title: How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance.
abstract: BACKGROUND
  Forty years of safe motherhood programming has demonstrated that isolated interventions will not reduce maternal mortality sufficiently to achieve MDG 5. Although skilled birth attendants (SBAs) can intervene to save lives, traditional birth attendants (TBAs) are often preferred by communities. Considering the value of both TBAs and SBAs, it is important to review strategies for maximizing their respective strengths.
  
  
  OBJECTIVE
  To describe mechanisms to integrate TBAs with the health system to increase skilled birth attendance and examine the components of successful integration.
  
  
  METHODS
  A systematic review of interventions linking TBAs and formal health workers, measuring outcomes of skilled birth attendance, referrals, and facility deliveries.
  
  
  RESULTS
  Thirty-three articles met the selection criteria. Mechanisms used for integration included training and supervision of TBAs, collaboration skills for health workers, inclusion of TBAs at health facilities, communication systems, and clear definition of roles. Impact on skilled birth attendance depended on selection of TBAs, community participation, and addressing barriers to access. Successful approaches were context-specific.
  
  
  CONCLUSIONS
  The integration of TBAs with formal health systems increases skilled birth attendance. The greatest impact is seen when TBA integration is combined with complementary actions to overcome context-specific barriers to contact among SBAs, TBAs, and women.
authors.affiliation: The Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia.
authors.forename: Abbey
authors.initials: A
authors.lastname: Byrne
authors.forename: Alison
authors.initials: A
authors.lastname: Morgan
mesh_terms: D019033:Delivery of Health Care, Integrated; D036861:Delivery, Obstetric; D005260:Female; D014943:Global Health; D006801:Humans; D008427:Maternal Health Services; D008428:Maternal Mortality; D008880:Midwifery / Q000193:education*; D010342:Patient Acceptance of Health Care; D011247:Pregnancy