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Obstetric complications and role of Traditional Birth

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  • Rana Asghar
    Review Article Obstetric complications and role of Traditional Birth Attendants in developing countries Dr. Rana Jawad Asghar (Source: Journal of College of
    Message 1 of 1 , Apr 29, 1999
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      Review Article

      Obstetric complications and role of Traditional Birth
      Attendants in developing countries

      Dr. Rana Jawad Asghar

      (Source: Journal of College of Physicians and Surgeons
      Pakistan, Jan 1999, Volume. 9(1): 55-57)


      Ninety nine percent of all maternal mortality is in the
      developing countries. With limited resources and shattered
      economies it may take a very longtime for these
      countries to provide qualified doctors, and nurses and back
      up structure to reduce high maternal mortality. By training
      TBA?s ( Traditional birth attendants) we could
      dramatically reduce the maternal mortality and other
      obstetric complications with very low cost and utilizing
      existing resources.

      Introduction and back ground:

      Obstetrics complication could be any problems arising in a
      pregnant woman and have effect on her or the fetus. Normal
      developmental stages of pregnancy can be
      disrupted when medical complications develop(1). There
      could be many causes of obstetric complications but the
      most common causes both in developed and
      developing countries are still prolonged obstructed labor,
      hypertensive disorders of pregnancy, hemorrhage, sepsis and
      complications of unsafe abortion. (2)

      Maternal mortality rates in developing countries average
      about 450 per 100,000 live births (goes up to 2000 in some
      areas (3)), compared with an estimated 30 per
      100,000 in developed countries. These rates vary widely
      between different areas of the same region or country. For
      example there may be two-fold high mortality in
      the rural than the urban area (4,5,6). But in some urban
      slums it may be worse than that in rural area because of
      poor hygiene and sanitation and over crowding.
      These people are at high risk of malnutrition and under
      nutrition. But these urban dwellers have the hospitals and
      clinics available at a shorted distance. This is yet
      another question if these services are accessible to them
      or not. Rural population has a very shortage of health
      personal or health facilities. In India four fifths of the
      population but only one fifth of the physicians, are in
      rural areas. In African countries health care coverage to
      rural area is even worse (7).

      According to WHO reproductive health problems account for
      more than one third of the total burden of disease in women
      (8). The World Health Organization
      estimates that 500,000 women die every year from
      complications of pregnancy, including abortion and
      virtually all these deaths occur in developing countries.
      percent)(9). The major causes of maternal mortality in
      developing countries are anemia, hemorrhage, eclempsia,
      infections, abortions, complication of obstructed

      But these deaths represent only a small proportion of the
      total morbidity and mortality attributable to the above
      causes. For every maternal death there are many
      more women in whom, after childbirth, disabilities develop
      that impair their general health and reproductive functions
      with possible reduction in their economic
      activity. For example it has been estimated that in sub-
      Saharan Africa for every maternal death, another 15 women
      are disabled or permanently crippled by
      incontinence, uterine prolapse and infertility due to
      pregnancy of birth related causes. Between two and three
      million African women are left handicapped from
      obstetric complications each year. Additionally, some women
      who survive delivery become chronically ill and eventually
      die from conditions such as diabetes and
      infectious hepatitis. (3)

      The frequency of maternal death in a country depends not
      only on the risk of an average pregnancy, but on the
      fertility rates as well. Not only do women in
      developing countries have higher risk of death with each
      pregnancy; they became pregnant more often. An average
      woman?s lifetime risk of dying a maternal death
      ranges from 1 in 21 in Africa, to one in 9850 in Northern
      Europe (7).

      A majority of the births in most developing countries,
      particularly in the rural areas, takes place at home,
      usually assisted by relatives or traditional birth
      (TBAs). (3) Frequent vaginal examination with unclean hands
      and the application of animal dung and herbal medicines to
      the vulva or the vagina are some of the
      practices, which may cause genital infection (9).

      Pelvic sepsis may follow after these deliveries or
      abortions and when untreated (as usually it happens in
      developing countries) may lead to chronic pelvic
      inflammatory disease which is the underlying cause of many
      cases of infertility, menstrual disorders and ectopic


      The means to prevent deaths from obstetric complications
      have existed for decades, antibiotics for infection,
      cesarean section for obstructed labor, blood transfusion
      and oxytocic drugs for hemorrhage, sedatives and other
      drugs for eclampsia (10). Unfortunately, such treatment is
      not accessible to most women in poor countries.

      The large number of TBAs are present in developing
      countries in most of the rural areas where there are no
      other health care facility exists. And it may take a very
      long time that these developing countries can afford to
      provide qualified doctors or nurses to all parts of their
      population. So it is important to use the immense
      potential which lies in the communities themselves for
      providing basic health care, thus making it possible for
      such communities to improve their capacity for serving
      themselves. TBAs constitute a large segment of that
      potential. This has been proved by many studies that by
      training TBAs in timely recognition and referral of
      pregnancy /delivery/neonatal complications the health
      situation can be improved (11,12,13,14).

      So an immense interest developed in the role of TBAs and
      several training schemes for TBAs were started in many
      developing countries since early 1970s.

      The major areas of training of TBAs are (7)

      *increased safety in the TBAs practice, such as
      cleanliness, especially washing of the hands and clean or
      sterile cord-cutting procedures.

      *non-interference during labor.

      *Care of mothers before, during and after delivery

      *identification and referrals of mother at risk

      *doing away with traditional harmful practices and leaving
      alone or supporting those that contribute to psychosocial

      While TBAs concept is becoming more popular day by day
      there are still some problems to be addressed.

      *lack of an organized system to supervise trained TBAs.

      *Provide continued training for them.

      *availability of basic supplies, such as cord care kits.

      Supervision of TBAs constitutes the major link between them
      and the formal health care system. A shortage of
      supervisory health personal, inadequate transportation
      systems and insufficient financial resources, problems
      cited in WHO survey of the 1972 remains the primary
      obstacles to the development of good supervision (5).

      While giving emphasis on TBAs does not by any way mean that
      there is less importance of referral hospitals, medicines
      and or Gyn & Obs centers staffed by
      well-qualified doctors and nurses. Even if there is no
      transport available for the high-risk mother?s mortality
      can not be improved very much even if the TBAs identify
      high-risk mothers. (15) Same if we don?t have enough and
      safe medicines available for ailments in pregnancy the
      condition may also not change much.

      In an interesting study in Bangladesh it was found that
      Neonatal deaths due to Tetanus in highly trained TBA?s
      cases was reduced to 6%(Control 24 %) and by
      vaccinating mothers with Tetanus Toxoid it was reduced to
      mere 1%(9). So we cant say that by just training TBA?s we
      can solve all the problems, but by providing
      all the back up services we certainly can reduce the high
      maternal mortality in developing countries. (16)

      It has also been argued that as 63% of all maternal deaths
      occur within 24 hours of birth and 80% occurs in the first
      week of birth so it is very important to increase
      the awareness of signs and symptoms of obstetric
      complications among women, family and TBA?s. Even though
      now TBA?s are not trained in emergency obstetric
      care, but it may be a good idea to start training them in
      selected aspects of emergency obstetric care. (2)

      Even though Anemia is not discussed here, but in terms of
      its social and economic consequences, anemia is the most
      important cause of morbidity in non-pregnant
      women of childbearing age in developing countries. Giving
      the TBAs training about picking the Anemic cases by pallor
      (very easily identifiable) and providing them
      supplies of iron and vitamin supplements (quite cheap to
      manufacture) we can reduce some complications by little
      intervention and little investment. (17) In some
      regions the 74 percent of pregnant women are undernourished
      and TBA?s are the main source of nutritional or dietary
      advice. (18) By training them in basic
      nutritional principles there is a real chance to correct
      the problem to some extent.

      Maternity waiting houses (MWH) is another way to reduce the
      risk in women who are at high risk of delivery
      complications and where they wait for the last few
      weeks of their pregnancy and receive medical supervision.
      This is not a new concept as they are functioning from
      beginning of this century in Europe. In the
      developing countries where they are functioning, the TBAs
      are the most important source to pickup the high-risk
      pregnancies and refer them to MWH. (19)

      Barriers to implementation:

      Access to care is a very major barrier. We need a well-
      established network of midwifes or TBA?s with the
      established hospitals. Doctors and TBAs must have very
      good working relationship to work in partnership. (20) The
      opposition from Medical staff (doctors, nurses, and
      midwives) is always a big barrier to implement
      TBA?s training and referral network. But if there are a few
      people who could listen to the cultural and economic needs
      of the population, things do change. (23)

      Provision of FREE ambulances is another factor, which may
      be difficult but not impossible so that high-risk
      deliveries could be refereed to hospitals or well equipped
      Gyn & Obs centers without wasting time and also considering
      that the family may be too poor to afford the ambulance.

      While discussing obstetrics problems we also should not
      forget the social, societal and hidden causes of poor
      health of women in these countries. Unless we address
      these issues the idea to improve health of women in
      developing country is quite far fetched. Until the society
      understand the importance of women health it may be a
      difficult issue to allocate resources for women health in
      economies which are already dying under the burden of heavy
      debts, corrupt or puppet rulers and waging
      civil wars. Unless health officials or policy makers can
      project these deficiencies or weaknesses in a dramatic way
      it may be very difficult to have the attention of
      power full sections of the society to this issue. We have
      to emphasize that women?s status is pivotal towards a
      sustainable development for the future. Targeted
      programs are needed to improve nutrition, health, literacy
      and employment prospects of women.

      The cultural status of women plays an important role in
      depriving her otherwise accessible health care. (15) Then
      there are social and religious beliefs that may
      complicate the situation more. At some places in South Asia
      women are discouraged to go outside home (thus deprived of
      medical supervision) in pregnancy and
      post partum (11). In Africa practices of female
      circumcision and infibulation must be stopped to decrease
      high maternal mortality. (22)

      The easy accessibility to contraceptive methods (may be
      with the help of TBA?s) could easily reduce the high
      maternal mortality and Obstetric complications by
      reducing the risk associated with pregnancy and childbirth.


      The TBA?s could be a big asset in decreasing high rate of
      obstetric complications in the developing countries. To be
      effective they need to be trained and respected
      by their medical colleagues. Availability of transport and
      accessibility of specialized medical care is an important
      part of this integrated approach. Community, public
      health and hospital systems have to be linked together in a
      standing relationship to decrease the high maternal
      mortality in the developing countries. Isolated efforts to
      strengthen one part and not others may be not very
      effective. (24)

      Dr. Rana Jawad Asghar

      Department of Epidemiology, International Health Program,
      University of Washington, Seattle, Washington, USA


      1. Obstetrics Care; Kathryn M. Andolsek ; 1990 ; published
      by Lea & Febiger

      2. Sibley L; Obstetric First Aid in the community?
      partners in safe motherhood. J Nurse Midwifery 1997 Mar-

      3. Paul BK; Maternal Mortality in Africa: 1980-
      87, Soc Sci Med 1993 Sep;37(6);745-52

      4. Essential elements of Obstetrics care at first
      referral level ; 1991 ; WHO.

      5. New trends in Maternal and Child Health,
      Moscow 1974, Regional office for Europe, World Health

      6. Health for a change ; Sue Dowling ; 1983;
      Child Poverty Action Group.

      7. Health Care of women and children in
      developing countries ; Helen M. Wallace, 1990; Third Party
      Publishing Company.

      8. Mbizvo-M-T; Reproductive and sexual health ;
      Central African Journal of Medicine ; 1996 March . 42(3) .
      P 80-5

      9. V. Fauveau ; Maternal tetanus ; International
      Journal of Gyn & Obs, 1993, 40; 3-12.

      10. T Mikkelsen-B; Training in the management of
      critical obstetrics problems ; European Journal of
      Obstetrics, Gynecology and Reproductive Biology
      ; 1996 March. 65(1) P 149-51.

      11. Kwast-B-E; Reduction of Maternal and
      perinatal mortality in rural and per-urban settings ;
      European Journal of Obstetrics, Gynecology and
      Reproductive Biology ; 1996 Oct. 69(1). P 47-53.

      12. Integrating maternal and child health
      services with primary health care ;1990 ; WHO.

      13. Hyppolito SB; Alternative model for low risk
      obstetric care in Third World rural and peri-urban areas,
      Int J Gynaecol Obstet 1992 Jun;38

      14. "The potential of the traditional birth
      Attendant" WHO offset publication, No 95, World Health
      Organisation, Geneva, 1986.

      15. Post M; Preventing Maternal Mortality through
      Emergency Obstetric Care; SARA Issues Papers April 1997.

      16. Thayaparan B; Prevention and control of
      tetanus in childhood. Curr Opin Pediatr 1998 Feb;10(1):4-8

      17. Diallo D; Role of iron deficiency in anemia
      in pregnant women in Mali, Rev Fr Gynecol Obstet 1995 Mar;90
      (30) :142-7

      18. Kogi-Makau W; Role of traditional birth
      attendants in the dissemination of advice on nutrition
      (letter) World Health Forum 1992;13(2-3):197-9

      19. Figa-Talamanca I, Maternal mortality and the
      problem of accessibility to obstetric care; the strategy of
      maternity waiting homes. Soc Sci Med 1996

      20. Dunn PM; Major ethical problems confronting
      perinatal care around the world. Int J Gynaelecol Obstet
      1995 Dec;51(3):205-10

      21. Situation Analysis on the Reproductive health
      of women in Pakistan. ; 1995 ; College of Physicians and
      Surgeons , Pakistan.

      22. Bang AT; Management of childhood pneumonia by
      traditional birth attendants, Bull World Health Organ

      23. Jambai A; Maternal health, war, and religious
      tradition: authoritative knowledge in Pujehun , Sierra
      Leone. Med Anthropol Q 1996

      24. Kwast BE; Building a community-based
      maternity program. Int J Gynaecol Obstet 1995 Jun;48

      Link to this article is as follows.

      Rana Jawad Asghar, MD. MPH
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