Info Service on Health Issues (April 09/01)
In Defence of
Traditional Birth Attendants
Kendra (GK) in Bangladesh is
well known for its pioneering work in the area of primary health care
one of which is the training of traditional birth attendants (TBAs).
September 2008, GK’s leaders Rafiqul Huda Chaudhury and Zafrullah Chowdhury
wrote an article published in D&C (Development and Cooperation),
Germany’s development magazine where they reported how through TBAs,
rural maternal mortality was reduced.
report drew a response from Dhaka based international health experts
who disagreed that TBAs should be entrusted with delivering babies,
rather professionally trained ‘skilled birth attendants’ (SBAs) should
do the job.
following reply by Drs. Rafiqul H. Chaudhury and Zafrullah Chowdhury
was first published in D&C February 2009.
In defence of
traditional birth attendants
By Rafiqul Huda Chaudhury and Zafrullah Chowdhury, D&C, February 2009
First and foremost,
we thank Mr. Dirk Gehl of KfW, Mr. Jean-Olivier Schmitz of GTZ and Dr.
Tracey Perez Koehlmoos of ICDDR, Dhaka for suggesting a comparative
study of GK Health Workers and trained TBAs with the work of qualified
SBAs in Bangladesh.
The suggested comparative
study should evaluate their
– attitude and performance in antenatal care (ANC) and postnatal care
– willingness, persuasion ability and skill in home-delivery,
– results in terms of mothers’ breast feeding of neonates,
– management of obstructed labour, threatened abortion, eclampsia, pre-eclampsia
and hemorrhage and prompt referral to public (government) health centres
in case of need,
– determination of caring for – and empathy with – pregnant women from
poor social classes,
– adherence to protocols for assisted delivery at home,
– cooperation with SBAs and
GK will provide
all support for such a comparative study to determine outcomes of home
delivery by trained TBAs and SBAs, provided KfW, GTZ and ICDDR organise/finance
such a study under the guidance of a team of independent academics and
We do not know, whether Mr. Gehl, Mr. Schmitz and Dr. Koehlmoos have
actually observed many home deliveries by TBAs in rural Bangladesh or
not. If they wish, GK will happily organise a visit for them to observe
firsthand some home deliveries by trained TBAs in villages.
It is often difficult for foreign-based experts, and even those based
in Dhaka, our capital city, to understand local culture, tradition
and needs. In 1972, when GK started training young rural women with
six to ten years of schooling to conduct basic diagnostic measures and
intervention and treatment of common diseases, professionals with national
and international state of knowledge raised a hue and cry, even questioning
the wisdom of allowing health workers to own, carry and use blood pressure
(BP) machines. Professional nurses in Britain
only got the official permission in 1994 to carry out some tasks GK
health workers have been performing in Bangladesh
To know more about abilities of health axillaries, please read “Tubectomy
by para-professional surgeons in rural Bangladesh”,
published in the Lancet, 27 September 1975. While Europe, including
Britain, is moving towards home delivery of babies,
foreign consultants in Bangladesh,
ignoring local culture, tradition and financial implications, are promoting
institutional delivery. For this reason, they often provide half backed
or twisted information. Moreover, they are not familiar with troubled
governance and the lack of accountability prevalent in Bangladesh’s public sector.
Indeed, “the debate over traditional versus health care” is relatively
recent in Bangladesh
in comparison to that in Europe and North America.
We should not forget TBAs in Europe were burnt as witches even in early
twentieth century; midwives in North America
were debarred from home deliveries till the 1940s due to crusades of
professional bodies and medical journals. Even today, medical professionals
in Europe and America
grumble against work done by SBAs on their own.
Professionals, due to their self-interest, will always “doubt” common
people’s ability and skill. Professionals always feel threatened by
other groups such as TBAs who work with ethical drive, motivation and
social commitments. One of us has worked with hundreds of TBAs in the
past 37 years, and never found a TBA asking for money before helping
to deliver a baby. Nor do the TBAs bargain for fees. They believe that
timely delivery even at odd hours of the night, is their moral obligation
and social duty. Acquiring skills through observation, apprenticeship
and practice is the first step towards the demystification of so-called
professional health care.
Surely, TBAs have some failures, which will decrease substantially not
by condemning them but by giving them five to seven days’ training and
yearly refreshers courses. In our experience, more maternal mortality
occurs at public and private health centres due to absenteeism of doctors
and other skilled workers, even when TBAs referred in time, helped organise
the transport and even accompanied distressed women to the clinics.
There have been many examples of professionals failing to provide prompt
help when a family could not pay enough. TBA shortcomings pale in comparison.
In the past, a TBA training programme run by UNICEF and other donors
failed because of faulty selection processes and inadequate training
places. In reality, TBAs were not selected for training. Instead, the
chosen were young women with no previous experience in child birth.
All training centres were located in Dhaka
and some district towns, but not in rural areas. Right from the start,
the programme had built-in failures.
Present SBA training, moreover, has striking similarities with the failed
TBA training programme. Most SBAs are former family-planning workers
whose job was to prevent conception, not to promote pregnancy. Before
training, none of the SBAs had experience of delivery at home. They
are familiarised with institutional delivery, though their supposed
job is to conduct home delivery in rural areas of Bangladesh.
As most SBAs do not feel confident to conduct home deliveries, they
discourage home deliveries, and refer pregnant women mostly to private
clinics from which SBAs benefit financially.
At present, around 10 % of the deliveries are conducted in government
hospitals and clinics, where negligence and inhuman treatment are quite
common, as Bengalis read in the newspapers day by day. In defence, physicians
take refuge in the shroud of shortage of staff and funds. On the other
hand, over 80 % of the deliveries in Bangladesh
are attended by TBAs at families’ homes with no cost involvement for
the government. Consider what would happen if all home deliveries were
converted into institutional deliveries.
Our focus is to train TBAs to recognise danger signs and to refer promptly.
Give them mobile phones so that they can consult doctors promptly. Trust
them to prescribe Misoprostol orally, rectally and vaginally. Ideally,
all TBAs should be trained to become SBAs. But as long as there are
not enough SBAs and the governmental health-sector’s incentive problems
remain unsolved, training TBAs is certainly the best choice.
Let’s not debate commonsense. It is not the TBAs fault that maternal
mortality in Third World countries
is not declining fast enough. The real problem is the absence of professionals
and/or inadequate facilities at state-run and private clinics – as well
as, to some extent, delay in taking decisions by the family concerned
and difficulties of arranging transport. That is what data from GK programme
GK data (Chaudhury and Chowdhury, 2008) also show that the percentage
of deliveries attended by medically trained personnel is higher for
women who died from complications related to pregnancy and child-birth
than for those women who delivered safely (22 % versus 2.6 %). Consistent
with the above findings, data also show a higher proportion of maternal
deaths (49 %) occurring in hospitals or clinics than at home (37%).
More doctors and more professionals do not necessarily guarantee better
health care. “Caring health care for all” can only be achieved by genuine
political commitment, a good number of physicians backed by many times
more health workers (including trained TBAs and SBAs) – all with humane
attitudes and caring services and ensuring accountability of health
service providers to the community in which they work under the supervision
of elected local Government. Skills development must not be the monopoly
of the professionals.
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