivery is a worthy objective. However, in many countries, where professional birth attendants are simply not available to rural populations or the urban poor, this ideal remains a distant goal. DHS analysis has shown that, out of 22 countries surveyed in sub-Saharan Africa, only one (Botswana) had professional birth attendants attending delivery in more than three quarters of cases (Macro International Inc. 1994). It is estimated that, world-wide, two thirds of all births occur outside health facilities (WHO 1997). Of these, midwives, or other professionals, conduct only a small proportion. The majority, around 60 million deliveries per annum, are currently attended by a traditional birth attendant, a relative, or, in some settings, no one (Alto 1991). Achieving skilled attendance at delivery for all is going to be a huge challenge. It has been calculated that, with an assumed load of 150 deliveries annually per midwife, plus associated prenatal and postnatal care, around 400,000 midwives will have to be trained (Walraven & Weeks 1999). These estimates can be expected to increase as rising numbers of young women enter the reproductive age group. Significant costs, which include salaries, housing and rural posting allowances, are inevitable. In addition to these direct costs there may be additional costs related to supervision and support. It is against this background that training of traditional birth attendants has been promoted on the basis that they are available, are already engaged in maternity care and appear to present a lower cost alternative (Belsey 1985).