Who is a traditional birth attendants

They attend to the majority of deliveries in the rural areas of developing countries. TBAs are highly respected in African communities. They perform cultural rituals and provide essential social support to women during childbirth. Their clients trust them and share their secrets with them. Without modern training on how to attend to pregnant women, however, TBAs are unable to recognise and respond appropriately to complications of pregnancy.

For this reason, deliveries attended by untrained TBAs are risky for women and their babies, leading to poor health outcomes and even death.

Training TBAs has been a key strategy for improving maternal and child health care in many African countries. Although such training has not contributed directly to reduction in maternal mortality, it does appear to improve their effectiveness in other areas such as the reduction of neonatal tetanus, increasing the provision and use of antenatal care, and increasing referrals in case of complications. Therefore, TBAs can be considered an important part of the informal community health care system.

Despite intensive training of TBAs, recent studies have concluded that the impact of training TBAs could also be counter-productive, as it would hold back the training of the necessary numbers of mid-level health care providers. However, TBAs would be the ideal group to use to increase awareness on family planning practices and fight female genital mutilation. Amref Health Africa agrees with WHO and UNICEF that TBAs cannot be substitutes for skilled providers, but strongly believes that they can contribute to the survival of mothers and newborns by facilitating access to needed information, clinical services and support.

In other words, TBAs, like other community health workers, can effectively convey vital information to families and communities in culturally appropriate ways that will help them to recognise danger signs during pregnancy and know where to go for help referral. Amref Health Africa believes that TBAs meet vital community needs in supporting women throughout pregnancy, childbirth and the post-partum periods.

Amref Health Africa advocates for TBAs to work closely with health planners, health professionals and other members of the formal health system as a strong link between the community and the health services.

Distance may delay or postpone the decision to go to the health facility phase one , and it determines travel time from village to health centre phase two. During the rainy season, some health centres are not accessible at all due to heavy floods. To overcome transportation problems and reach a health centre when labour has already started, mothers' shelters maternity waiting homes , places where women can wait for labour during the last few weeks of pregnancy, were constructed near some health centres.

Although practical problems such as the provision of food and care for other children need to be solved Figa'- Talamanca , maternity waiting homes can function well, as long as basic elements are provided Stekelenburg et al.

Women who were assisted by SBAs or trained TBAs value highly that these birth attendants are trained to conduct "a clean and safe delivery. Most inhabitants of Lukulu District seem to be aware of some of the dangers of pregnancy and delivery.

They express overwhelming confidence in the capacity of health centre staff. Trained TBAs belong to the same category as trained, qualified staff according to many villagers. They are seen as "the eyes of the health centre.

This comparison of the skills of trained TBAs with those of health centre staff is realistic. At least half of the deliveries in health centres are attended by classified daily employees CDEs who, like trained TBAs, have no formal medical education. So, whereas all health centre staff were referred to as SBAs in this survey, the term applies to half of them at most.

This illustrates the current worldwide discussion about the definition of a skilled attendant. Some attendants who are supposed to be skilled are not Harvey et al. A remarkably high number of women described an emergency situation fast delivery to explain why an untrained TBA conducted the delivery.

Apparently untrained TBAs are rescuers for those who cannot reach the health facility in time. They are present in most villages. The socio-cultural role of trained and untrained TBAs should not be underestimated. Trained TBAs could therefore play an influential role in linking communities to health facilities, for example, by educating communities about risks of pregnancy and delivery, informing women about their estimated date of delivery, assisting them in being well prepared and providing them with continuous emotional support van Roosmalen et al.

While national and regional programs should focus on increasing the numbers of properly trained midwives, in certain districts where serious shortages of trained health workers exist and investments have been made in the past to empower and train TBAs, continuation of TBA-support programs should be considered. A short-term additive value can be expected.

This strategy will succeed only if both TBAs and health workers are willing to co-operate. Regular training should be organized for TBAs, and they should be compensated for the work they do. Providing them with a regularly replenished delivery kit and a mode of transportation e. On these conditions, TBAs could be of great value at improving pregnancy outcome in developing countries.

Indicators to evaluate the effect of such programs should be developed, for example, the number of referrals or percentage of skilled attendants including trained TBAs present during delivery. Maternal mortality ratios are not appropriate indicators to evaluate the effect of TBA support programs at the district level.

The closer women live to a health facility, the more likely they are to choose to give birth there. Whereas trained TBAs and SBAs are preferred because of their skills acquired by training, untrained TBAs assist when lack of time, transportation or money keep women in labour from reaching the health centre. As long as there is no improvement in the district's poverty level and infrastructure, women will continue to give birth in the village without the assistance of SBAs.

Socio-cultural reasons for assistance from TBAs will not be easy to overcome. Besides, the current number of SBAs in Zambia is too small to assist all women in labour.

Therefore, TBAs cannot yet be excluded from safe motherhood programs. Initiated and carried out the survey. Drafted first version of the manuscript. Initiated the survey. Revised the manuscript critically for substantial intellectual content. Junist Chilwana , health worker Lukulu District, participated in the survey. Martin Liyungu , health worker Lukulu District, participated in the survey. Supervised the survey and revised the manuscript critically for substantial intellectual content.

Initiated and supervised the survey, revised the first manuscript critically for substantial intellectual content and drafted the manuscript for Journal of World Health and Population. Cabral, M. Kamal, V. Kumar and L. Training of traditional birth attendants TBAs. A guide for TBA trainers. Geneva: World Health Organization. Central Statistical Office, Lusaka, Zambia. Central Board of Health, Lusaka, Zambia. Introduction"; "Chapter 9. Maternal and Child Health.

Cham, N. Sundby and S. Figa'- Talamanca, I. Harvey, S. W Bland n, A. McCaw-Binns, I. Sandino, L. Urbina, C. G mez, P. Ayabaca, S. Djibrina and the Nicaraguan maternal and neonatal health quality improvement group. With suitable training and supervision these dangers can be minimized and her potential used to improve the health of mothers and babies.

Increasingly countries are recognizing that the TBA will represent a major resource where women do not have access to services for either cultural or geographic barriers. The effective use of this resource will require an understanding and appreciation of the TBA's role and contribution by all health authorities, flexibility in the development of training programs and the co-operation of the TBAs themselves.

The strength of the TBA comes from the fact that she is part of the cultural and social life of the community in which she lives.