Safe Beginnings with Trained Birth Attendants

	A traditional birth attendent learns how to resuscitate an infant.

If you are a pregnant woman living in rural Honduras and you develop complications during labor, you may face a seven-hour trek over horrible roads to the nearest health facility. If you’re fortunate, someone you know owns a vehicle. If not, you may be transported by people on foot, carrying you in a hammock.

Such inaccessibility to health care is the norm in certain remote areas of Honduras and other parts of Latin America, and is a central reason for the high rates of maternal mortality in these areas — about 280 deaths per 100,000 live births (compared to 6 in 100,000 in the U.S.).

And almost half of all women do not receive skilled assistance at birth.

While pregnancy and birth are usually perfectly normal processes, dangerous complications do occur with 15 percent of pregnant women, and as many as 585,000 worldwide die of complications that could have been prevented. The main culprits include postpartum hemorrhage, miscarriage, infection, obstructed delivery and pregnancy-induced hypertension. Most maternal deaths occur within one week of delivery. The majority of them occur in the world’s poorest countries, where most births take place under the care — if under any care at all — of a traditional birth attendant (TBA).

Poor people tend to balk at seeking any health care in these areas because of costs and time lost in covering the long distances to facilities. “The problem is that there are not enough health professionals out there, there won’t be for a long time, and there may never be in the places where they’re most needed,” says David Shanklin, ChildFund’s senior health specialist. “So we need to come up with other solutions.”

At the 2010 conference of the American Public Health Association in November, Shanklin presented on the value that TBAs can provide in helping these rural populations access appropriate health care. Central to how ChildFund works is maximizing the resources that are already in place in communities. TBAs are already in place in many communities where we work. “Because they’re in the communities, they identify the women — they open the door,” says Shanklin.

In fact, an engaged community is a critical resource for improving access to health care. Also presenting at the APHA conference was ChildFund regional health advisor Alfonso Rosales, who spoke about ChildFund’s experience in the Americas Region. In a two-year pilot program implemented in Honduras, Guatemala and Bolivia from 2007-2009, ChildFund helped communities set up community health units, called Unidades Comunitarias de Salud (UCOS), in the poorest areas — 25 in Honduras alone, run by 230 trained volunteers and supported by dozens more local members of community health committees.

“This is the provision of basic health services and linkages to the public health system in areas where there are none,” says Shanklin. “Community-based care collapses costs and time requirements.”

The UCOS brought significant improvements in pregnancy-related outcomes, thanks to wider use of healthy practices such as tetanus-toxoid injections, new razors to cut umbilical cords, promotion of immediate breastfeeding and postpartum care within the first seven days after birth. The number of births referred to and attended by skilled health professionals doubled during the pilot project while the number of births attended by trained TBAs decreased by 14 percent.

But coverage is still incomplete. So, if you are a pregnant woman living in Honduras, you develop complications during labor and you are unable to get to a trained health care provider, you want your local TBA to know what she’s doing.

In Honduras, ChildFund is implementing a USAID-funded program focused on improving maternal and neonatal outcomes. One component involves an intensive TBA training effort. Gilberto Mendez, ChildFund’s Institutional Learning team leader, traveled recently to the Reitoca area to observe how the facilitators use instructional materials to train TBAs. He says he was “favorably impressed.”

But one issue requires further attention. Mendez recalls, “At one point, one of the facilitators said, ‘All right, let’s look at page 19,’ and some of the women didn’t react. They couldn’t find page 19.” Most of the women, it turned out, were illiterate. A Ministry of Health staffer told Mendez that it was safe to assume that as many as 90 percent of the women in the target areas were illiterate; it was a generational characteristic among the women, most of whom were 50 to 70 years old. This knowledge will make a difference as ChildFund continues to refine TBA training materials and find younger TBAs to follow in the footsteps of their mothers and grandmothers.

Still, says Mendez, the facilitators had good visual aids and models, and were diligent in verifying that each student understood and was able to follow each procedure, including sterilizing instruments, avoiding postpartum infection, knowing when bleeding is excessive and providing referral case management.

Perhaps their most important training is on how to recognize, prevent and respond to obstetrical emergencies and to decide quickly when to make a referral and transfer the woman to the closest hospital or clinic. ChildFund TBAs are paid a bonus when they make referrals, which mitigates any loss of income but encourages them to make more referrals. This is in line with the Honduran Ministry of Health’s effort to promote assisted delivery at health centers as the norm rather than the exception.

Another component of the Honduras maternal-child health program that Mendez encountered was a facility built to house pregnant women as they approach delivery. One reason women often do not take advantage of obstetrical care where it is available is that it costs too much to stay nearby. The new facility, a home away from home, can shelter up to 15 women at a time. Program staff reports that they have already exceeded their expected numbers for the year.

Says Mendez, “It looks like all of this is having the effects that they were looking for — more clean, safe deliveries at health centers.”