Traditional birth attendant training for improving health behaviours and pregnancy outcomes

Traditional birth attendants are important providers of maternity care in developing countries. Many women in those countries give birth at home, assisted by family members or traditional birth attendants (TBAs). TBAs lack formal training and their skills are initially acquired by delivering babies and apprenticeships with other TBAs. Governments and other organisations have conducted training programmes to improve their skills and to link TBAs to health services. There is disagreement about whether these training programmes are effective. This review included six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births and examined the effect of TBA training, or additional training, on TBA behaviour and on pregnancy outcomes. We conclude that while there are a few more studies meeting the inclusion criteria and the results are promising for some outcomes, more evidence is needed to establish the potential of TBA training to improve peri-neonatal mortality. A lack of contrast in training in the intervention and control clusters and an insufficient number of studies may have contributed to the lack of observed differences in maternal deaths and deaths of their babies (early neonatal deaths).

Authors' conclusions: 

The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.

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Background: 

Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes.

Objectives: 

To assess the effects of TBA training on health behaviours and pregnancy outcomes.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search.

Selection criteria: 

Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs.

Data collection and analysis: 

Three authors independently assessed study quality and extracted data in the original and first update review. Three authors and one external reviewer independently assessed study quality and two extracted data in this second update.

Main results: 

Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).

Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).

Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).

We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01). 

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