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. (99 percent)(9). The major causes of maternal mortality in developing countries are anemia, hemorrhage, eclempsia, infections, abortions, complication of obstructed labor.
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 attendants (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 pregnancies.
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 support.
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. (3)
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
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