Journal of Obstetrics and Gynaecology (January 2004) Vol. 24, No.
1, 5–11
OBSTETRICS
The impact of maternal mortality interventions using
traditional birth attendants and village midwives
ALISON M. RAY1 and H. M. SALIHU2
1
Department of International Health and 2Department of Maternal and Child Health,
University of Alabama at Birmingham, Alabama, USA
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Summary
Traditional birth attendants (TBAs) and village midwives have been
employed in many interventions to reduce maternal mortality in
developing countries. This study reviews the results of 15 TBA- and
midwife-based interventions that aim to improve skilled assistance
in delivery and recognition and referral of complications. Outcome
measures used to evaluate the impact of the programmes varied.
Five of the five programmes reviewed that evaluated their impact on
maternal mortality demonstrated a decline in maternal mortality
ratios, two of three studies measuring morbidity-related indicators
found improvement of some but not all morbidity outcomes, six of
seven showed a trend of improved referral rates, and three of three
found high levels of knowledge retention among trained TBAs.
For personal use only.
Programmes with the greatest impact utilised TBAs and village
midwives within multisectoral interventions. These findings suggest
that TBAs and village midwives contribute to positive programme
outcomes. Further investigation is needed to determine the nature
of their contribution within larger programmes.
Introduction
The greatest health disparity between developed and
developing countries is seen in the levels of maternal
mortality. Globally, it is estimated that 585 000 women die
of pregnancy-related causes every year and that 99% of
those deaths occur in developing countries. Regional
estimates of maternal deaths range from 1100 deaths per
100 000 live births in sub-Saharan Africa, 430 in South Asia
and 190 in Latin America and the Caribbean to 12 deaths
per 100 000 live births in industrialised countries (WHO,
UNICEF, UNFPA, 2001). At an individual level, these
statistics translate to a one in 13 lifetime risk of pregnancy-
related death for women in sub-Saharan Africa compared to
a risk of one in 4085 for women in industrialised countries.
Even these statistics may not reflect fully the magnitude of
the problem. Maternal mortality is difficult to measure due
to the lack of complete vital registration systems in many
developing countries, particularly in rural areas where the
problem is typically most severe. Population-based survey
methods can be used to improve estimates, but require a
large sample size to provide reliable current statistics at a
national level due to the relative rarity of the event
(AbouZahr and Wardlaw, 2001).
The incidence of maternal mortality in developing
countries is tragic because it is almost entirely preventable,
as demonstrated by the extremely low risk of maternal death
in developed countries. The five leading causes of maternal
Correspondence to: Hamisu Salihu MD, PhD, Department of Maternal and Child Health, University of Alabama at Birmingham, 1665
University Blvd, Room 320, Alabama 35294, USA. Tel: (205) 934 6469; Fax: (205) 934 8248; E-mail: hsalihu@uab.edu
ISSN 0144-3615 print/ISSN 1364-6893 online/04/010005-07 # Taylor & Francis Limited, 2004
DOI: 10.1080/01443610310001620206
death, including haemorrhaging, sepsis, complications of
unsafe abortion, hypertensive disorders and obstructed
labour, can almost always be controlled and treated with
medical interventions that have been available in developed
countries for about 60 years (Maine and Rosenfield, 1999).
The tragedy of the premature death of a mother due to
pregnancy-related causes also has serious consequences for
the family she leaves behind. In developing countries
orphaned children under the age of 5 years face a risk of
death as high as 50% (Tsui et al., 1997).
Since the 1980s, the prevention of maternal mortality in
developing countries has received growing attention from
international health organisations. The Safe Motherhood
Initiative, launched at the Nairobi Conference in 1987,
brought international agencies together with national
governments and non-governmental organisations in a
collaborative effort to improve maternal survival. However,
despite intensive programmatic activity, very little progress
has been made in the past 15 years in attaining Safe
Motherhood’s initial goal of reducing maternal mortality by
half by 2000. Implementation of effective interventions to
prevent the death of mothers in pregnancy and childbirth
continues to be a challenge to global public health in the
21st century.
Efforts to reduce maternal mortality have employed a
range of strategies, including prevention of unintended
pregnancy, antenatal care and skilled attendance during
childbirth. Family planning interventions contribute to the
reduction of maternal mortality by preventing exposure to
the health risks of pregnancy when conception is not
intended. Family planning components have also been
incorporated effectively into interventions to treat complica-
tions of unsafe abortions. The detection and treatment of
certain health conditions and diseases during pregnancy
through antenatal interventions can contribute to improved
outcomes. Anaemia is strongly associated with maternal
mortality and can be managed during pregnancy by iron
and folate supplements as well as, in some cases, control of
malaria and helminth infection. Detection of hypertension is
important for assuring appropriate management and
referral of women at risk of developing eclampsia. However,
while antenatal care can help reduce the incidence of some
complications, the majority of potentially fatal complica-
tions that arise in labour and delivery cannot be predicted
during pregnancy. That is why skilled attendance during
 6 A. M. Ray and H. M. Salihu
labour and delivery and access to emergency obstetric care
are essential to the reduction of maternal mortality.
Early interventions designed to improve management of
labour and delivery focused on traditional birth attendants
(TBAs). It was believed that providing training in hygienic
delivery and life-saving techniques to those who were
already attending births in underserved areas would provide
the most far-reaching and cost-effective strategy for
increasing maternal survival. However, many of these early
programmes failed to demonstrate a reduction in maternal
mortality (De Brouwere et al., 1998). Other interventions
have focused on improving the availability and quality of
emergency obstetric care, including facilities for blood
transfusion and caesarean section together with other
medical interventions, such as manual removal of placenta
and administration of drugs (Maine and Rosenfield, 1999).
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Given the nature of the leading causes of maternal
mortality, the capacity to treat obstetric complications
through the provision of these essential services is critical to
improving maternal survival. However, it is unlikely that
many district hospitals in developing countries would even
have the capacity or the resources to attend all births in the
area. The fact remains that at least 60% of births in
developing countries take place outside a health facility and
almost half are attended only by a TBA, family members or
no one (Walraven and Weeks, 1999).
Trained birth attendants can potentially play a vital role
in reducing maternal deaths by assisting in labour and
delivery at the community level and providing appropriate
For personal use only.
management and referral of complications, but after many
midwife and traditional birth attendant-based interventions,
there continues to be much debate about the exact role they
should play due to inconsistency in programme results.
While some interventions have demonstrated a decline in
maternal mortality ratios, such as the primary health care
programme in Farafenni, The Gambia and the community
maternity care programme in Matlab, Bangladesh, others
have apparently had little impact due in part to low
numbers of births attended by those trained, as was seen in
a follow-up study of trained TBAs in the Sahel of Burkina
Faso (Greenwood et al., 1990; Fauveau et al., 1991; Dehne
et al., 1995).
In this review, we examine maternal mortality interven-
tions that focus on improved management of labour and
delivery through training of midwives and traditional birth
attendants in order to understand better the programme
components contributing to intervention successes and
shortcomings.
Methods
A literature search was performed in the MEDLINE and
PUBMED databases for 1966 through February 2003 using
the following keywords: maternal mortality, developing
countries, midwifery, traditional birth attendants and
maternal death. Relevant articles, including review articles
and commentaries, were collected for cross-referencing and
further database searches were conducted with author
names in order to access additional resources not readily
retrieved in the keyword search. The literature search
included only English-language articles (Table I).
The articles selected for this review met three inclusion
criteria. First, they evaluated the outcomes of interventions
designed to address maternal mortality in developing
countries. Secondly, the interventions employed traditional
birth attendants and/or village midwives at a community
level; that is, outside health facilities. Thirdly, the interven-
tions focused on improved management of labour and
delivery. Evaluation studies were chosen so that evidence of
the impact of different intervention designs may be
compared. However, outcomes chosen to measure impact
varied between studies and ranged from maternal mortality
ratios and referral rates to incidence of postpartum infection.
Interventions utilising traditional birth attendants and
village midwives to assist in labour and delivery were
selected to provide insight into the roles they might play in
communities in improving maternal survival, based on
correlation between intervention designs and favourable
pregnancy outcomes. In some of the evaluation studies
chosen for this review, village midwives and TBAs are part of
a larger network of providers employed in the intervention.
Such variations in intervention components will also be
considered in analysis of outcomes and their implications.
Articles focused on maternal mortality interventions
using only indirect prevention strategies, such as family
planning and anemia reduction, were excluded from this
review, as well as those focused exclusively on emergency
obstetric care as a means of improving maternal survival.
While both may make an important contribution to the
overall reduction of maternal mortality, the purpose of this
review is to evaluate interventions that address improved
management of the direct causes of death in pregnancy
beginning with improved assistance in home deliveries,
where many of the world’s births still take place.
Results
Of the 15 maternal mortality interventions studied in this
review, eight (53.3%) were conducted in Africa, five (33.3%)
in Asia and two (3.3%) in Latin America. Twelve of the 15
studies employed trained traditional birth attendants as the
instrument of intervention (80%), while three utilised village
midwives (20%), whose formal training ranged from 1 to 4
years. The outcome measures used to evaluate programme
impact varied, but may be grouped into the following
categories for the purpose of this analysis: maternal
mortality, morbidity, referral rates and knowledge and
practices of TBAs.
Maternal mortality ratios (MMR) decreased in the five
interventions in which they were measured (Brennan, 1988;
Greenwood et al., 1990; Fauveau et al., 1991; Bashir, 1991;
Schaider et al., 2000). The magnitude of the decline ranged
from 50% (Brennan, 1988) to 82% (Bashir, 1991) of the
original level of maternal mortality, with an average decline
of 67.6%. Among these studies, two also reported impact as
compared to a control group. In the midwife-based
programme in Bangladesh there was a significant difference
(OR = 0.35, 95% CI: 0.13 – 0.93, P 5 0.05) between the
post-intervention maternal mortality ratios in the interven-
tion compared to the control areas (Fauveau et al., 1991). In
the Gambian primary health care intervention study, there
was no significant difference between the intervention and
control groups in the rate of change in MMRs during the
study period, although the decline from 2416/100 000 to
1051/100 000 within the intervention group was significant
(Greenwood et al., 1990). The Angolan TBA training
intervention showed the second greatest decline in maternal
mortality (76%), from 1241/100 000 to 293/100 000 (Schai-
der et al., 1999). However, the validity of these results is
questionable as the ‘pre-intervention’ data was taken from

various historical nationwide and regional estimates and
compared to the maternal mortality ratios among TBA-
assisted home deliveries only, excluding hospital deliveries
in the study area. The study that demonstrated the greatest
decline, from 10.1/1000 to 1.86/1000, evaluated an inter-
vention in Pakistan that had been in place for 10 years—the
longest intervention of the 5 in which maternal mortality
was measured (Bashir, 1991).
The incidence of pregnancy-related morbidities including
intra- and postpartum complications and postpartum
infection were measured to evaluate the impact of three of
the 15 interventions (Goodburn et al., 2000; Smith et al.,
2000; Bailey et al., 2002). Two of the three studies
demonstrated a protective effect against certain morbidities,
including intrapartum fever, retained placenta and post-
partum complications (haemorrhage, fever and/or convul-
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sions) (Smith et al., 2000; Bailey et al., 2002). In both studies
the reduction in these specific morbidities was substantial,
with a protective odds ratio of 0.30 for intrapartum fever and
0.35 for retained placenta (95% CI: 0.14 – 0.65 and 0.13 –
0.96) in the Ghana intervention, and a 58% reduction in the
incidence of postpartum complications (OR = 0.42, 95% CI:
0.21 – 0.81) in the Guatemala study (Smith et al., 2000; Bailey
et al., 2002). However, results were not uniformly positive. In
the intervention evaluated by Smith et al. (2000), training had
no significant impact on intra- and postpartum haemorrha-
ging or postpartum infection. In the third intervention in
which morbidity was measured, postpartum infection was the
only outcome monitored, and no significant change in
For personal use only.
incidence was found to result from traditional birth attendant
training. In all three studies examining morbidity outcomes,
data were collected from the clients of trained and untrained
TBAs after delivery. Thus, women with fatal complications
were excluded from these analyses and the data reported was
based on the recollection of the client.
Referral rates were used in seven studies to evaluate the
interventions’ success in directing women to higher levels of
care in the case of serious complications (Araujo et al., 1983;
Greenwood et al., 1990; Ibrahim et al., 1992; Alisjahbana et
al., 1995; Smith et al., 2000; Ronsmans et al., 2001; Bailey et
al., 2002). The results of five of these studies indicated
improved referral practices in the intervention area. In West
Java, Indonesia, trained TBAs were twice as likely to refer
patients with intrapartum complications as untrained TBAs,
and in the Gambian study the percentage of women
delivering in health facilities was significantly higher in the
intervention group (Greenwood et al., 1990; Alisjahbana et
al., 1995). The number of clients referred to higher levels of
care by trained TBAs tripled in the third year of the
intervention in Sudan compared to the first year, but the
significance of this outcome is difficult to assess due to lack of
a control group in the study (Ibrahim et al., 1992). In Brazil,
trained TBAs demonstrated competent referral practices,
with referral rates from 85% to 100% for women presenting
such complications as prolonged or obstructed labour,
placenta previa and transverse presentation (Araujo et al.,
1983). Again, the lack of a control group or pre-intervention
data makes interpretation of these results difficult. Trained
TBAs in Guatemala also referred a greater percentage of
clients with complications than untrained TBAs, but the
improvement was not significant (Bailey et al. 2002). The
results of the Ghana intervention suggest that trained TBAs
were more likely to refer patients in the intrapartum and
postpartum periods (OR for training = 1.95 and 1.04,
respectively); however, the difference was not significant
Traditional maternal mortality interventions 7
(Smith et al., 2000). By contrast, the results of one study
indicated that referrals decreased after the intervention.
Following the intervention in South Kalimantan, Indonesia,
the proportion of women admitted to the hospital with a
complication requiring a life-saving medical intervention (as
a percentage of live births) declined from 1.1% to 0.7%
(Ronsmans et al., 2001). The number of life-saving obstetric
interventions as a proportion of total live births is used as an
indicator of met need for emergency obstetric care, based on
the estimate that at least 1% of pregnant women will require
a medical facility-based obstetric intervention to save their
lives (De Brouwere et al., 1998).
The outcome of the intervention was evaluated through
assessment of the knowledge and practices of the traditional
birth attendants after training in three of the studies (Eades
et al., 1993; Akpala, 1994; Dehne et al., 1995). Overall,
trained TBAs demonstrated high levels of knowledge of
hygienic delivery practices and risk factors for pregnancy
complications. High proportions also reported that they
would refer patients presenting such risk factors as history
of obstetric complication and very short stature to a higher
level of care in the studies conducted in Nigeria and Ghana
(Eades et al., 1993; Akpala, 1994). The trained TBAs in the
three studies also reported providing additional services
including antenatal care and malaria prophylaxis, and in
Nigeria and Ghana TBAs also provided education on
immunisation and family planning. However, while the
Nigerian TBAs attended 72 births a year on average, in
Ghana the TBAs performed an average of only seven births
a year and in Burkina Faso 10 of the 17 TBAs trained
attended few or no births outside of their families (Eades et
al., 1993; Akpala, 1994; Dehne et al., 1995).
Discussion
There has been much debate surrounding the potential role of
traditional birth attendants and village midwives in interven-
tions to reduce maternal mortality. Those who support the
involvement of TBAs cite the importance of strengthening the
skills of those who already assist in deliveries and their
position to serve as referral links to emergency obstetric
services and educate families to recognize signs of complica-
tion (Sibley and Armbruster, 1997; Walraven and Weeks,
1999). Others question whether TBA-based programmes are
worth the resources due to lack of evidence of training’s
impact on maternal mortality rates (De Brouwere et al., 1998;
Weil and Fernandez, 1999). It has been asserted that
professional midwives are the best instrument for commu-
nity-based interventions (De Brouwere et al., 1998).
However, as seen in the three midwife-based interventions
in this review, the training and resources available for
midwifery practice, particularly in rural areas, varies from
country to country, and there are still few studies evaluating
their efficacy in a village setting. This study attempts to shed
light on this debate by reviewing the results of interventions
that have employed traditional birth attendants and village
midwives, so that the roles they have played in programmes
that have been successful and those that not have been
successful may be understood more clearly.
In this review of 15 studies of the impact of traditional
birth attendant and village midwife-based maternal mortal-
ity interventions, five of the five programmes reviewed that
evaluated their impact on maternal mortality resulted in a
decline in maternal mortality ratios, two of three studies
measuring morbidity-related indicators found improvement
 8 A. M. Ray and H. M. Salihu
Table I. Summary of intervention studies on maternal mortality and morbidity

Article Country Intervention Sample Study Outcome(s) measured Results

instrument size design

1. Obstetric complica- Guatemala Trained TBAs 3518 deliveries Quasi experi- Morbidity: development of obste- Incidence of postpartum compli-
tions: does training TBAs mental tric complication referral: referral cations decreased. Referral rates
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make a difference? of patients with complication declined but didn’t show signifi-
(Bailey et al., 2002) cant change
2. Evaluation of compre- Indonesia Village mid- 23 792 deliv- Evaluation Referral: number of life-saving Percentage of women admitted to
hensive home-based wives eries survey obstetric interventions as percen- hospitals requiring life-saving
midwifery programme tage of total live births obstetric intervention declined
(Ronsmans et al., 2001) from 1.1% to 0.7%
3. Training TBAs in clean Bangladesh Trained TBAs 800 deliveries Cross-sectional Morbidity: incidence of postpar- 45% trained vs. 19.3% untrained
delivery does not prevent tum infection. Practice of clean practice clean delivery. No sig-
postpartum infection delivery nificant effect on incidence of
(Goodburn et al., 2000) postpartum infection
4. The impact of TBA Ghana Trained TBAs 1961 deliveries Cross-sectional Morbidity: intrapartum referral, Three outcomes significantly as-
training on delivery com- postpartum referral, foul dis- sociated w/ training (P 5 0.05):
plications (Smith et al., charge, intrapartum fever, re- Retained placenta (OR = 0.30),
For personal use only.

2000) tained placenta, intrapartum/ intrapartum excessive bleeding

postpartum excessive bleeding, (OR = 0.35) and labour
labour 4 18 hours 4 18 hours (OR = 2.57). Only 2
represent positive outcome asso-
ciations with training
5. International maternal Angola Trained TBAs 19 666 Prospective Mortality: maternal mortality ra- 293/100 000 compared to 1241/
mortality reduction: out- deliveries longitudinal tios (MMR) 100 000 from historical control
come of TBA education data
and intervention
(Schaider et al., 1999)
6. Integrated village Indonesia Trained TBAs 3,275 Longitu-dinal Referral: percentage of TBA pa- 18.6% referred with intrapartum
maternity service to deliveries tients referred with complications complications in the study area
improve referral patterns compared to 9.6% in the control
(Alisjahbana et al., 1995) area
7. Training birth atten- Burkina Faso Trained TBAs 17 trained Follow-up Knowledge and practices: risk High levels of retained knowledge
dants in the Sahel (Dehne TBAs knowledge and factors, hygienic delivery, malaria of risk factors, hygiene and mal-
et al., 1995) practices prophylaxis, postpartum haemor- aria prophylaxis in 2-year follow-
survey rhage management, number of up survey. Low levels of knowl-
births attended edge of postpartum haemorrhage
management, low number of
births attended for most
(continued overleaf )
 Table I (continued )

Article Country Intervention Sample Study Outcome(s) measured Results

instrument size design

8. Evaluation of knowl- Nigeria Trained TBAs 74 trained & Follow-up Knowledge and practices: referral Significant differences in referral
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edge and practices of
trained TBAs (Akpala,
1994)
9. TBAs and maternal
mortality (Eades et al.,
1993)
For personal use only.
untrained knowledge and practices for specified risk factors, of women based on age ( 5 16,
TBAs practices sur- additional services provided 4 35), very short, history of hae-
vey morrhage, oedema, extended la-
bour. No difference in referral of
other risk categories. No un-
trained TBAs provided additional
services (antenatal care, immuni-
sation, family planning)
Ghana Trained TBAs 35 trained Follow-up Knowledge and practices: referral Reports high% of trained TBAs
TBAs knowledge and practices for specified risk factors who refer in case of antepartum
practices sur- bleeding, postpartum haemor-
vey rhage, seizure, and obstructed
labour

10. The role of the village Sudan Village 6275 deliveries Prospective Referral: referral rates in preg- Referral rates tripled in 3rd year of
midwife in detection of midwives longitudinal nancy and delivery intervention
high-risk pregnancy and
newborns (Ibrahim et al.,
1992)
11. Effect on mortality of Bangladesh Village 19 355 deliv- Quasi-experi- Mortality: maternal mortality From 20/4548 to 6/4424 (440/
community-based mater- midwives eries mental ratios (MMR) 100,000 to 136/100 000) in inter-
nity-care program vention area Significant OR of

Traditional maternal mortality interventions

(Fauveau et al., 1991)
12. Maternal mortality in
Pakistan. Success story of
Faisalabad District
(Bashir, 1991)
13. Evaluation of PHC
programme: impact of
trained TBAs on outcome
of pregnancy (Green-
wood et al., 1990)
14. Training TBAs re-
duces maternal mortality
and morbidity (Brennan,
1988)*
obstetric death between interven-
tion and pre-intervention peri-
od = 0.31 (95% CI: 0.11 – 0.81)
Pakistan Trained TBAs 2145 deliveries Prospective Mortality: maternal mortality After 10-year programme, MMR
longitudinal ratios (MMR) dropped from 10.1/1000 to 1.86/
1000
The Gambia Trained TBAs 2586 deliveries Quasi-experi- Mortality: maternal mortality 1051/100 000 compared to 2716/
mental ratios (MMR) Referral:% of 100 000 pre-intervention. Signifi-
women delivering in health facility cant increase in% delivering in
health facility in intervention
group
Nigeria Trained TBAs __ __ Maternal mortality ratio: MMR 4/1000 compared to 10/1000
before the intervention
(continued overleaf )

9
 10 A. M. Ray and H. M. Salihu

of some but not all morbidity outcomes, six of seven showed

placenta previa, abrupto placen-

prolonged or obstructed labour,

tae and transverse presentation

86 – 100% of women presenting
a substantial trend of improved referral rates and three of
three found high levels of knowledge retention.
Based on these results, it seems that TBAs and
community-based midwives did play a role in reducing
maternal mortality ratios. However, it is difficult to draw
conclusions about the exact contribution of the TBA or
midwife based on these evaluations. In three of the five
interventions measuring maternal mortality, the TBA/
midwife training was part of larger interventions that

referred
Results

involved other components including improved transporta-

tion, improved emergency obstetric care facilities, and the
initiation of a primary health care programme (Greenwood
et al., 1990; Fauveau et al., 1991; Bashir, 1991). Because the
findings reported reflect the change in maternal mortality
Referral: percentage of women

which resulted from the presence of the whole programme,

with complications referred to
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the impact of the TBAs and midwives themselves cannot be

pinpointed without further information. In order to under-
stand better the role of the birth attendants in the reduction
Outcome(s) measured

of maternal mortality, it would be helpful to know the

survival rates of the births attended by the TBAs and
midwives themselves, and their referral rates to indicate
their impact within a multisectoral intervention.
Due to measurement constraints, such as the large
hospital

quantity of data required to record changes in relatively

rare events such as maternal mortality accurately, the
majority of studies in this review employed alternative
indicators to evaluate the impact of the interventions. In
three of the studies the incidence of specific morbidities was
For personal use only.

longitudinal

used to evaluate the effectiveness of TBA training. The

Prospective

results of this review showed positive impact on some

design

specific morbidity indicators as a result of training, but there

Study

was no consistent trend among the three studies. While the

incidence of postpartum complication was reduced signifi-
cantly in the Guatemalan study, TBA training was not
1880 deliveries

significantly associated with reduced rates of postpartum

haemorrhage in the Ghana intervention or with reduction of
postpartum infection in Bangladesh (Smith et al., 2000;
Sample

Goodburn et al., 2000; Bailey et al., 2002). In the Ghana

size

study, the morbidities that were significantly reduced

through training, retained placenta and intrapartum fever
were not evaluated in the other studies. Thus, it is difficult to
Trained TBAs

draw conclusions about the impact of TBA training on

Intervention
instrument

morbidity based on the data reviewed in this study. It

should also be noted that evaluation of morbidity outcomes
in intervention studies can be problematic due to the
difficulty of classifying morbidities consistently, particularly
when the diagnostic data are based on patient recall, as was
the case in all three of these studies.
Recognition of signs of serious complications that require
higher levels of care is an important component of TBA and
*Complete documentation not accessible.
Country

midwife training. Among the seven studies that used referral

Brazil

rates to evaluate the impact of this aspect of training, six

found improved referral practices and in two of these the
improvement was significant. In the two interventions that
yielded a significant change in referrals, TBA training was
care in Northeast Brazil
15. Improving obstetric

accompanied by enhancement of hospital facilities to ensure

availability of appropriate obstetric care and an emergency
(Araujo et al., 1983)
(continued )

transport system (Greenwood et al., 1990; Alisjahbana et

al., 1995). Assurance of emergency transport for referrals
was also an important component in the Brazil intervention
(Araujo et al., 1983). Although its significance was not
evaluated due to the study design, the intervention
Table I

Article

conducted in a rural region of Sudan also resulted in a

substantial increase in referral without such additional

programme components (Ibrahim et al., 1992). However, it
was also observed that there was no significant improve-
ment in pregnancy outcome among those hospitalized
(Ibrahim et al., 1992). In the interventions that did not
produce a significant increase in referral rates, it is possible
that the results were due in part to the TBAs failure to
recognize serious complications (Smith et al., 2000; Rons-
mans et al., 2001; Bailey et al., 2002). However, other
factors such as the cost of hospital services, lack of access to
transportation and patients’ distrust of health care facilities
might also have acted as barriers to referral (Ronsmans et
al., 2001; Bailey et al., 2002).
Interventions evaluated by follow-up survey showed high
levels of knowledge retention among traditional birth
attendants even several years after training, indicating their
capacity for learning new practices despite low levels of
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education and literacy limitations (Eades et al., 1993; Akpala,
1994; Dehne et al., 1995). However, the knowledge of the TBAs
may only be considered as an indirect measure of the impact of
their training in the community. As seen in the studies included
in this review, there is a great dealof variability in the number of
births attended annually in the different programmes,
indicating that successful training alone does not guarantee a
positive impact on maternal health.
The diversity of intervention designs and outcome
measures used in the studies included in this review make
it difficult to draw concrete conclusions about the ideal role
of TBAs and village midwives. Given the heterogeneity of
the settings in which they were implemented, even
For personal use only.
comparing apparently similar studies is complicated by
variation in resources and health facilities available as well
as cultural differences in childbirth practices. Overall the
findings of this review indicate that TBAs and village
midwives can play an important role in interventions to
improve pregnancy outcomes in developing countries.
However, in the programmes that were most successful,
they did not act alone but rather as part of multisectoral
interventions which also ensured access to emergency
obstetric care in the case of life-threatening complications
that cannot be managed efficiently by TBAs or village-based
midwives. In order to understand better the contribution of
trained TBAs and village midwives to the positive outcomes
of these multisectoral programmes, studies are needed to
compare the impact of interventions to improve the
availability of hospital-based emergency obstetric care that
integrate trained TBAs and village midwives in the referral
network with the outcomes of those that do not.
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