matrix database literature.xlsx

TABEL EVIDENCE MATRIX FOR LITERATUR

LJ

METHODOLOGICAL CHARACTERISTICS CONTENT SPESIFIC FINDING

Year Study Design Studi Population Sampel Size Results Conclusion Other Comments

1 2013

MODEL “PELATIHAN PEDULI DUKUN BAYI” UNTUK MENINGKATKAN POTENSI SEBAGAI AGENT OF CHANGE PELAKSANAAN INISIASI MENYUSU DINI

Lead Author, Article Title, Jurnal Citation Intervention

Characteristic

Pfeiffer and Mwaipopo, Delivering at home or in a health facility? health-seeking behaviour of women and the role of traditional birth attendants in Tanzania, BMC Pregnancy and Childbirth 2013, 13:55 http://www.biomedcentral.com/1471-2393/13/55

Using a mixed-methods approach, quantitative as well as qualitative

The study focused on various levels within the society and the health system, involving (1) women who had delivered in the past 2 months, (2) TBAs, and (3) community members

200 women were interviewed: 100 of them in urban and 100 in rural sites. 14 TBAs (10 in Masasi District and 4 in Ward Ilala, Dar es Salaam), the community perspective, 8 Focus-Group Discussions (4 in Ward Ilala and 4 in Maundo)

N/A not an intervention

The results from the urban site show that significant achievements have been made in terms of promoting pregnancy- and delivery-related services through skilled health workers. Pregnant women have a high level of awareness and clearly prefer to deliver at a health facility. The scenario is different in the rural site (Masasi District), where an adequately trained health workforce and well-equipped health facilities are not yet a reality, resulting in home deliveries with the assistance of either a TBA or a relative.

Instead of focusing on the traditional sector, it is argued that more attention should be paid towards (1) improving access to as well as strengthening the health system to guarantee delivery by skilled health personnel; and (2) bridging the gaps between communities and the formal health sector through communitybased counselling and health education, which is provided by well-trained and supervised village health workers who inform villagers about promotive and preventive health services, including maternal and neonatal health.

Several formative research studies that aim at evaluating the effectiveness and cost of scaleable strategies are being implemented in order to improve neonatal and maternal health in rural southern Tanzania through community-based interventions and by introducing community health workers

LJ


Year Study Design Studi Population Sampel Size Results Conclusion Other CommentsLead Author, Article Title, Jurnal Citation Intervention

Characteristic

2 2010Christopher J Gill, et. Al "Effect of training traditional birth attendants on neonatalmortality (Lufwanyama Neonatal Survival Project):randomised controlled study" BMJ 2011; 342:d346doi:10.1136/bmj.d346

Prospective, cluster randomised and controlled effectiveness study.

All births carried out by study birth attendants occurred at mothers’ homes, in rural village settings.

127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status)

Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits).

Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductionsin mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia werereduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups.

Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting.

This approach has high potential to be applied to similar settings with dispersed rural populations.


NO


Year Study Design Studi Population Sampel Size Intervention Characteristic Results Conclusion Other Comments

1 2013 N/A not an intervention


Lead Author, Article Title, Jurnal Citation

Pfeiffer and Mwaipopo, Delivering at home or in a health facility? health-seeking behaviour of women and the role of traditional birth attendants in Tanzania, BMC Pregnancy and Childbirth 2013, 13:55 http://www.biomedcentral.com/1471-2393/13/55

Using a mixed-methods approach, quantitative as well as qualitative

The study focused on various levels within the society and the health system, involving (1) women who had delivered in the past 2 months, (2) TBAs, and (3) community members

200 women were interviewed: 100 of them in urban and 100 in rural sites. 14 TBAs (10 in Masasi District and 4 in Ward Ilala, Dar es Salaam), the community perspective, 8 Focus-Group Discussions (4 in Ward Ilala and 4 in Maundo)

The results from the urban site show that significant achievements have been made in terms of promoting pregnancy- and delivery-related services through skilled health workers. Pregnant women have a high level of awareness and clearly prefer to deliver at a health facility. The scenario is different in the rural site (Masasi District), where an adequately trained health workforce and well-equipped health facilities are not yet a reality, resulting in home deliveries with the assistance of either a TBA or a relative.

Instead of focusing on the traditional sector, it is argued that more attention should be paid towards (1) improving access to as well as strengthening the health system to guarantee delivery by skilled health personnel; and (2) bridging the gaps between communities and the formal health sector through communitybased counselling and health education, which is provided by well-trained and supervised village health workers who inform villagers about promotive and preventive health services, including maternal and neonatal health.

Several formative research studies that aim at evaluating the effectiveness and cost of scaleable strategies are being implemented in order to improve neonatal and maternal health in rural southern Tanzania through community-based interventions and by introducing community health workers

NO


Year Study Design Studi Population Sampel Size Intervention Characteristic Results Conclusion Other CommentsLead Author, Article Title, Jurnal Citation

2 2010Christopher J Gill, et. Al "Effect of training traditional birth attendants on neonatalmortality (Lufwanyama Neonatal Survival Project):randomised controlled study" BMJ 2011; 342:d346doi:10.1136/bmj.d346

Prospective, cluster randomised and controlled effectiveness study.

All births carried out by study birth attendants occurred at mothers’ homes, in rural village settings.

127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status)

Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits).

Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductionsin mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia werereduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups.

Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting.

This approach has high potential to be applied to similar settings with dispersed rural populations.

NO




4 Administration of misop2010

Ebuehi and Akintujoye, Perception and utilization of traditional birth attendants by pregnant women attending primary health care clinics in a rural Local Government Area in Ogun State, Nigeria. Dove Press Journals; International Journal of Women’s Health 3 Februari 2012

A quantitative design ; a descriptive cross-sectional study

The study was carried out among registered pregnant women attending the antenatal clinics of selected PHCs inIfo LGA.

250 pregnant women attending four randomly selected primary health care clinics in the LGA..

Almost half (48.8%) of the respondents were in the age group 26–35 years, with a mean age of 29.4 kurang lebih7.33 years. About two-thirds (65.6%) of the respondents had been pregnant 2–4 times before. TBA functions, as identified by respondents, were: “taking normal delivery” (56.7%), “providing antenatal services” (16.5%), “performing caesarean section” (13.0%), “providing family planning services” (8.2%), and “performing gynaecological surgeries” (5.6%). About 6/10 (61.0%) respondents believed that TBAs have adequate knowledge and skills to care for them, however, approximately 7/10 (69.7%) respondents acknowledged that complications could arise from TBA care. Services obtained from TBAs were: routine antenatal care (81.1%), normal delivery (36.1%), “special maternal bath to ward off evil spirits” (1.9%), “concoctions for mothers to drink to make baby strong” (15.1%), and family planning services (1.9%). Reasons for using TBA services were: “TBA services are cheaper” (50.9%), “TBA services are more culturally acceptable in my environment” (34.0%), “TBA services are closer to my house than hospital services” (13.2%), “TBAs provide more compassionate care than orthodox health workers” (43.4%), and “TBA service is the only maternity service that I know” (1.9%). Approximately 8/10 (79.2%) of the users (past or current) opined that TBA services are effective but could be improved with some form of training (78.3%). More than three-quarters (77.1%) opposed the banning of TBA services. Almost 7/10 (74.8%) users were satisfied with TBA services.

Study findings revealed a positive perception and use of TBA services by the respondents. This underlines the necessity for TBAs’ knowledge and skills to be improved within permissible standards through sustained partnership between TBAs and health systems.

It is hoped that such partnership will foster a healthy collaboration between providers of orthodox and traditional maternity services that will translate into improved maternal and neonatal health outcomes in relevant settings.

A randomised, double-blind, placebo-controlled tria

A total of 1119 women giving birth at home.

intervention=534 women and control=585 women

consenting women were randomised to receive 600 lg oral misoprostol (n = 534) or placebo (n = 585) after delivery to determine whether misoprostol reduced the incidence of PPH (‡500 ml)

Oral misoprostol was associated with a significant reduction in the rate of PPH (‡500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59–0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62–1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34–0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants.

Postpartum administration of 600 lg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible.

Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug. Misoprostol may be the only feasible PPH prevention option, it should be endorsed as a safe and effective alternative intervention for use at home deliveries.

NO



5 2012Georgina Msemo, Augustine Massawe et.al, Newborn Mortality and Fresh Stillbirth Rates in Tanzania After Helping Babies Breathe Training, Pediatrics 2013;131;e353; originally published online January 21, 2013; DOI: 10.1542/peds.2012-1795, http://pediatrics.aappublications.org/content/131/2/e353.full.html

design was used for implementation

HBB was implemented in 8 hospitals designated as study sites. Master trainers from the 3 major referral hospitals, 4 associated regional hospitals, and 1 district hospital were trained in the HBB program to serve as trainers for national dissemination

A before(n = 8124) and after (n = 78 500)

Implementation of HBB Training Program

Implementation was associated with a significant reduction in neonatal deaths (relative risk [RR] with training 0.53; 95% confidence interval [CI] 0.43–0.65; P =.0001) and rates of FSB (RR with training0.76; 95% CI 0.64–0.90; P = .001). The use of stimulation increased from 47% to 88% (RR 1.87; 95% CI 1.82–1.90; P =.0001) and suctioning from 15% to 22% (RR 1.40; 95% CI 1.33–1.46; P =.0001) whereas face mask ventilation decreased from 8.2% to 5.2% (RR 0.65; 95% CI 0.60–0.72; P = .0001).

HBB implementation was associated with a significant reduction in both early neonatal deaths within 24 hours and rates of FSB. HBB uses a basic intervention approach readily applicable at all deliveries.

These findings should serve as a call to action for other resource-limited countries striving to meet Millennium Development Goal 4

NO



6

2009 N/A not an interventionGary L. Darmstadt, Anne CC Lee et.al, INTRAPARTUM-RELATED DEATHS: EVIDENCE FOR ACTION 5; 60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?, International Journal of Gynecology and Obstetrics 107 (2009) S89–S112, journal homepage: www.elsevier.com/locate/ijgo

review the evidence for the effect of care by different community cadres during pregnancy and childbirth. we use GRADE criteria to assess the quality of evidence for the mortality-effect of these community-based providers on outcomes related to acute intrapartum hypoxia

Searches of the following databases of the medical literature were conducted: PubMed, Popline, EMBASE, LILACS, IMEM, African Index Medicus, Cochrane, and World Health Organization (WHO) documents.

The initial search was conducted in November 2002, and was updated May 2009. Keyword searches relevant for this paper included “birth asphyxia/asphyxia neonatorum,” “hypoxic ischaemic encephalopathy/hypoxic ischemic encephalopathy,” “neonatal encephalopathy,” or “neonatal mortality,” and a combination of “TBA/trained TBA/traditional birth attendant,” “community health worker/village health workers/community health aides,” “birthing center,” “skilled birth attendant/skilled attendant,” or “community midwives OR midwifery.”

The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%–47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a metaanalysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.

Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. Whilethe role of the TBA is still controversial, strategies emphasizing partnerships with the health system shouldbe further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

More research is needed to determine the cost- effectiveness, sustainability, scalability and long-term impact, including neurodevelopmental outcomes, of such approaches. While the goal is to have a skilled attendant at every birth, innovative community strategies with health systems strengtheningmay provide childbirth care to the poor, help reduce the gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

NO



7 2012Sabin LL, Knapp AB, MacLeod WB, Phiri-Mazala G, Kasimba J, et al. (2012) Costs and Cost-Effectiveness of Training Traditional Birth Attendants to Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study (LUNESP). PLoS ONE 7(4): e35560. doi:10.1371/journal.pone.0035560.

LUNESP was a cluster-randomized trial

All TBAs and mothers who participated in the LUNESP trial, in an impoverished rural district in north-central Zambia among a population with limited access to health care

A total of 120 TBAs were initially randomized to receive the intervention trainings and equipment, or to continue their existing standard of care

All TBAs received one ‘clean delivery’ kit per birth for their regular TBA duties, which included a delivery sheet, cord cutter, cotton cord ties, latex gloves, and soap. Training for intervention TBAs commenced with 4-day sessions for each group of 30 TBAs, followed by 1–2 day refresher trainings approximately every 3–4 months for the duration of the trial. The trainings were conducted collaboratively by a US-based neonatologist and a local master trainer (a Zambian nurse-midwife), assisted by 6–8 Zambian facilitators. To demonstrate competency, intervention TBAs indicated skills retention at each retraining session. Each intervention TBA received one resuscitator mask, a polypropylene bottle with chlorinated water, and a laminated reference card summarizing NRP and trigger conditions for AFR. They also received each of the following per delivery: two flannel receiving blankets, a soft rubber bulb syringe, two 250 mg amoxicillin capsules, one 2-ounce mixing cup and spoon, and a 3 ml oral syringe. A more detailed description of the design, training, and analytic methods used in LUNESP has been published elsewhere

We calculated LUNESP’s financial and economic costs and the economic cost of implementation for a forecasted ten-year program (2011–2020). In each case, we calculated the incremental cost per death avoided and disability-adjusted life years (DALYs) averted in real 2011 US dollars. The forecasted 10-year program analysis included a base case as well as ‘conservative’ and ‘optimistic’ scenarios. Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. The estimated financial and economic costs of LUNESP were $118,574 and $127,756, respectively, or $49,469 and $53,550 per year. Fixed costs accounted for nearly 90% of total costs. For the 10-year program, discounted total and annual program costs were $256,455 and $26,834 respectively; for the base case, optimistic, and conservative scenarios, the estimated cost per death avoided was $1,866, $591, and $3,024, and cost per DALY averted was $74, $24, and $120, respectively. Outcomes were robust to variations in local costs, but sensitive to variations in intervention effect size, number of births attended by TBAs, and the extent of foreign consultants’ participation.

Based on established guidelines, the strategy of using trained TBAs to reduce neonatal mortality was ‘highly cost effective’.

We strongly recommend consideration of this approach for other remote rural populations with limited access to health care. Moreover, it shows that the cost-effectiveness of this strategy can likely be improved if implemented programmatically over a longer time horizon and with deliberate cost-saving measures. These results further strengthen the rationale for implementing programs similar to LUNESP in other disadvantaged communities with extremely limited access to health care.

NO



8 2012Christopher J. Gilla,b, Nicholas G. Guerinac, et. Al., Training Zambian traditional birth attendants to reduce neonatal mortality in the Lufwanyama Neonatal Survival Project (LUNESP), Int J Gynaecol Obstet. 2012 July ; 118(1): 77–82. doi:10.1016/j.ijgo.2012.02.012


pregnant women, their husbands, clinic staff, and TBAs; local village headmen and religious leaders

98% of the TBAs considered farming as their primary vocation. Their educational level was low: 17% had never attended school and only 13% had progressed beyond primary school. The TBAs were members of the communitiesthey served, used clean delivery kits for every birth, and were registered, supported, and tracked by the Lufwanyama DHMT. On average, the intervention TBAs delivered 1.3 infants per month, or approximately 33 infants per TBA (interquartile range, 16–44; maximum 112) during the study, which was conducted between September 2006 and November 2008.

The study tested 2 interventions: a simplified version of the American Academy of Pediatrics’ neonatal resuscitation protocol (NRP); and antibiotics with facilitated referral (AFR).

The LUNESP study showed that trained TBAs can be highly effective at reducing neonatal mortality in remote rural settings. Given how successful this strategy proved to be, it seems puzzling that TBAs are so rarely included in national health programs. Key elements that enabled the positive study result were: focusing on common and correctible causes of mortality; selecting a study population with high unmet public health need; early community mobilization to build awareness and support; emphasizing simplicity in the intervention technology and algorithms; using a traditional training approach appropriate to students with low literacy rates; requiring TBAs to demonstrate their competence before completing each workshop; and minimizing attrition of skills by retraining and reassessing the TBAs regularly throughout the study.

An effective NRP training model was created that is suitable for community-based neonatal interventions, in research or programmatic settings, and by practitioners with limited obstetric skills and low rates of literacy.

The skills and approaches adopted in LUNESP should be highly generalizable to other remote populations with limited access to health facilities.

NO



9 2010 N/A not an interventionL Keri, D Kaye, and K Sibylle, Referral practices and perceived barriers to timely obstetric care among Ugandan traditional birth attendants (TBA), Journal List Afr Health Sciv.10(1); Mar 2010

Qualitative methods

All focus groups were held in Luganda, the local language familiar to all research participants.

The six focus groups, which ranged in size from 5 to 12 participants

While TBAs, particularly those with previous training, appear willing to refer problematic pregnancies and labors, more serious problems exist that could lessen any positive effects of training. These problems include reported abuse by doctors and nurses, and seeing fistula as a disease caused by hospitals.

Training of TBAs can be helpful to standardize knowledge about and encourage timely emergency obstetric referrals, as well as increase knowledge about the causes and preventions of obstetric fistula. However, for full efficacy, training

must be accompanied by greater collaboration between biomedical and traditional health personnel, and increased infrastructure to prevent mistreatment of pregnant patients by medical staff.

NO



10 2011Matendo et al. Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect, BMC Medicine 2011, 9:93 http://www.biomedcentral.com/1741-7015/9/93

That study was a population-based, prospective interventional study

The number of communities selected from the DRC was determined by the sample size calculation for the FIRST BREATH Trial, and the number of deliveries observed was a function of the timing of the study periods for that trial

Baseline data collection=Screened (n = 1,916), Consented (n = 1,893), Births < 1500 grams or missing (n = 26), Eligible for primary outcome (n = 1,867), Post ENC baseline data collection=Screened (n = 5,615), Consented (n = 5,612), Births < 1500 grams or missing (n = 84), Eligible for primary outcome (n = 5,528). Intervention group (NRP training): Screened (n = 2,930), Consented (n = 2,928), Births < 1500 grams or missing (n = 45), Eligible for primary outcome (n = 2,883) dan control group Screened (n = 3,365), Consented (n = 3,365), Births < 1500 grams or missing (n = 48), Eligible for primary outcome (n = 3,317)

study conducted in two phases. In the first phase, theimpact of training using the ENC program was evaluated using an active baseline design. A period of prospective data collection was followed by ENC training and continuation of data collection. This phase was followed by a cluster randomized trial of training using an adaptation of the Neonatal Resuscitation Program (NRP: American Academy of Pediatrics and American Heart Association; 2000 edition). Communities were randomized to either receive NRP training (intervention communities) or to continue to provide care without additional training (control communities).

More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.

Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.

A train-thetrainermodel appears to be effective; the use of this strategymay minimize the impact of the isolation of manyrural communities and their distance from sites of traditionalmedical education. Our findings suggest that implementationshould include a strategy for re-enforcementfollowing the initial training.

NO



11

2011 N/A not an interventionWilson et.al, Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis, BMJ 2011;343:d7102 doi: 10.1136/bmj.d7102 (Published 1 December 2011)

Systematic review with meta-analysis

Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were “birth attend*”, “traditional midwife”, “lay birth attendant”, “dais”, and “comadronas”.

six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants.

All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12;three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26).

Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.

Use of traditional birth attendants without an appropriate package of training, support, linkage with healthcare institutions, and resource supply is unlikely to be effective. Potentially important components that support strategies incorporating traditional birth attendants and that have been proved to be beneficial10 include training and support, as well as linkage with healthcare professionals, continued skill development, access to resources such as clean birth kits and resuscitation equipment, and effective referral pathways. The most effective intervention to improve perinatal and maternal outcomes is the use of skilled birth attendants. Enhanced access to care during pregnancy and labour, in areas with poor coverage of skilled birth attendants, can form part of the solution to meet millennium development goals 4 (reducing child mortality) and 5 (improving maternal health).

NO



12 2012 Survey N/A not an interventionHome birth attendants in low income countries: who are they and what do they do?, Garces et al. BMC Pregnancy and Childbirth 2012, 12:34 http://www.biomedcentral.com/1471-2393/12/34

The survey was administered to a sample of birth attendants conducting home or out-of-facility deliveries in 7 sites in 6 countries (India, Pakistan, Guatemala, Democratic Republic of the Congo, Kenya and Zambia)

A total of 1226 home birth attendants were surveyed.

A total of 1226 home birth attendants were surveyed. Less than half the birth attendants were literate. Eighty percent had one month or less of formal training. Most home birth attendants did not have basic equipment (e.g., blood pressure apparatus, stethoscope, infant bag and mask manual resuscitator). Reporting of births and maternal and neonatal deaths to government agencies was low. Indian auxilliary nurse midwives, whoperform some home but mainly clinic births, were far better trained and differed in many characteristics from the birth attendants who only performed deliveries at home.

Home birth attendants in low-income countries were often illiterate, could not read numbers and had little formal training. Most had few of the skills or access to tests, medications and equipment that are necessary to reduce maternal, fetal or neonatal mortality.

In the longer term, or presently in locations where hospitals can absorb the care for women currently delivering at home, an appropriate role for many HBAs might be to help direct pregnant women and their newborns, and especially those with complications, to facilities able to care for them. This approach seems appropriate since, despite their low level of education and medical skills, many of the HBAs are valued members of their communities and are often the local source of information and advice regarding childbirth. As countries or regions move more of their deliveries into hospitals, rather than shunting the HBAs aside, it seems appropriate whenever possible to value the stature of the HBAs in their communities and with appropriate training, explore a role for the HBAs in providing life saving care to pregnant women and their newborns. Incorporatin HBAs into the formal health system as pregnancy advisers, as is currently being done in parts of India, seems like an experiment worth undertaking.

NO



13

2010

14 2009

Carlo et.al, Newborn Care Training and Perinatal Mortality in Communities in Developing Countries, N Engl J Med. 2010 February 18; 362(7): 614–623. doi:10.1056/NEJMsa0806033

a train-the-trainer model

local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia)

intervention was (N=57, 643). The controlled trial (N=62,366).

train-the-trainer educational program utilized various teaching methods for participant learning, including clinical practice sessions and demonstrations to train all birth attendants in the study procedures and in the two courses.

The 7-day follow-up rate was 99.2%. Following Essential Newborn Care training, there was no significant reduction from baseline in all-cause 7-day neonatal (RR 0.99; CI 0.81, 1.22) or perinatal mortality; there was a significant reduction in the stillbirth rate (RR 0.69; CI 0.54, 0.88; p<0.01). Seven-day neonatal mortality, stillbirth, and perinatal mortality were not reduced in clusters randomized to Neonatal Resuscitation Program training as compared with control clusters.

Seven-day neonatal mortality did not decrease following the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced following this intervention. Subsequent training in the NeonatalResuscitation Program did not significantly reduce the mortality rates. (clinicaltrials.gov number, NCT00136708).

These data suggest that training in basic neonatal care may have a role in improving perinatal outcomes in the developing world, although more work is needed to further reduce perinatal mortality.

Falle et.al, Potential Role of Traditional Birth Attendants in Neonatal Healthcare in Rural Southern Nepal, J HEALTH POPUL NUTR 2009 Feb;27(1):53-61 ISSN 1606-0997

The survey instrument

The population of 230,000 in this area lives mainly in rural farming communities and consists of two broadly-defined ethnic groups: Maithili-speaking ‘Madeshi’ (originating from the southern plains region and comprising mostly lower castes) and mainly Nepali-speaking ‘Pahadi’ (originating from the hills and comprising mostly higher castes, i.e. Brahmin and Chettri).

Randomly selected TBAs (n=93) (54 Madeshi and 39 Pahadi)

Comparisons between Pahadi and Madeshi, and trained and untrained TBAs

TBAs were interviewed to gain a more thorough understanding of their knowledge, at¬titudes, and practices regarding maternal and newborn care. Practices, such as using a clean cord-cutting instrument (89%) and hand-washing before delivery (74%), were common. Other beneficial practices, such as thermal care, were low. Trained TBAs were more likely to wash hands with soap before delivery, use a clean delivery-kit, and advise feeding colostrum. Although mustard oil massage was a universal practice, 52% of the TBAs indicated their willingness to consider alternative oils. Low-cost, evidence-based interven¬tions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high. Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care.

Some clean delivery practices, such as the use of a clean cord-cutting instrument, were very high overall, and others, such as hand-washing, were significantly higher among trained TBAs. Breastfeeding is a standard practice in Nepal, al¬though early and exclusive breastfeeding continues to remain a challenge (19,22). Efforts to promote colostrum and early and exclusive breastfeeding, especially in the Madeshi community, could be of great benefit given the significantly lower levels of knowledge and practice and higher rates of neona¬tal mortality in these communities. Mustard oil is of questionable safety for newborns (27) and could be replaced by oils that have been shown to enhance skin-barrier function and reduce mortality, such as sunflower oil (28-30).

Given the current pervasiveness of deliveries in the home, the potential to work with TBAs to promote and pro¬vide available low-cost, low-tech and effective in¬terventions that address immediate neonatal care should be further explored. The TBAs in this setting indicated their willingness to consider alternatives to mustard oil, confirming previous research on attitudes towards alternative oils in the general population (26) and suggesting the potential for development and testing of com¬munity-based interventions.

NO



15 2012 N/A not an interventionTedla Mulatu Temesgen, Jemal Yousuf Umer, Dawit Seyoum Buda, Tilahun Nigatu Haregu. Contribution of traditional birth attendants to the formal health system in Ethiopia: the case of Afar region, Pan Afr Med J. 2012;13(Supp 1):15, http://www.panafrican-med-journal.com/content/series/13/1/15/full

A qualitative study

The district health office (2) and head of women affairs (1) were interviewed about their views on TTBAs and whether they were willing to support the collaboration between TTBAs and formal health service providers. Women (3) from the community were also interviewed about their experiences with TTBAs during their pregnancy and delivery andabout their perspective on maternity care in health facilities. The men (kebeleleaders and married adult men) from the community were interviewed about their views on the role of TTBAs in the health system and their recommendations. Furthermore, 7 TTBAs were interviewed

21 in-depth interviews and 6 focus group discussions were conducted with health service providers, trained traditional birth attendants, mothers, men, kebele leaders and district health personnel

The findings of this study indicate that trained traditional birth attendants are the backbone of the maternal and child health development in pastoralist communities. However, the current numbers are inadequate and cannot meet the needs of the pastoralist communities including antenatal care, delivery, postnatal care and family planning. In addition to service delivery, all respondents agreed on multiple contributions of trained TBAs, which include counselling, child care, immunisation, postnatal care, detection of complication and other social services.

Without deployment of adequate numbers of trained health workers for delivery services, trained traditional birth attendants remain vital for the rural community in need of maternal and child health care services. With close supportive supervision and evaluation of the trainings, the TBAs can greatly contribute to decreasing maternal and newborn mortality rates.

TTBAs remain a vital resource in rural Ethiopia, particularly in the provision of maternal and child health care services. With availability of requisite tools and equipment, close supportive supervision, access to continuing education and recognition by the formal health system, trained traditional birth attendants can effectively contribute towards efforts to decrease maternal and newborn mortality rates in the country. Both governmental and non-governmental bodies should give the necessary recognition andsupport to this cadre of traditional health service providers.

NO



16 2010 N/A not an interventionThatte et.al, Traditional birth attendants in rural Nepal: Knowledge, attitudes, and practices about maternal and newborn health, Glob Public Health. 2010 ; 4(6): 600–617. doi:10.1080/17441690802472406

A Qualitative study

TBAs were identified by local community members. TBAs who had attended at least one delivery in the previous three months and who had been involved in antenatal, intrapartum, and postnatal care were eligible for participation in the study. This excluded delivery assistants who were only responsible for cutting the cord or giving oil massage during or after delivery. Trained TBAs were those who had received any type of delivery training outside the home through a local health centre and/or hospital.

Twentyone trained and untrained TBAs participated in focus groups and in-depth interviews about antenatalcare, delivery practices, maternal complications, and newborn care.

Antenatal care included advice about nutrition and tetanus toxic (TT) immunization but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs though hand washing practices differed by training status. There was no standard practice to identify maternal complications such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

TBAs continue to play an important role in home deliveries in Nepal. While the role of TBAs in managing maternal complications remains uncertain, practices such as oral administration of misoprostol and planning ahead for maternal complications, may improve outcomes and may be feasible for TBAs TBAs are also present during the immediate postpartum period when healthy neonatal practices are essential. Education, behaviour change, and service delivery interventions can address important causes of neonatal deaths. Immediate and exclusive breastfeeding, improved resuscitation methods, education about hand washing before delivery and thermal care are interventions that may be feasible for TBAs with proper training.

This qualitative research provides unique details about traditional practices of TBAs in rural Nepal. Information may be used to develop structured surveys about TBA practices in the community. Future programs and research should explore integrating TBA training and practices with that of existing community health workers while acknowledging their important cultural role.


NO






Characteristic

Ebuehi and Akintujoye, Perception and utilization of traditional birth attendants by pregnant women attending primary health care clinics in a rural Local Government Area in Ogun State, Nigeria. Dove Press Journals; International Journal of Women’s Health 3 Februari 2012

A quantitative design ; a descriptive cross-sectional study

The study was carried out among registered pregnant women attending the antenatal clinics of selected PHCs inIfo LGA.

250 pregnant women attending four randomly selected primary health care clinics in the LGA..

Almost half (48.8%) of the respondents were in the age group 26–35 years, with a mean age of 29.4 kurang lebih7.33 years. About two-thirds (65.6%) of the respondents had been pregnant 2–4 times before. TBA functions, as identified by respondents, were: “taking normal delivery” (56.7%), “providing antenatal services” (16.5%), “performing caesarean section” (13.0%), “providing family planning services” (8.2%), and “performing gynaecological surgeries” (5.6%). About 6/10 (61.0%) respondents believed that TBAs have adequate knowledge and skills to care for them, however, approximately 7/10 (69.7%) respondents acknowledged that complications could arise from TBA care. Services obtained from TBAs were: routine antenatal care (81.1%), normal delivery (36.1%), “special maternal bath to ward off evil spirits” (1.9%), “concoctions for mothers to drink to make baby strong” (15.1%), and family planning services (1.9%). Reasons for using TBA services were: “TBA services are cheaper” (50.9%), “TBA services are more culturally acceptable in my environment” (34.0%), “TBA services are closer to my house than hospital services” (13.2%), “TBAs provide more compassionate care than orthodox health workers” (43.4%), and “TBA service is the only maternity service that I know” (1.9%). Approximately 8/10 (79.2%) of the users (past or current) opined that TBA services are effective but could be improved with some form of training (78.3%). More than three-quarters (77.1%) opposed the banning of TBA services. Almost 7/10 (74.8%) users were satisfied with TBA services.

Study findings revealed a positive perception and use of TBA services by the respondents. This underlines the necessity for TBAs’ knowledge and skills to be improved within permissible standards through sustained partnership between TBAs and health systems.

It is hoped that such partnership will foster a healthy collaboration between providers of orthodox and traditional maternity services that will translate into improved maternal and neonatal health outcomes in relevant settings.


NO



4 Administration of misoprostol2010

5 2012



A randomised, double-blind, placebo-controlled tria

A total of 1119 women giving birth at home.

intervention=534 women and control=585 women

consenting women were randomised to receive 600 lg oral misoprostol (n = 534) or placebo (n = 585) after delivery to determine whether misoprostol reduced the incidence of PPH (‡500 ml)

Oral misoprostol was associated with a significant reduction in the rate of PPH (‡500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59–0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62–1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34–0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants.

Postpartum administration of 600 lg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible.

Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug. Misoprostol may be the only feasible PPH prevention option, it should be endorsed as a safe and effective alternative intervention for use at home deliveries.

Georgina Msemo, Augustine Massawe et.al, Newborn Mortality and Fresh Stillbirth Rates in Tanzania After Helping Babies Breathe Training, Pediatrics 2013;131;e353; originally published online January 21, 2013; DOI: 10.1542/peds.2012-1795, http://pediatrics.aappublications.org/content/131/2/e353.full.html


HBB was implemented in 8 hospitals designated as study sites. Master trainers from the 3 major referral hospitals, 4 associated regional hospitals, and 1 district hospital were trained in the HBB program to serve as trainers for national dissemination

A before(n = 8124) and after (n = 78 500)

Implementation of HBB Training Program

Implementation was associated with a significant reduction in neonatal deaths (relative risk [RR] with training 0.53; 95% confidence interval [CI] 0.43–0.65; P =.0001) and rates of FSB (RR with training0.76; 95% CI 0.64–0.90; P = .001). The use of stimulation increased from 47% to 88% (RR 1.87; 95% CI 1.82–1.90; P =.0001) and suctioning from 15% to 22% (RR 1.40; 95% CI 1.33–1.46; P =.0001) whereas face mask ventilation decreased from 8.2% to 5.2% (RR 0.65; 95% CI 0.60–0.72; P = .0001).

HBB implementation was associated with a significant reduction in both early neonatal deaths within 24 hours and rates of FSB. HBB uses a basic intervention approach readily applicable at all deliveries.

These findings should serve as a call to action for other resource-limited countries striving to meet Millennium Development Goal 4


NO






Gary L. Darmstadt, Anne CC Lee et.al, INTRAPARTUM-RELATED DEATHS: EVIDENCE FOR ACTION 5; 60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?, International Journal of Gynecology and Obstetrics 107 (2009) S89–S112, journal homepage: www.elsevier.com/locate/ijgo

review the evidence for the effect of care by different community cadres during pregnancy and childbirth. we use GRADE criteria to assess the quality of evidence for the mortality-effect of these community-based providers on outcomes related to acute intrapartum hypoxia

Searches of the following databases of the medical literature were conducted: PubMed, Popline, EMBASE, LILACS, IMEM, African Index Medicus, Cochrane, and World Health Organization (WHO) documents.

The initial search was conducted in November 2002, and was updated May 2009. Keyword searches relevant for this paper included “birth asphyxia/asphyxia neonatorum,” “hypoxic ischaemic encephalopathy/hypoxic ischemic encephalopathy,” “neonatal encephalopathy,” or “neonatal mortality,” and a combination of “TBA/trained TBA/traditional birth attendant,” “community health worker/village health workers/community health aides,” “birthing center,” “skilled birth attendant/skilled attendant,” or “community midwives OR midwifery.”

The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%–47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a metaanalysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.

Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. Whilethe role of the TBA is still controversial, strategies emphasizing partnerships with the health system shouldbe further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

More research is needed to determine the cost- effectiveness, sustainability, scalability and long-term impact, including neurodevelopmental outcomes, of such approaches. While the goal is to have a skilled attendant at every birth, innovative community strategies with health systems strengtheningmay provide childbirth care to the poor, help reduce the gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

NO



7 2012Sabin LL, Knapp AB, MacLeod WB, Phiri-Mazala G, Kasimba J, et al. (2012) Costs and Cost-Effectiveness of Training Traditional Birth Attendants to Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study (LUNESP). PLoS ONE 7(4): e35560. doi:10.1371/journal.pone.0035560.

LUNESP was a cluster-randomized trial

All TBAs and mothers who participated in the LUNESP trial, in an impoverished rural district in north-central Zambia among a population with limited access to health care

A total of 120 TBAs were initially randomized to receive the intervention trainings and equipment, or to continue their existing standard of care

All TBAs received one ‘clean delivery’ kit per birth for their regular TBA duties, which included a delivery sheet, cord cutter, cotton cord ties, latex gloves, and soap. Training for intervention TBAs commenced with 4-day sessions for each group of 30 TBAs, followed by 1–2 day refresher trainings approximately every 3–4 months for the duration of the trial. The trainings were conducted collaboratively by a US-based neonatologist and a local master trainer (a Zambian nurse-midwife), assisted by 6–8 Zambian facilitators. To demonstrate competency, intervention TBAs indicated skills retention at each retraining session. Each intervention TBA received one resuscitator mask, a polypropylene bottle with chlorinated water, and a laminated reference card summarizing NRP and trigger conditions for AFR. They also received each of the following per delivery: two flannel receiving blankets, a soft rubber bulb syringe, two 250 mg amoxicillin capsules, one 2-ounce mixing cup and spoon, and a 3 ml oral syringe. A more detailed description of the design, training, and analytic methods used in LUNESP has been published elsewhere

We calculated LUNESP’s financial and economic costs and the economic cost of implementation for a forecasted ten-year program (2011–2020). In each case, we calculated the incremental cost per death avoided and disability-adjusted life years (DALYs) averted in real 2011 US dollars. The forecasted 10-year program analysis included a base case as well as ‘conservative’ and ‘optimistic’ scenarios. Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. The estimated financial and economic costs of LUNESP were $118,574 and $127,756, respectively, or $49,469 and $53,550 per year. Fixed costs accounted for nearly 90% of total costs. For the 10-year program, discounted total and annual program costs were $256,455 and $26,834 respectively; for the base case, optimistic, and conservative scenarios, the estimated cost per death avoided was $1,866, $591, and $3,024, and cost per DALY averted was $74, $24, and $120, respectively. Outcomes were robust to variations in local costs, but sensitive to variations in intervention effect size, number of births attended by TBAs, and the extent of foreign consultants’ participation.

Based on established guidelines, the strategy of using trained TBAs to reduce neonatal mortality was ‘highly cost effective’.

We strongly recommend consideration of this approach for other remote rural populations with limited access to health care. Moreover, it shows that the cost-effectiveness of this strategy can likely be improved if implemented programmatically over a longer time horizon and with deliberate cost-saving measures. These results further strengthen the rationale for implementing programs similar to LUNESP in other disadvantaged communities with extremely limited access to health care.


NO



8 2012



Characteristic

Christopher J. Gilla,b, Nicholas G. Guerinac, et. Al., Training Zambian traditional birth attendants to reduce neonatal mortality in the Lufwanyama Neonatal Survival Project (LUNESP), Int J Gynaecol Obstet. 2012 July ; 118(1): 77–82. doi:10.1016/j.ijgo.2012.02.012


pregnant women, their husbands, clinic staff, and TBAs; local village headmen and religious leaders

98% of the TBAs considered farming as their primary vocation. Their educational level was low: 17% had never attended school and only 13% had progressed beyond primary school. The TBAs were members of the communitiesthey served, used clean delivery kits for every birth, and were registered, supported, and tracked by the Lufwanyama DHMT. On average, the intervention TBAs delivered 1.3 infants per month, or approximately 33 infants per TBA (interquartile range, 16–44; maximum 112) during the study, which was conducted between September 2006 and November 2008.

The study tested 2 interventions: a simplified version of the American Academy of Pediatrics’ neonatal resuscitation protocol (NRP); and antibiotics with facilitated referral (AFR).

The LUNESP study showed that trained TBAs can be highly effective at reducing neonatal mortality in remote rural settings. Given how successful this strategy proved to be, it seems puzzling that TBAs are so rarely included in national health programs. Key elements that enabled the positive study result were: focusing on common and correctible causes of mortality; selecting a study population with high unmet public health need; early community mobilization to build awareness and support; emphasizing simplicity in the intervention technology and algorithms; using a traditional training approach appropriate to students with low literacy rates; requiring TBAs to demonstrate their competence before completing each workshop; and minimizing attrition of skills by retraining and reassessing the TBAs regularly throughout the study.

An effective NRP training model was created that is suitable for community-based neonatal interventions, in research or programmatic settings, and by practitioners with limited obstetric skills and low rates of literacy.

The skills and approaches adopted in LUNESP should be highly generalizable to other remote populations with limited access to health facilities.

9 2010L Keri, D Kaye, and K Sibylle, Referral practices and perceived barriers to timely obstetric care among Ugandan traditional birth attendants (TBA), Journal List Afr Health Sciv.10(1); Mar 2010

Qualitative methods

All focus groups were held in Luganda, the local language familiar to all research participants.

The six focus groups, which ranged in size from 5 to 12 participants


While TBAs, particularly those with previous training, appear willing to refer problematic pregnancies and labors, more serious problems exist that could lessen any positive effects of training. These problems include reported abuse by doctors and nurses, and seeing fistula as a disease caused by hospitals.

Training of TBAs can be helpful to standardize knowledge about and encourage timely emergency obstetric referrals, as well as increase knowledge about the causes and preventions of obstetric fistula.

However, for full efficacy, training must be accompanied by greater collaboration between biomedical and traditional health personnel, and increased infrastructure to prevent mistreatment of pregnant patients by medical staff.


NO



10 2011



Matendo et al. Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect, BMC Medicine 2011, 9:93 http://www.biomedcentral.com/1741-7015/9/93

That study was a population-based, prospective interventional study

The number of communities selected from the DRC was determined by the sample size calculation for the FIRST BREATH Trial, and the number of deliveries observed was a function of the timing of the study periods for that trial

Baseline data collection=Screened (n = 1,916), Consented (n = 1,893), Births < 1500 grams or missing (n = 26), Eligible for primary outcome (n = 1,867), Post ENC baseline data collection=Screened (n = 5,615), Consented (n = 5,612), Births < 1500 grams or missing (n = 84), Eligible for primary outcome (n = 5,528). Intervention group (NRP training): Screened (n = 2,930), Consented (n = 2,928), Births < 1500 grams or missing (n = 45), Eligible for primary outcome (n = 2,883) dan control group Screened (n = 3,365), Consented (n = 3,365), Births < 1500 grams or missing (n = 48), Eligible for primary outcome (n = 3,317)

study conducted in two phases. In the first phase, theimpact of training using the ENC program was evaluated using an active baseline design. A period of prospective data collection was followed by ENC training and continuation of data collection. This phase was followed by a cluster randomized trial of training using an adaptation of the Neonatal Resuscitation Program (NRP: American Academy of Pediatrics and American Heart Association; 2000 edition). Communities were randomized to either receive NRP training (intervention communities) or to continue to provide care without additional training (control communities).

More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.

Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.

A train-thetrainermodel appears to be effective; the use of this strategymay minimize the impact of the isolation of manyrural communities and their distance from sites of traditionalmedical education. Our findings suggest that implementationshould include a strategy for re-enforcementfollowing the initial training.

NO



11 2011 N/A not an interventionWilson et.al, Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis, BMJ 2011;343:d7102 doi: 10.1136/bmj.d7102 (Published 1 December 2011)

Systematic review with meta-analysis

Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were “birth attend*”, “traditional midwife”, “lay birth attendant”, “dais”, and “comadronas”.

six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants.

All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P<0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P<0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p<0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P<0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12;three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26).

Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.

Use of traditional birth attendants without an appropriate package of training, support, linkage with healthcare institutions, and resource supply is unlikely to be effective. Potentially important components that support strategies incorporating traditional birth attendants and that have been proved to be beneficial10 include training and support, as well as linkage with healthcare professionals, continued skill development, access to resources such as clean birth kits and resuscitation equipment, and effective referral pathways. The most effective intervention to improve perinatal and maternal outcomes is the use of skilled birth attendants. Enhanced access to care during pregnancy and labour, in areas with poor coverage of skilled birth attendants, can form part of the solution to meet millennium development goals 4 (reducing child mortality) and 5 (improving maternal health).


NO



12 2012 Survey



Characteristic

Home birth attendants in low income countries: who are they and what do they do?, Garces et al. BMC Pregnancy and Childbirth 2012, 12:34 http://www.biomedcentral.com/1471-2393/12/34

The survey was administered to a sample of birth attendants conducting home or out-of-facility deliveries in 7 sites in 6 countries (India, Pakistan, Guatemala, Democratic Republic of the Congo, Kenya and Zambia)

A total of 1226 home birth attendants were surveyed.


A total of 1226 home birth attendants were surveyed. Less than half the birth attendants were literate. Eighty percent had one month or less of formal training. Most home birth attendants did not have basic equipment (e.g., blood pressure apparatus, stethoscope, infant bag and mask manual resuscitator). Reporting of births and maternal and neonatal deaths to government agencies was low. Indian auxilliary nurse midwives, whoperform some home but mainly clinic births, were far better trained and differed in many characteristics from the birth attendants who only performed deliveries at home.

Home birth attendants in low-income countries were often illiterate, could not read numbers and had little formal training. Most had few of the skills or access to tests, medications and equipment that are necessary to reduce maternal, fetal or neonatal mortality.

In the longer term, or presently in locations where hospitals can absorb the care for women currently delivering at home, an appropriate role for many HBAs might be to help direct pregnant women and their newborns, and especially those with complications, to facilities able to care for them. This approach seems appropriate since, despite their low level of education and medical skills, many of the HBAs are valued members of their communities and are often the local source of information and advice regarding childbirth. As countries or regions move more of their deliveries into hospitals, rather than shunting the HBAs aside, it seems appropriate whenever possible to value the stature of the HBAs in their communities and with appropriate training, explore a role for the HBAs in providing life saving care to pregnant women and their newborns. Incorporatin HBAs into the formal health system as pregnancy advisers, as is currently being done in parts of India, seems like an experiment worth undertaking.

13 2010Carlo et.al, Newborn Care Training and Perinatal Mortality in Communities in Developing Countries, N Engl J Med. 2010 February 18; 362(7): 614–623. doi:10.1056/NEJMsa0806033

a train-the-trainer model

local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia)

intervention was (N=57, 643). The controlled trial (N=62,366).

train-the-trainer educational program utilized various teaching methods for participant learning, including clinical practice sessions and demonstrations to train all birth attendants in the study procedures and in the two courses.

The 7-day follow-up rate was 99.2%. Following Essential Newborn Care training, there was no significant reduction from baseline in all-cause 7-day neonatal (RR 0.99; CI 0.81, 1.22) or perinatal mortality; there was a significant reduction in the stillbirth rate (RR 0.69; CI 0.54, 0.88; p<0.01). Seven-day neonatal mortality, stillbirth, and perinatal mortality were not reduced in clusters randomized to Neonatal Resuscitation Program training as compared with control clusters.

Seven-day neonatal mortality did not decrease following the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced following this intervention. Subsequent training in the NeonatalResuscitation Program did not significantly reduce the mortality rates. (clinicaltrials.gov number, NCT00136708).

These data suggest that training in basic neonatal care may have a role in improving perinatal outcomes in the developing world, although more work is needed to further reduce perinatal mortality.


NO



14 2009



Characteristic

Falle et.al, Potential Role of Traditional Birth Attendants in Neonatal Healthcare in Rural Southern Nepal, J HEALTH POPUL NUTR 2009 Feb;27(1):53-61 ISSN 1606-0997

The survey instrument

The population of 230,000 in this area lives mainly in rural farming communities and consists of two broadly-defined ethnic groups: Maithili-speaking ‘Madeshi’ (originating from the southern plains region and comprising mostly lower castes) and mainly Nepali-speaking ‘Pahadi’ (originating from the hills and comprising mostly higher castes, i.e. Brahmin and Chettri).

Randomly selected TBAs (n=93) (54 Madeshi and 39 Pahadi)

Comparisons between Pahadi and Madeshi, and trained and untrained TBAs

TBAs were interviewed to gain a more thorough understanding of their knowledge, at¬titudes, and practices regarding maternal and newborn care. Practices, such as using a clean cord-cutting instrument (89%) and hand-washing before delivery (74%), were common. Other beneficial practices, such as thermal care, were low. Trained TBAs were more likely to wash hands with soap before delivery, use a clean delivery-kit, and advise feeding colostrum. Although mustard oil massage was a universal practice, 52% of the TBAs indicated their willingness to consider alternative oils. Low-cost, evidence-based interven¬tions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high. Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care.

Some clean delivery practices, such as the use of a clean cord-cutting instrument, were very high overall, and others, such as hand-washing, were significantly higher among trained TBAs. Breastfeeding is a standard practice in Nepal, al¬though early and exclusive breastfeeding continues to remain a challenge (19,22). Efforts to promote colostrum and early and exclusive breastfeeding, especially in the Madeshi community, could be of great benefit given the significantly lower levels of knowledge and practice and higher rates of neona¬tal mortality in these communities. Mustard oil is of questionable safety for newborns (27) and could be replaced by oils that have been shown to enhance skin-barrier function and reduce mortality, such as sunflower oil (28-30).

Given the current pervasiveness of deliveries in the home, the potential to work with TBAs to promote and pro¬vide available low-cost, low-tech and effective in¬terventions that address immediate neonatal care should be further explored. The TBAs in this setting indicated their willingness to consider alternatives to mustard oil, confirming previous research on attitudes towards alternative oils in the general population (26) and suggesting the potential for development and testing of com¬munity-based interventions.

NO


Year Study Design Studi Population Sampel Size Results Conclusion Other CommentsLead Author, Article Title, Jurnal Citation Intervention

Characteristic

15 2012Tedla Mulatu Temesgen, Jemal Yousuf Umer, Dawit Seyoum Buda, Tilahun Nigatu Haregu. Contribution of traditional birth attendants to the formal health system in Ethiopia: the case of Afar region, Pan Afr Med J. 2012;13(Supp 1):15, http://www.panafrican-med-journal.com/content/series/13/1/15/full

A qualitative study

The district health office (2) and head of women affairs (1) were interviewed about their views on TTBAs and whether they were willing to support the collaboration between TTBAs and formal health service providers. Women (3) from the community were also interviewed about their experiences with TTBAs during their pregnancy and delivery andabout their perspective on maternity care in health facilities. The men (kebeleleaders and married adult men) from the community were interviewed about their views on the role of TTBAs in the health system and their recommendations. Furthermore, 7 TTBAs were interviewed

21 in-depth interviews and 6 focus group discussions were conducted with health service providers, trained traditional birth attendants, mothers, men, kebele leaders and district health personnel


The findings of this study indicate that trained traditional birth attendants are the backbone of the maternal and child health development in pastoralist communities. However, the current numbers are inadequate and cannot meet the needs of the pastoralist communities including antenatal care, delivery, postnatal care and family planning. In addition to service delivery, all respondents agreed on multiple contributions of trained TBAs, which include counselling, child care, immunisation, postnatal care, detection of complication and other social services.

Without deployment of adequate numbers of trained health workers for delivery services, trained traditional birth attendants remain vital for the rural community in need of maternal and child health care services. With close supportive supervision and evaluation of the trainings, the TBAs can greatly contribute to decreasing maternal and newborn mortality rates.

TTBAs remain a vital resource in rural Ethiopia, particularly in the provision of maternal and child health care services. With availability of requisite tools and equipment, close supportive supervision, access to continuing education and recognition by the formal health system, trained traditional birth attendants can effectively contribute towards efforts to decrease maternal and newborn mortality rates in the country. Both governmental and non-governmental bodies should give the necessary recognition andsupport to this cadre of traditional health service providers.


NO



16 2010



Characteristic

Thatte et.al, Traditional birth attendants in rural Nepal: Knowledge, attitudes, and practices about maternal and newborn health, Glob Public Health. 2010 ; 4(6): 600–617. doi:10.1080/17441690802472406

A Qualitative study

TBAs were identified by local community members. TBAs who had attended at least one delivery in the previous three months and who had been involved in antenatal, intrapartum, and postnatal care were eligible for participation in the study. This excluded delivery assistants who were only responsible for cutting the cord or giving oil massage during or after delivery. Trained TBAs were those who had received any type of delivery training outside the home through a local health centre and/or hospital.

Twentyone trained and untrained TBAs participated in focus groups and in-depth interviews about antenatalcare, delivery practices, maternal complications, and newborn care.


Antenatal care included advice about nutrition and tetanus toxic (TT) immunization but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs though hand washing practices differed by training status. There was no standard practice to identify maternal complications such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

TBAs continue to play an important role in home deliveries in Nepal. While the role of TBAs in managing maternal complications remains uncertain, practices such as oral administration of misoprostol and planning ahead for maternal complications, may improve outcomes and may be feasible for TBAs TBAs are also present during the immediate postpartum period when healthy neonatal practices are essential. Education, behaviour change, and service delivery interventions can address important causes of neonatal deaths. Immediate and exclusive breastfeeding, improved resuscitation methods, education about hand washing before delivery and thermal care are interventions that may be feasible for TBAs with proper training.

This qualitative research provides unique details about traditional practices of TBAs in rural Nepal. Information may be used to develop structured surveys about TBA practices in the community. Future programs and research should explore integrating TBA training and practices with that of existing community health workers while acknowledging their important cultural role.

matrix database literature.xlsx

Documents