A lack of skilled birth attendants, coupled with poor access to emergency obstetrical care, underlie most of the 500,000 maternal deaths per year in low and middle-income countries. Only half of the deliveries that take place in the developing world occur with the help of a skilled attendant; the rest have a TBA or a relative present, and a significant minority happen alone.

Given the widespread involvement of TBAs in obstetrical care in under-resourced settings, the WHO began encouraging TBA training initiatives in the 1980s. The training programs varied considerably, but most curricula focused on preventative issues, including antenatal care, risk assessment, clean delivery techniques, cord care, immunizations, and breast-feeding. TBAs were trained to refer for obstetrical emergencies.

How could you categorize this intervention?

What strengths and weaknesses of a TBA program would you anticipate?

What outcome measures would you track to determine its impact?

For three decades, NGOs and governments invested heavily in TBA programs, but inadequate attention was paid to systematic, high-quality evaluation of their efficacy. A meta-analysis of 90 studies found that a majority relied upon self-reporting of TBA’s behavior (such as good hygiene practices). The few that reported direct outcomes (incidence of appropriate referrals, incidence of infection, hemorrhage, or maternal mortality) did not show a reliable reduction in morbidity or mortality. Reasons included slow referral for obstructed labor, unhygienic conditions, and inadequate skills and equipment to deal with post-partum hemorrhage.