By Ellen Hodnett, professor ellen.hodnett@utoronto.ca

Traditional birth attendants, regardless of how well trained or resourced, are commonly thought to be a poor substitute for care by skilled birth attendants (defined as care providers with professional qualifications, such as doctors, midwives, or nurses) in a healthcare facility. In the linked meta-analysis of studies of deliveries assisted by traditional birth attendants, Wilson and colleagues found that offering training, support, and resources—such as clean delivery kits—to traditional birth attendants reduced perinatal and neonatal deaths in low income countries. This study provides compelling evidence that trained and supported traditional birth attendants save babies’ lives.

There are enormous economic and logistical barriers to the provision of skilled birth attendants in many countries, especially where women live in remote areas with inadequate transport to healthcare facilities. “Healthcare facility” is a term that encompasses everything from a stand alone birth centre to a tertiary care hospital. There is little evidence on the relative merits of most types of healthcare facility, although a review concluded that outcomes for healthy childbearing women and their babies are better for hospital based alternative birth settings than for conventional hospital wards. There are also enormous obstacles to changing care givers’ attitudes and behaviours in healthcare facilities. Innovations such as the World Health Organization Reproductive Health Library and the Better Births initiative in South Africa have involved comprehensive strategies to increase the likelihood of humane evidence based care, with modest success.

The authors of the current meta-analysis acknowledge the heterogeneity of interventions in the included studies, but they argue that the consistency of the individual studies’ findings supports the message that traditional birth attendants make a difference. It could be argued that heterogeneity poses a major challenge to successful implementation of interventions, particularly in resource poor countries, because the key components of the intervention under study cannot be definitively identified. However, the notion that the “active ingredients” of a complex intervention can be pinpointed is rooted in an assumption that the various components can be treated as though each is a single intervention and standardised into a one size fits all package. A BMJ editorial challenged this view, arguing that effective complex interventions are based on theory driven principles, which ensure that the process is standardised while the content is tailored to identified community needs.

Over the past six years, despite massive efforts, there has been little progress towards achieving millennium development goal 4 (reducing child mortality) or millennium development goal 5 (improving maternal health), except in a few countries where recent statistics give reason for hope. We know much about what constitutes safe and effective care for most pregnant women. The major research challenges are in the translation of this knowledge—how to effectively implement what is known, and how to influence policy to support the proper delivery of interventions that are known to be effective. With clear evidence that training and support for traditional birth attendants reduces perinatal mortality, WHO is ideally positioned to lead the way in the knowledge translation efforts that are the crucial next steps. But WHO cannot act without the invitation and backing of countries themselves. How can the political will be created, particularly in societies where women and children are at best second class citizens?

At least one country has resorted to legislation. The review of continuous support for women during childbirth was used to persuade the government of Brazil to enact the “Companion Law,” which states that all women have the right to companionship during labour and birth. But surely legislation is not the only, or best, solution to all forms of substandard care. We badly need more effective and flexible means of ensuring knowledge translation.

Trained, supported, and adequately resourced traditional birth attendants save babies’ lives and potentially save their mothers’ lives too. Some countries may welcome communication of this information. For settings in which less positive attitudes to maternal and child health prevail, the urgent research priority is to devise effective knowledge translation strategies that will ensure that the fundamental human rights of women and children are met.

Source: BJM (Helping doctors make better decisions)

http://www.bmj.com/content/344/bmj.e365