Sharing knowhow and joining forces towards Health for All
Contribution to the Annual Report 2012 of the MMI Network

Bridging the gap between communities and formal health services

Abeba is a Traditional Birth Attendant in a pastoralist area of South Omo, Ethiopia. Since receiving training on safe delivery and a delivery kit from us three years ago, she has delivered over 60 babies. (c) Health Poverty Action
Abeba is a Traditional Birth Attendant in a pastoralist area of South Omo, Ethiopia. Since receiving training on safe delivery and a delivery kit from us three years ago, she has delivered over 60 babies. (c) Health Poverty Action

Despite the indicator of 90% of births attended by skilled health personnel under Millennium Development Goal 5 (to reduce maternal mortality by ¾), 52 million births still take place without a skilled birth attendant every year. (1)

The statistics on skilled birth attendance highlight the huge inequalities both between and within countries. Across upper middle income countries the rate of skilled birth attendance (SBA) is 99% in comparison with 49% in low income countries, with lows of 10-12% in some areas. In Bangladesh, SBA is 75% among the richest fifth of the urban population whilst for the poorest fifth the figure is only 6%. (2) SBA is particularly low amongst indigenous women, who are much less likely to access skilled attendance than other groups. (3) For indigenous women and those from other cultural and ethnic minorities, the numerous practical barriers – which can include user fees, underfunded and ill-equipped health systems, shortage of health workers and lack of transport – are compounded by cultural ones. Culturally inappropriate services which dictate how women should give birth, widespread discrimination, and language barriers make accessing mainstream health services a frightening and humiliating experience for many women. It is therefore not surprising that many choose to give birth instead with the assistance of Traditional Birth Attendants (TBA).

With concerns about the safety of attendance by TBAs, from the 1970s to 1990s the World Health Organization (WHO) actively supported the training of TBAs as a strategy to mitigate the high rates of maternal mortality. (4) However, this is widely considered to have been ineffective in reducing maternal deaths (5) and globally focus has now shifted towards skilled birth attendance. Yet as the statistics show, we are still a long way from achieving this.

Some have argued that this siloed approach to improving maternal health care is the reason for these failures and that an integrated approach that combines the medical knowledge of skilled attendants, with the local knowledge and community acceptance of TBAs is needed.

This is the approach taken by Health Poverty Action. In almost all the countries in which we work, many women give birth at home in the presence of a TBA rather than going to health facilities for skilled birth attendance. In many communities, TBAs may be the only ‘health worker’ in the vicinity, as often there is neither a health facility nor health outreach services.

Our programmes recognise that TBAs are generally the first level of contact for pregnant women in the communities and that they are in an important position to influence women (and their family’s) decisions. They largely have the trust of village women (and men) and can be formidable advocates for health-seeking practices in relation to a pregnancy.

Health Poverty Action works to change the role of TBAs, while still acknowledging them as trusted and respected members of the community. We train TBAs to take on a revised role which can include identifying and visiting pregnant women in their communities, encouraging them to attend antenatal care visits, and looking for risk factors in pregnancy. They are also trained to provide accurate advice on topics such as nutrition and breastfeeding. When women go into labour, TBAs often accompany them to the heath centre, acting as a translator and advocate for the women with the health staff, reassuring women and acting as a cultural bridge between them and the health workers. Our programmes create strong links between the trained TBAs and health workers within the formal health system. In many cases TBAs and health workers are given mobile phones and credit so that they can keep in touch with each other and the ambulance for effective referrals of emergency obstetric care cases.

In areas in which SBA is currently impractical, we believe there must be recognition that TBAs remain necessary to conduct deliveries, at least as an interim measure, and we provide support, training and clean delivery kits. For example, the introduction of Free Health Care in Sierra Leone in April 2010 abolished user fees for pregnant women, lactating mothers and children under five introduced in conjunction with a ban on TBA delivery.

Following the ban, Health Poverty Action developed an innovative scheme whereby TBAs are trained and re-positioned and re-branded as Maternal Health Promoters. In this new role their focus is to refer pregnant women to health facilities for anti-natal are and delivery, as well as supporting women through the pregnancy with nutrition, breastfeeding, monitoring malaria prevention and signposting for family planning, rather than actual delivery. We have also established Birth Waiting Rooms, rooms provided by community members to lodge pregnant women who are waiting to give birth. Health Poverty Action is now working with government and other NGOs to expand the Maternal Health Promoter curriculum more widely in the country.

In addition to the removal of the financial incentive, (prior to the 2010 changes TBAs would receive payment following delivery and a share of the user fees paid to health services) a key challenge in redefining the role of TBAs in Sierra Leone has been poor communication between TBAs and health systems, leading to TBAs feeing devalued and posing a barrier to referrals. We have therefore found that strategies that work to strengthen the relationships between TBAs and health centres are vital to improving referrals for skilled birth attendance.



  1. World Health Organisation (2012) OPTIMIZE MNH. WHO recommendations. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting.
  2. accessed 03.03.2013
  3. Sabine Gabrysch, Claudia Lema, Eduardo Bedriñana, Marco A Bautista, Rosa Malca, Oona MR Campbell & J Jaime Miranda , Bulletin of the World Health Organization, 1 July 2009.
  4. “Making Every Mother and Child Count.” World Health Report 2005, page 70.
  5. Interim Report of Task Force 4 on Child Health and Maternal Health 2004, Millennium Project (UNDP), quoting: Rosenfield and Maine 1985; Greenwood, Greenwood et al. 1987; Greenwood, Bradley et al. 1990; Maine 1991; Goodburn, Chowdhury et al. 2000; Smith, Coleman et al. 2000
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