Sharing knowhow and joining forces towards Health for All
Contribution to the Annual Report 2011 of the MMI Network

The risk of birth

A TBA in Guatemala (Barbara Kühlen, action medeor)
A TBA in Guatemala (Barbara Kühlen, action medeor)

Due to the shortage of funds, developing countries are often forced to decide whether to invest into the training of medical midwives or the instruction of traditional birth attendants. The international donor community is focusing on the training of midwives and is therefore ignoring the living reality of millions of women. The protection of the health of mothers and children should not and must not be an “either-or-decision”. Both midwives and traditional birth attendants play an important role in supplying a medical as well as humanly acceptable quality of service, and none should be excluded from the health system.

In September 2010, a global initiative for improving maternal and child health was announced on the Millennium Development Summit by Ban Ki Moon. The professional supervision of births was to be increased. However, since there is still a lack of trained midwives, there is a need for Traditional Birth Attendants (TBAs) - but their work is being debated.

Although there have been reductions in maternal mortality globally, still about 350,000 women die in the aftermath of pregnancy or childbirth each year – 99% of whom are in developing countries. Most of them die because of complications which could be avoided if proper follow up is done during pregnancy and all deliveries take place under the supervision of trained health personnel. Forty eight million women worldwide (35%) give birth to their children without the help of medical staff and in developing countries the average is 59 %. The WHO estimates that, worldwide, there is a lack of about 350,000 midwives.

Programs in Indonesia and Tunisia show that investment in trainings of midwifes and birth attendants lead to a decrease in maternal deaths. But in most of the countries of the South there still seems to be a long way to go. In Ethiopia there are only about 1000 midwives – giving rise to 1 midwife per 76,000 pregnant women. This is far less than the WHO recommendation of 1 midwife per 175 pregnant women.

Due to this gap in health personnel availability, the non-accessibility of adequate health facilities as well as cultural reasons, most of the births are accompanied only by TBAs. These are mostly women who acquired their knowledge through intuition, practical experience or skills passed down from their mothers or relatives. TBAs care for the women during pregnancy, child birth and in post-partum period as well as for their newborn babies. Depending on the country, they also serve as a bridge between the community and the public health sector and send the women to the health centers or hospitals if needed.

The support given to TBAs by a particular government differs greatly between countries. There might be rejection as well as active encouragement. As there are almost no reliable figures on the impact of the TBAs work on maternal mortality, the critics fear that they can do harm on women’s and children’s health. Therefore they want to reduce their role and use the limited funds for training of professional health personnel. On the other hand many stakeholders in the health sector believe that well-instructed Traditional Birth Attendants could minimize the risk of pregnancy and giving birth and could improve the women’s sexual and reproductive health. In the face of inadequate funding in the health sector, the ideal of training sufficient midwives and other medical staff is too far from being reached to solve the huge challenge of maternal health in the next decade.

In contrast to the midwives, TBAs are located in the community and women do not have to travel far to reach them. There is also no language barrier and no ethnical discrimination, as TBAs come from the local communities they work in, such as in Guatemala.

The low level of knowledge among women about sexual and reproductive health is another big challenge. Women often do not recognize the physical changes that take place in their bodies and about the importance of regular medical check-ups. The long reproductive phase is another cause for pregnancy risks. Only 24% of married women use modern contraceptives in Uganda, 24% in Tanzania and 44% in Guatemala. In these areas TBAs educate their patients and inform them about family planning and sexual and reproductive health issues. They reach a large number of village members and often even men listen to their teachings as TBA generally have a high reputation in the community. This is important in many rural settings as most often the men are the ones who decide about questions of sexual and reproductive health. The public health sector is not able to fulfill the task of educating and informing the population about sexual health issues.


For reaching the Millennium Development Goals 4 and 5 (reduction of child mortality and improvement of maternal health) different strategies have to be asserted. More funds have to go into the medical training of midwives and their number has to be increased. In order to achieve that, working conditions and payment have to be improved. Institutions of primary and secondary health care need to be better equipped – with material as well as staff resources. Health service has to be affordable and has to respect socio-cultural factors. In areas where this is not (yet) possible, the Traditional Birth Attendants’ position as trusted persons during pregnancy and childbirth, as well as a bridge to the public health sector should be accepted, improved and rewarded. For achieving this, an intensive discourse with the respective national health systems is indispensable.

Contribution to the MMI Annual Report 2011. Authors: Barbara Kühlen and Frederike Möller-Frentzen, action medeor, and Caroline J. Kent, Deutsche Stiftung Weltbevölkerung

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