Table 2

Impact of training traditional birth attendants on stillbirths and perinatal mortality

Source

Location and Type of Study

Intervention

Stillbirths/Perinatal Outcomes


Reviews and meta-analyses


Sibley et al. 2007 [45]

Pakistan and rural Guatemala.

Meta-analysis (Cochrane). 2 RCTs included (N = 18,699 pregnant women).

Assessed the effects of trained (intervention) vs. untrained (controls) traditional birth attendants.

SBR: adj. OR = 0.69 (95% CI: 0.57–0.83).


Sibley and Sipe 2004* [46]

24 countries and three regions.

Meta-analysis (non-Cochrane). 60 studies included

Assessed the effects of the training of TBAs (intervention) vs. untrained TBA baseline (controls).

PMR: 8% reduction with TBA training (statistically significant)

Birth asphyxia-associated PMR: 11% with TBA training (statistically significant).


Intervention studies


Alisjahbana 1995 [54]

Indonesia (West Java). 2 districts.

Longitudinal, intervention study. N = 3275 pregnant women (N = 2275 in the intervention district, and N = 1000 in the controls).

Assessed the impact of the intervention in a district where training was given at all levels of the health care system (informal and formal) and birthing homes were established in villages with special attention to referral, transportation, communication and appropriate case management. There was no intervention in the control district.

PMR: 99/2275 (43.5/1000) vs. 37/1000 (37/1000) in study and control villages respectively [NS]. There was a decrease in PMR in the intervention village with time, compared to no change in the control village.


Greenwood et al. 1990 [53]

Gambia (Farafenni area). 41 rural villages.

Before-after intervention study.

Assessed the impact of primary heatlh care (PHC) programme in villages (intervention) vs. villages without the PHC programme (controls). Survey was also done for one year before and three years after the start of the programme.

SBR: 50/1000 (61/1220) vs. 51.9/1000 (37/712) in the PHC village vs. non-PHC villages in the post intervention period. (SBR increased in both PHC and non-PHC villages during first post-intervention year, possibly due to improved surveillance).

PMR: 81.1/1000(99/1220) vs. 88.4/1000 (63/712) in PHC villages vs. non-PHC villages in the post intervention period.

NMR: Decreased ~50% in the PHC village from the pre-intervention to the post-intervention period. No change in NMR in non-PHC villages.

In PHC villages 65% of women were assisted at childbirth by a trained TBA during the post-implementation period and the proportion of women who delivered in a hospital or health centre increased.


Larsen et al 1983 [159]

South Africa. Rural community.

Observational study. 4 traditional birth attendants caring for 22 pregnant women with no access to professional health care.

Assessed the impact of the training of TBAs over a 2 year period (intervention).

PMR: 0/1000. No statistical data given.


Observational studies


Andersson 2000 [50]

Sweden (Sundsvall and Skelleftea). Population-based data

Retrospective cohort study. Perinatal deaths (N = 4876) among N = 116211 newborns during the years 1831–1899.

Assessed the impact of the implementation of the midwifery system (43.7% of home deliveries were midwife assisted in 1871–1880 vs. 73.4% during the last decade of the century). Access to the midwives was 73.6% among more urban mothers vs. 50.8% among rural mothers.

PMR: 42/1000 births during the years 1831–1899.

PMR: RR = 0.75 (95% CI: 0.66–0.84) among urban mothers comparing the decade after the midwifery system to the years before.

PMR: RR = 0.79 (95% CI: 0.72–0.87) among rural mothers comparing the decade after the midwifery system to the years before.

Prevented fractions of perinatal deaths: 32% vs. 15% comparing the decade after the midwifery system to the years before. respectively.


Egullion et al. 1985 [51]

Zimbabwe (Manicaland). Clinics, health centers and hospitals.

An intervention study. Over 4000 TBAs were trained by December 1984.

To assess the impact on pregnancy outcomes of a culturally sensitive training of TBAs based on the risk approach and including information about clean delivery, pregnancy including ANC and birth preparedness, normal duration of labour, postnatal care, and harmful traditional practices. Training conducted by maternity nurses, and included fostering linkages between TBAs and the health system.

No statistical data provided, but "marked improvements" were noted, such as reduction in neonatal tetanus, and earlier arrival of obstructed labour cases at the hospital.


Kwast et al. 1996 [49]

Guatemala, Indonesia, Bolivia and Nigeria. Four different community-based projects between 1989 and 1993.

Different study designs. Before-and-after studies in Guatemala and Indonesia.

Bolivia (the Warmi project): formed women's groups, trained birth attendants, husbands and women on safe birth practices, and strengthened referral linkages with the hospital, including a subsidy for hospital admissions.

Guatemala (the Quetzaltenango maternal and neonatal health project): enhanced the skills of 400 TBAs vs. comparison areas where no such training was initiated.

Indonesia (the Tanjungsari regionalization project): improved maternity services from village to hospital, including establishment of communication and transport links vs. a comparison sub-district without this intervention.

Nigeria: provided life-saving skills training for midwives and interpersonal communication skills for all providers.

PMR (Bolivia): 105/1000 vs. 38/1000 births before and after the intervention, respectively.

PMR (Guatemala): decreased among referred women in both the implementation and the control areas. 22.2% vs. 11.8% among referred women before and after implementation in the intervention area (P = 0.003).

PMR (Indonesia): 47.7/1000 to 35.8/1000 births over 18 months of the project. 42.1/1000 vs. 25.9/1000 among all women delivered by the TBA during the last 6 months of the project. 98.7/1000 vs. 49.6/1000 among those with complications delivered by the TBA over the last 6 months of the project.

Intrapartum SBR (Nigeria): 5.5% vs. 1.8% before and after the project. 57% reduction in postpartum haemorrhage (3.7 to 1.6%) and of 70% reduction in prolonged labour (from 20.6 to 6.2%).


Matthews et al. 1995 [52]

Nigeria (Uyo). Canadian-Nigerian safe motherhood project in the clan area within the catchment area of the government hospital.

An intervention program. TBAs (N = 120) were registered for the course which took seven months.

To assess the impact of the training TBAs to use a pictorial method (a card with drawings and symbols) to identify and record risk conditions in childbirth on maternal and neonatal outcomes.

PMR: 25/1000 (20/795).

Of these deaths, eight occurred in the group of mothers transferred to hospital. The remaining twelve babies had died at birth in the villages.


Foord 1995 [160]

Gambia (West Kiang district vs. Upper Baddibu district).

An intervention study with a control district. N = 1516 women (794 in intervention and 722 in control area respectively)

To assess the impact of the intervention in the West Kian district through upgrading of personnel, TBA training, improved treatment and referral schemes, and increased number of visits to rural outreach areas vs. control district (Upper Baddibu) without this intervention.

Fetal death (miscarriage + SB): 39.9/1000 vs. 24.5/1000 in intervention and control districts, respectively.

Early PMR: 54.9/1000 vs. 39.6/1000 in intervention and control districts, respectively.


* Web table could not be constructed because the review does not provide detailed data on studies with impact on perinatal mortality

Bhutta et al. BMC Pregnancy and Childbirth 2009 9(Suppl 1):S7   doi:10.1186/1471-2393-9-S1-S7

Open Data