Traditional birth attendant training for improving health behaviours and pregnancy outcomes.
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 remains limited and conflicting.


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


METHODS
We searched the Trials Registers of the Cochrane Pregnancy and Childbirth Group and Cochrane Effective Practice and Organisation of Care Group (EPOC) (June 2006); electronic databases representing fields of education, social, and health sciences (inception to June 2006); the internet; and contacted experts.


METHODS
Published and unpublished randomized controlled trials (RCT), controlled before/after and interrupted time series studies comparing trained and untrained TBAs or women cared for/living in areas served by TBAs.


METHODS
Three authors independently assessed study quality and extracted data.


RESULTS
Four studies, involving over 2000 TBAs and nearly 27,000 women, are included. One cluster-randomized trial found significantly lower rates in the intervention group regarding stillbirths (adjusted OR 0.69, 95% confidence interval (CI) 0.57 to 0.83, P < 0.001), perinatal death rate (adjusted OR 0.70, 95% CI 0.59 to 0.83, P < 0.001) and neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82, P < 0.001). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22, P = 0.24) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18 to 1.90, P < 0.001). A controlled before/after study among women who were referred to a health service found perinatal deaths decreased in both intervention and control groups with no significant difference between groups (OR 1.02, 95% CI 0.59 to 1.76, P = 0.95). Similarly, the mean number of monthly referrals did not differ between groups (P = 0.321). One RCT found a significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10 to 3.90, P = 0.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95% CI 0.62 to 3.03, P = 0.44). Another RCT found no significant differences in frequency of postpartum haemorrhage (OR 0.94, 95% CI 0.76 to 1.17, P = 0.60) among women cared for by trained versus TBAs.


CONCLUSIONS
The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness.
Sibley
L M
LM
Nell Hodgson Woodruff School of Nursing, Lillian Carter Center for International Nursing, Emory University, 1520 Clifton Road, Room 428, Atlanta, Georgia 30322, USA. lsibley@emory.edu
Sipe
T A
TA
Brown
C M
CM
Diallo
M M
MM
McNatt
K
K
Habarta
N
N
D005260:Female; D015438:Health Behavior; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008428:Maternal Mortality; D008880:Midwifery / Q000193:education*; D011247:Pregnancy; D011256:Pregnancy Outcome; D016032:Randomized Controlled Trials as Topic