EDITORIAL: Traditional Versus Birth Attendants in Provision of Maternity Care: Call for Paradigm Shift

Friday Okonofua, Rosemary Ogu


The World Health Organization1 defines a traditional birth attendant (TBA) as: “a person (usually a woman) who assists a pregnant woman at childbirth, and who initially acquired her skills delivering babies by herself or working with other TBAs”. Estimates indicate that between 60-90% of births in some parts of sub-Saharan Africa are assisted by TBAs, with countries such as Chad, Niger and Nigeria reaching extremely high proportion of TBA-attended deliveries.  A report from the Cameroon2 suggests that less than 50% of births are attended by skilled birth attendants (i.e. nurses, midwives and doctors), whereas about 26.8% are attended by family members, 22.2% by TBAs and 5.9% by women themselves.  

While the prevalence of TBA-births is high in many parts of Africa, the question remains unanswered as to whether this situation is healthy for the promotion of maternal health in the continent.  Increasing women’s access to skilled birth attendants is one of the proven interventions for reducing maternal mortality around the world.  Countries such as Sweden, Finland and the Netherlands with lower rates of maternal mortality have nearly 100 percent skilled birth utilization rate, while there is increasing propensity by governments in high-income countries to promote and sustain women’s access to quality, evidencebased maternity care.  In the few areas in the United States, for example where maternal mortality has been known to rise, this was largely due to women using traditional, and non-evidence based forms of care due to personal or religious convictions. Interestingly, the attainment of optimal rates of skilled birth attendants in countries with high prevalence of maternal mortality is one of the subgoals of the Millennium Development Goals.

 Furthermore, the result of a systematic review5 has failed to show any association between the trainingof TBAs and declines in rates of maternal mortality.  Consequently, the WHO recommends that countries seeking accelerated reduction in maternal mortality should concentrate on increasing the access of pregnant women to skilled birth attendance. Yet, recent reviews and documentations3, 4 continue to recommend TBA re-training and use by African countries, mainly based on arguments relating to the scarcity of skilled birth attendants, the lower cost of services by TBAs and community/traditional acceptance of the services they provide. This edition of the African Journal of Reproductive Health features two articles that explore the use of TBAs versus skilled birth attendants for maternity care in two African countries. The paper by Lerberg and Sundby6 and their colleagues from the Gambia indicate that rural women are aware of the benefits of delivering in orthodox health care institutions with skilled providers. Among rural women interviewed, only about 27% had planned to deliver at home, but nearly 70% later were eventually delivered at home by TBAs.  This tendency to deliver with TBAs despite women’s initial plan to deliver in hospital was due to personal constraints in reaching their preferred places of delivery.  Up to 75% reported not having enough time to go to hospitals, while 30% indicated that this was due to lack of transportation. Thus, interventions based on provision of social safety nets in terms of cost reduction, transport provision and conditional cash transfers for women who seek hospital delivery would likely be effective in increasing the proportion of women delivered by skilled birth attendants in this population of women.  The second paper by Gloria Hamela and her colleagues from Malawi7, demonstrate that although TBAs may not be effective in reducing maternal mortality, they can be engaged in the provision of various components of maternal health care.  The team showed that training TBAs on prevention of mother to child transmission of HIV was effective in improving women’s access to HIV counselling, testing and treatment in the Kawale District of Malawi. Malawi, a country with the most comprehensive option B+ policy on prevention of mother to child transmission of HIV in Africa, is evidently aware that without engaging traditional forms of care that women use for maternity care, it would be unable to scale up this policy to reach all categories of vulnerable women.  Thus, deploying TBAs to counsel women and referring them to the formal health care system for orthodox evidence-based care is a novel approach that requires replication throughout the African continent.  The point being made in this edition of the journal is to propose that African countries would need to pursue policies on integrating TBAs to formal systems of health care, not necessarily for the purpose of achieving immediate maternal mortality reductions, but to achieve scale and improved intermediate outcomes for maternal health.  Such interventions should best focus on redirecting women from traditional forms to modern maternity care, providing simple and correct information on maternal health care to women, and linking rural women to primary prevention methods, including modern family planning methods.  Examples of such novel use of TBAs are beginning to emerge in many parts of Africa. In Sierra Leone, the World Bank is funding a scheme whereby it pays £1 for every woman that a TBA brings to the hospital.  Also in Cameroon, a maternal and child e-health project is underway called “call a midwife” in which TBAs will be provided with modern communication methods to enable them link up to formal service providers for the purpose of averting deaths in the hands of TBAs due to complications.  The Abiye maternal health project in Ondo State of Nigeria includes registration of all pregnant women in the state, their linkage to formal health providers with mobile phones and the provision of completely free tertiary level maternity care.  Such innovative safety nets provided to poor vulnerable women will help increase the use of evidence-basedmaternity care and improve both intermediate and immediate indicators of maternal health. We conclude that the high rate of maternal mortality in parts of Africa can be better tackled if a proactive approach is developed for increasing women’s access to modern maternity care.  Knowing that women die from complicated deliveries for which TBAs are ill-prepared to handle, but accepting that it would be difficult to completely do away with TBAs in the short term, we recommend a policy shift that engages TBAs to deal with intermediate components of maternal health care.  As the determinants of TBA use in sub-Saharan Africa are driven by ignorance, illiteracy and poverty, a long term approach will be to focus on women’s education and socioeconomic empowerment, and the re-organization of the health care system to target and implement appropriate safety nets for the protection of the reproductive health and rights of women.

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World Health Organization. Report of the Alma Ata Conference on Primary Health Care. Health for All series, No. 1. Geneva, WHO 1978.

Benjamin W, Emmanuel D, Pius M, Patricia M, Birth attendants trained in prevention of mother to child transmission of HIV in rural Cameroon. Afr. J Women’s Health 2007; 52: 334-341

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Sibley LM et al. Traditional birth attendants training for improving health behaviours and pregnancy outcomes. Cochrane Database of Systematic Reviews 2007, Issue 3: Summary available at: http://www. cochrane .org/reviews/en/ab005460.html/accessed Feb 2014.

Lerberg PM, Sundby J, Jammeh A, Fretheim A. Barriers to skilled birth attendance: A survey among mothers in rural Gambia. Afr J Reprod Health 2014; 18(1): 34-42.

Gloria Hamela, Charity Kabondo, Tapiwa Tembo et al. Evaluating the benefits of incorporating traditional birth attendants in HIV Prevention of Mother to Child Transmission service delivery in Lilongwe, Malawi. African Journal of Reproductive Health, 2014 18:1


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