170419 Training Traditional Birth Attendants in Bangladesh: A Model of Integration and Assessment

Wednesday, October 29, 2008

Tami Rowen, MS, MD , Department of Obstetrics Gynecology and REproductive Sciences, University of California, San Francisco, San Francisco, CA
Background: It has been estimated that, worldwide, nearly 600,000 women die each year during pregnancy or childbirth. These deaths are caused by hemorrhage, infection, eclampsia, obstructed labor and complications from abortions. In addition, over 50,000,000 women experience complications and 4,000,00 neonates also die annually. 99% of these deaths occur in the developing world and the disparity in maternal health outcomes between developed and developing countries is growing.

In Bangladesh the number of births without “skilled” attendance is close to 90 %. This includes both the urban and rural communities, where there is a significant difference in education, resources and access. Given the high number of births that take place at home without the help of an SBA, it has been assumed that the high maternal mortality, morbidity and infant death statistics in the developing world are a result of unskilled care. This has led to many programs to combat poor maternal health outcomes. Many of these previously focused on training traditional birth attendants(TBA) to recognize, refer and sometimes treat pregnancy complications. There has been great variation in the interpretations of these studies, leading to intense debate within the international community as to the most beneficial and cost-effective way to improve maternal and infant health in the developing world. The most prominent international aid organizations such as the World Health Organization (WHO), UNICEF, UNFPA, Planned Parenthood and many others now promote the exclusive use of “skilled” care at every birth, effectively dismissing any use of traditional birth attendants, and, consequently, reducing funding for training to provide maternal health services. Now, nearly ten years later, there is still no consensus, with many authorities continuing to reject the use of TBAs. However, there continue to be studies promoting the training of TBAs in life saving skills as well as in the use of oral and rectal misoprostol to control hemorrhage. These studies have reintroduced the use of TBAs in reducing maternal mortality and morbidity, acknowledging the large role TBAs continue to play in their communities while testing new and innovative measures to improve reproductive health in the developing world.

Most of the research that has been conducted on TBA training often fails to critically analyze the training itself, focusing on long term outcomes without measuring content and knowledge gained in the training. Failure of TBA training does not necessarily mean a failure of TBAs but could result from improper instruction.

TBAs assist in 64-80% of deliveries in Bangladesh and have a strong cultural role in pregnancy and delivery. Many organizations in Bangladesh have prioritized TBA training, including Gonoshsthaya Kendra (GK). The overall goal of the training is to form a linkage with the TBAs that will ensure referral to an EmOC facility if necessary. The focus is not on treatment of emergency complications as much as activities to promote trust and recognition of complications. There is no formal evaluation of GK's TBA training. The TBAs are brought back to the centers for refresher courses every 6 months, but there is no standardized way to measure the knowledge they have gained or whether this knowledge is used in the field. Furthermore, there is only anecdotal knowledge about the differences between TBAs in the various regions served by GK subcenters. There has been no standardized investigation in the form of surveys or questionnaires that could provide background information relevant to the trainers.

Methods: In order to properly assess GK's training, a GK TBA training was attended during winter 2005-2006. The goal of the study was to assess whether there was successful knowledge transfer during the training. Knowledge assessments were provided before and after to answer this question. The impact of a TBAs background may influence her knowledge acquisition and thus background questions were asked prior to the training. Lastly, the training content was qualitatively evaluated in terms of the topics covered, and materials and methods employed. The results of this qualitative portion were compared to existing recommendations for training topics and methods published by the WHO is 1994.

Two training were attended to provide a large enough sample size to detect any differences in knowledge-based questions before and after the training. The background questions were asked to provide important information about the TBAs that could be used in future trainings and also to detect possible influences in knowledge gained from the training. The overall results provided important information about the differences between both the TBA's background and their knowledge retention in the training.

Results: GK's goal for the training was to create a linkage with TBAs in the community that would lead to improved referral. They also sought to encourage TBAs to practice preventative care and recognize complications. Their goals were very much in line with the 1994 WHO recommendations for TBA training. The results of the qualitative portion of this study demonstrate their success in covering nearly all the topics recommended by the WHO. Whether or not the topics were successfully transmitted, however, was the reason behind the knowledge assessment.

There were significant improvements in knowledge after the training, especially in important content areas. Questions related to delivery complications, hemorrhage and eclampsia, resulted in significant improvements in knowing the importance of referral. Given the repeated mention of the importance of referral here, this finding is a very positive result of the study. The other two significant improvements were related to measuring blood loss, a crucial step in preventing severe PPH, and treating an apnic newborn. These are critical elements to providing proper maternal and reproductive healthcare at household level and can potentially save lives. GK's training was successful in transmitting this information.

The nonsignificant knowledge assessment results were related to high baseline knowledge about hygienic delivery, ANC, maternal nutrition and PPH prevention. The high baseline knowledge supports GK's support of using TBAs in their maternal health programs.

Conclusions and Significance: Bangladesh's current government policy promotes the training and utilization of skilled care. This is important as skilled care should be a long-term goal but may deny the important role TBAs can play in their society. TBAs may be the first to recognize not only a delivery problem, but also an abortion complication or a domestic violence situation in a woman's household. GK made the determination to take advantage of their role and have a unique niche in the community because of their dedication to health at the community level.

The positive findings of this study do not negate the many areas in which GK's training can in fact be improved. The importance of more participation and skill sharing, fewer lectures and videos and a more community-centered approach should be emphasized to improve the training. These elements will hopefully ensure that all TBAs leave the training selecting the correct response.

The training alone, however, may not account for the lack of differences in knowledge retention. Results show that TBAs' background plays an important role in how they respond to new knowledge. This is important for the GK trainers to understand but also to serve as an example to any organization that seeks to train TBAs. This study demonstrated that not only does a TBAs background affect her knowledge acquisition but that there can be a great amount of diversity within a small region.

The global implications of this study are also very significant. As noted earlier, there is a dearth of information on the specifics of any given training. This study is novel in its approach as it provides both a qualitative and a quantitative approach to studying TBA training. What remains to be seen, however, is whether or not the improved knowledge seen in after GK's training correlates to improved care in the community and thus timely identification of complications and higher referrals rates. This would be a crucial component of any follow-up study. A follow-up should include assessment of the same knowledge based questions as well as a comparison of referral rates before and after the training.

It is necessary to acknowledge the many ways in which a TBA cannot save a woman's life in the case of a delivery complication. This argument has been used to support the emphasis on skilled care in developing nations and to disregard TBAs. Skilled care can and should be promoted, but simply focusing time and resources into new hospitals or training programs ignores the fact that women in developing nations will continue to use TBAs at home. Without effective linkage to the women in need, there is no use for the skilled care facilities.

This is perhaps the area in which GK's training can serve as the greatest example. GK's emphasis on providing a linkage with the TBAs is the most likely method by which to ensure improved delivery care in the region.

Learning Objectives:
1. Understand current international policy regarding TBA training 2. Understand the limitation of past evaluations of TBA training 3. Evaluate one example of training from a mixed methods approach to evaluation

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I consucted the research and designed the poster
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.