For Peer Review Only

BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

Emerging role of traditional birth attendants in mountainous terrain of Chitral District, Pakistan

ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-006238

Article Type: Research

Date Submitted by the Author: 27-Jul-2014

Complete List of Authors: Shaikh, Babar; Aga Khan Foundation, Pakistan, Health & Built Environment Khan, Sharifullah; Aga Khan Foundation, Health & Built Environment Maab, Ayesha; Aga Khan Foundation, Health & Built Environment Amjad, Sohail; Aga Khan Foundation, Health & Built Environment

Primary Subject Health services research Heading:

Health policy, Obstetrics and gynaecology, Public health, Qualitative Secondary Subject Heading: research, Reproductive medicine

Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Keywords: Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Public health < INFECTIOUS DISEASES

http://bmjopen.bmj.com/

on September 28, 2021 by guest. Protected copyright.

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Emerging role of traditional birth attendants in mountainous terrain of Chitral District, Pakistan 4 5 6 7 Babar Tasneem Shaikh, PhD, FRCP Edin - Aga Khan Foundation 8 9 Sharifullah Khan, MPH - Aga Khan Foundation 10 11 Ayesha Maab, MSc - Aga Khan Foundation 12 13 Sohail Amjad, MPH - Aga Khan Foundation 14 15 For peer review only 16 17 18 19 Running title: Role of traditional birth attendants 20 21 22 23 24 25 Corresponding author 26 27 Dr Babar Tasneem Shaikh 28 29 Aga Khan Foundation (Pakistan) 30 31 Level Nine, Serena Business Complex 32 33 Khayaban-e-Suharwardy, Islamabad

34 http://bmjopen.bmj.com/ 35 t: +92 51 111-253-254 36 37 f: +92 51 2072552 38 39 e: [email protected] 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Abstract: 4 5 Introduction: Shortage of health workforce is the major impediment in the achievement of health related 6 7 MDGs 4 & 5. It is important to review strategies to maximize strengths of traditional birth attendants 8 9 (TBAs) and skilled birth attendants in resource limited settings. However, role of TBAs in the provision of 10 11 maternal, newborn and child health (MNCH) care has been a subject of discussion. This research 12 13 endeavors to identify the role of TBAs in supporting the MNCH care, mainstreaming with the formal health 14 15 system and their livelihoodFor prospects. peer review only 16 17 Methods: A qualitative exploratory study was conducted in predominantly rural district Chitral, Pakistan. 18 19 About seven Key informant interviews (KIIs) with health managers, and four focus group discussions 20 21 (FGDs) were conducted with community midwives (CMWs), TBAs and member of Village Health 22 23 Committee (VHC). 24 25 Results: The study identified that community has trust and faith in TBAs and her services. TBAs have 26 27 had a pivotal role in health promotion activities such as breast feeding promotion and vaccination. TBAs 28 29 conduct deliveries, and refer high risk cases to formal health system. With regard to CMW introduction in 30 31 system, TBAs are positive and welcome this addition. Yet, their livelihood has suffered after CMWs 32 33 deployment. Monetary incentives to them in recognition of referrals to CMWs could be one solution.

34 http://bmjopen.bmj.com/ 35 There ought to be a meaningful interaction between the two cadres at the village level. VHC is an active 36 37 forum for strengthening coordination between them and to ensure an alternate and permanent livelihood 38 39 support system for the TBAs. 40 41 Conclusion: TBAs assuredly support the need for continuum of care for pregnant women, lactating 42 on September 28, 2021 by guest. Protected copyright. 43 mothers and children under five. The district health authorities must figure out ways to foster a healthy 44 45 interface vis-à-vis roles and responsibilities of TBAs and CMWs. 46 47 48 49 Keywords: Maternal Newborn & Child Health, Traditional birth attendant, Community midwife, Qualitative 50 51 research, Pakistan. 52 53 54

55 56

57 58 59 60 2

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Strengths & Limitations of the study 4 5 Use of qualitative methods provided rich insight into women’s interpretations and decision-making 6 7 regarding health care seeking during and after pregnancy in a relatively conservative setting of Pakistan. 8 9 10 11 The findings represent a specific sample size, study site and socio-cultural milieu and therefore may not 12 13 be generalized for the entire province or country. 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Introduction 4 5 6 Despite all advances toward MDGs 4 & 5, every year 6.6 million children die before five years of age 7 8 (44% as newborns) and 289,000 maternal deaths occur, mostly from preventable causes (1). This state 9 10 of affairs has raised serious global concern over the years in developing countries to ensure availability 11 12 and accessibility of human resources for ensuring continuum of care for expecting mothers. Uniform 13 14 availability and distribution of skilled birth attendants is critical to consider while looking at health service 15 For peer review only 16 utilization trends (2). The Millennium Declaration in 2000 signed by 189 nations, recognized proportion of 17 18 births assisted by trained birth as an important indicator to track maternal and child survival indicators 19 20 (3,4). To increase the availability and accessibility of maternal and child health care services, training of 21 22 TBAs and strengthening the partnership between community midwives (CMWs) and TBAs is widely 23 24 acknowledged worldwide (5,6). Nonetheless, role of the TBAs cannot be effective in a weak primary 25 26 health care system and in an unplanned referral mechanism (7). 27 28 29 30 In order to attain MDG-5, isolated interventions are not able to reduce maternal mortality sufficiently. It is 31 32 important to review strategies to maximize strengths of TBAs as well and skilled birth attendants. 33

34 Evidence suggests that skilled birth attendance has increased in regions where TBAs are integrated with http://bmjopen.bmj.com/ 35 36 the formal health system (8). However, integration of TBAs with the formal health system may require 37 38 capacity development and supervision of TBAs, collaboration skills for health workers, involvement of 39 40 TBAs at health facilities and, improved capacity on communication and referral systems. With this 41 42 approach, TBAs may positively contribute to maternal and child health outcomes (9). Trainings of the on September 28, 2021 by guest. Protected copyright. 43 44 TBAs not only enhance their knowledge and skills on obstetric care and referral mechanism, but also lead 45 46 to greater community acceptance and a greater consumer satisfaction. They can play a vital role in birth 47 48 preparedness and identification of danger signs (10). Training of TBAs has shown impact on perinatal 49 50 and neonatal deaths which can be significantly reduced (11). Moreover, TBAs have been a critical 51 52 contributor in providing skilled MNCH care in rural population of developing countries due to inadequate 53 54 numbers of human resource for service delivery (12). Therefore, role of trained TBAs in healthcare 55 56 provision cannot be undermined. Developing countries have used TBAs as a key strategy to improve 57 58 maternal and child health care (13). They have been effective in improving referral mechanism and links 59 60 4

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 with the formal health care system (14). Literature review has suggested that a TBA is preferred over a 4 5 midwife who is young, unmarried girl and without children. This trend is more common in countries where 6 7 fresh CMWs are recently deployed such as Pakistan (15,16). Another reason for the community 8 9 acceptance of TBAs is that they are affordable option than professional midwives and she often accepts 10 11 payment in kind (17). Moreover, TBAs are always happy to make house visits, warranting mother’s 12 13 privacy. 14 15 For peer review only 16 17 Pakistan is among the few countries in South Asia that continues to have dismal maternal and child 18 19 health indicators. In Pakistan, Maternal Mortality Ratios (MMR) is high, ranging from 240 to 700 per 20 21 100,000 live births. The top three causes of maternal death are postpartum hemorrhage, eclampsia and 22 23 sepsis. Approximately two-thirds of all births (61%) take place at home due to limited access to health 24 25 facilities. Home based deliveries are usually attended by the TBA and now newly deployed community 26 27 midwives in some rural parts of the country (18). While some maternity care indicators appear to have 28 29 improved over the last two decades, women’s access to prenatal health care continues to be low in 30 31 Pakistan18. 32 33

34 http://bmjopen.bmj.com/ 35 Realizing the need for community health work force, Government of Pakistan launched the national 36 37 MNCH program in 2006 to help the rural women deliver safely (19). Although the program has been 38 39 successful in countries such as Malaysia and Indonesia, challenges faced by the CMW program of 40 41 Pakistan are multifaceted. These challenges are related to acceptance by community, competition with 42 on September 28, 2021 by guest. Protected copyright. 43 other service providers, weak referral system, inadequate skill set and lack of community involvement 44 45 (20). 46 47 48 49 The intervention 50 51 To address health system constraints, Chitral Child Survival Program (CCSP) of Aga Khan Foundation 52 53 Pakistan (AKF-P) deployed CMWs, supported community financing scheme, improved referral linkages 54 55 and implemented a behavior change communication campaign from 2008-2014. CCSP was implemented 56 in close partnership of Department of Health, Khyber Pakhtunkhwa, Aga Khan Health Services (AKHSP), 57 58 59 60 5

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Pakistan and Aga Khan Rural Support Program (AKRSP). The CCSP interventions, especially the role of 4 5 community based saving groups, village health committees (VHCs) and community based emergency 6 7 maternal referral mechanism to achieve project results showed that CCSP had attempted to engage the 8 9 TBAs proactively. The project empowered TBAs on Birth Preparedness and Complications Readiness 10 11 (BPCR) plans and integrated referral mechanisms. Involvement of TBAs in the project was meaningful to 12 13 generate the community acceptability for young CMWs, identification of high risk cases, and referrals of 14 15 complications to CMWFor and transporting peer pregnant review woman to health facility only in time. 16 17 18 19 This research endeavored to identify the role of TBAs in supporting the MNCH care, partnership 20 21 mechanism with the formal health system and also explored livelihood options for TBAs. 22 23 24 25 Methodology 26 27 a) Study site 28 29 The study was conducted in Chitral district, north western border of Pakistan, from March-April 2014. 30 31 The population of the intervention area is 200,000, about 57% of the total population of the district 32 33 and residing in 243 villages. The government department of health and Aga Khan Health Services

34 http://bmjopen.bmj.com/ 35 Pakistan (AKHSP) are the two primary formal sector healthcare providers in Chitral. The public-sector 36 37 healthcare infrastructure in the district includes 22 civil dispensaries, 21 basic health units; three tehsil 38 39 headquarters and one district headquarter hospital (21). AKHSP operates its own 32 health facilities 40 41 in Chitral which include 17 health centers, eight family health centers, four dispensaries and three 42 on September 28, 2021 by guest. Protected copyright. 43 secondary care facilities, covering 60% of Chitral district. The MMR in the province is 275/100,000 44 45 live births; whereas under five mortality is 75/1000 live births (18). Despite the presence of skilled 46 47 birth attendants under MNCH program, large proportion of the deliveries is still attended by TBAs in 48 49 Chitral district. 50 51 52 53 b) Study Design and data collection 54 55 The project documents and other relevant studies were thoroughly reviewed and the collated 56 information guided to design the qualitative data collection instruments. A qualitative exploratory 57 58 59 60 6

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 study entailed seven KIIs and four FGDs conducted with different study participants. Field guides 4 5 included open ended questions, covering topics such as role of TBAs in supporting MNCH care and 6 7 CCSP project activities, community experience with TBAs, working relationships and linkages with 8 9 the formal health system and sustainability/livelihood of TBAs. To ensure quality control, information 10 11 collected through note-taking was cross-checked for completeness and consistency before and 12 13 during data processing by the research team. 14 15 For peer review only 16 17 c) Study participants 18 19 Community based health workers i.e. CMWs and TBAs; members of VHC and Community Based 20 21 Saving Group (CBSG) were included in the discussion. The participants were encouraged by the 22 23 moderator (PI) to interact with each other and comment on experiences and perceptions regarding 24 25 role of TBAs, partnership with formal health system, and livelihood of TBAs. KIIs were conducted with 26 27 two government health managers, two AKF-P managers, and three AKHSP managers. All the FGDs 28 29 were conducted in the community; whereas KIIs were conducted in the respective offices of health 30 31 managers. Table-1 presents the detail of the methods employed for the study. 32 33

34 http://bmjopen.bmj.com/ 35 Table-1: Detail of methods employed in qualitative study 36 37 Total number Cadre Method Area 38 of respondents 39 Mori Lshat, Barini, Awi, Miragarm, Sore 40 Laspoor, Raman, Terich Payeen, Lot Owir CMWs FGD 10 41 Bala, Lot Owir Payeen, Gohkir, Parsan, Owir 42 Lasht Arkari, Besti Arkari, Khuz, Phashk on September 28, 2021 by guest. Protected copyright. 43 Lower Porth, Brock Kalaway, Porth Bala, TBAs FGD 5 44 Raman, Brock Baraman Deh 45 VHC FGD 8 Morder 46 47 CBSG FGD 10 Morder 48 Health managers 49 (AKHSP, AKF-P 7 KIIs 07 Chitral city 50 & DHD) 51 52 53 Purposive sampling technique was adopted, inviting the participation of those CMWs, and TBAs who had 54 55 been serving actively in their local communities for the last two years. These health workers were 56 57 identified with the help of health managers of AKHSP and government. Likewise, only those members of 58 59 60 7

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 VHC were invited for FGD, who had been active for the last two years. Each participant of the FGD and 4 5 KII was given the verbal information about the study by the research team and was given a consent form 6 7 prior to participation. 8 9 10 11 d) Data analysis 12 13 A qualitative content analysis was applied to analyze the information manually from all the FGDs and 14 15 KIIs. A stepwise approachFor was peer adopted for thereview content analysis. The only analysis aimed at finding manifest 16 17 and latent meaning of data. The transcribed data was initially read several times by the principal 18 19 researcher in order to find the sense of the whole. At first stage the segmentation of information was done 20 21 i.e. segments and sub-segments of information were organized. Subsequently the significant information 22 23 was extracted which was related to research questions. At second stage the common views of the 24 25 respondents were put together at one place. At third stage, data was coded (different responses 26 27 highlighted) and then these codes were grouped into categories and abstracted into sub-themes and a 28 29 main theme. At final stage, the meanings of themes/descriptions were interpreted by keeping in view and 30 31 considering the cultural context of the participants. 32 33

34 http://bmjopen.bmj.com/ 35 Results 36 37 The main theme which came out was the “emerging role of TBAs to improve Maternal, Newborn and 38 39 Child Health”. After content analysis, following sub-themes were identified: 40 41 1. Community experience with CMWs and TBAs 42 on September 28, 2021 by guest. Protected copyright. 43 2. View of participants on utilization of TBAs in formal health system 44 45 3. Role of TBAs in supporting obstetric care 46 47 4. Linkages and coordination among TBAs and CMWs 48 49 5. Livelihood of TBAs 50 51 52 53 54 55 56 57 58 59 60 8

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Table-2: Matrix of qualitative research analysis 4 5 Nodes Sub-nodes 6 7 Community experience with - Availability of CMWs have empowered women for health care seeking 8 CMWs and TBAs - Community has trust and faith in TBAs and their services 9 10 -TBAs have pivotal role in health promotion activities such as health 11 messages on breast feeding, mother and child immunization. 12 Linkage of TBAs with formal 13 -TBAs must assist CMW who is naïve to reproductive health matters. health system 14 -TBAs can be involved in linking high risk cases to CMW and health 15 For peer review only 16 facility. 17 - TBAs promote health messages for expecting mothers, assist CMW in 18 Role of TBAs in supporting 19 delivery, identify expectant mothers with high risks, refer such cases to obstetric care 20 formal health system, and support post-natal care 21 22 - Mixed responses in terms of relationship between CMWs and TBAs 23 Linkages and coordination - VHC is an active forum for coordination 24 25 among TBAs and CMWs - Coordination is better at places where TBA gets some share of CMW 26 income 27 28 - CMWs could offer some incentives to TBAs to strengthen referrals and 29 assistance in skilled delivery 30 Livelihood of TBAs 31 - VHCs decide TBA incentive share of CMW income 32 - Community pay in kind contribution to recognize services of TBA 33

34 http://bmjopen.bmj.com/ 35 36 Community experience with CMWs and TBAs 37 38 Availability of CMWs and the supportive role of TBAs in obstetric care has benefited communities, by and 39 40 large. Most of the respondents shared that availability of CMWs has empowered women in order to seek 41 essential and emergency obstetric care in rural communities. Members of VHC appreciated the binding 42 on September 28, 2021 by guest. Protected copyright. 43 relation of CMWs with TBAs. Despite availability of CMWs, the community members still have greater 44 45 trust and faith in TBAs who live and deals with the village women since ages. Some of the respondents 46 47 told that they avail services of TBAs due to her rich experience as compared to CMWs who are young 48 49 and yet naïve to various reproductive health matters. 50 51 52 53 “TBA still has the critical role as being more in proximity to the village women. She enjoys far more trust of 54 55 the communities. She has a years’ long rapport with the families. People tend to follow her advice.” 56 57 (Director Health & Built Environment, AKFP) 58 59 60 9

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 “I consider the role of TBAs important for two reasons; firstly they have been trusted by the communities, 6 7 so they need to be taken on board for enhancing referrals to CMWs. Secondly, if they are not engaged 8 9 properly then they will do more harm by doing deliveries and might spread negative propaganda too 10 11 about the CMWs”. (KIIAKFP Senior Program Officer) 12 13 14 15 “I take my wife andFor child to CMWpeer to see forreview medical help or treatment only for maternal and child health 16 17 problems? In our village, Dai (TBA) enjoys good relationship with the CMW”. (FGDVHC, Morder)” 18 19 20 21 “My family often seeks services from a TBAshe has all the experience.” (FGDVHC, Morder) 22 23 24 25 “The TBAs are working since long time and they have developed trust in the communities”. (KII, AKHSP 26 27 Manager) 28 29 30 31 Linkage of TBAs with formal health system 32 33 TBAs have pivotal role in health promotion activities such as health messages on nutrition, breast

34 http://bmjopen.bmj.com/ 35 feeding, and vaccination promotion. Viewpoints of participants revealed that TBAs can be mainstreamed 36 37 in a formal health system by assigning health promotion activities and for referring high risk cases to 38 39 CMW and health facility. 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 “The TBAs have role in referring of high risk cases and expectant mothers for delivery to CMWs. TBAs

44 st 45 are also playing very good role in the community in identifying pregnant mothers during 1 trimester in the 46 47 community, arranging TT vaccinations and providing education on nutrition during pregnancy.” (GM, 48 49 AKHSP) 50 51 52 53 “They (TBAs) must be linked with the formal health system especially for health promotion, referrals and 54 assisting deliveries with CMWs, when needed” (FGDVHC, Morder) 55 56

57 58 59 60 10

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Role of TBAs in supporting obstetric care 4 5 TBAs have pivotal role in terms of identifying pregnancy related complications and assisting safe obstetric 6 7 care services with CMWs. Traditionally, TBAs have been involved in the promotion of better nutrition 8 9 practices for pregnant mothers, breastfeeding practices, TT vaccination of expectant mothers, prevention 10 11 of neonatal hypothermia, and post-natal care including family planning. TBAs have a crucial role in 12 13 strengthening referral and coordination mechanisms with CMWs and with the health facility. Findings of 14 15 the KIIs and FGDsFor revealed thatpeer some TBAs werereview even involved in assistingonly deliveries with CMWs. 16 17 18 19 “Many TBAs, no doubt have a sound folk wisdom, which can be used for various health promotion 20 21 messages, especially where there is no other community health worker. Moreover, TBAs can be trained 22 23 in providing antenatal care, TT vaccine, Misoprostol administration, recognizing the danger signs of 24 25 pregnancy etc. This will give her a feeling that she still has a role to play in saving women’s lives.” 26 27 (Director Health & Built Environment, AKFP) 28 29 30 31 “TBAs promote breastfeeding and healthy nutritional practices in our community for mother and children; 32 33 and they can keep on doing that”. (FGDVHC, Morder)

34 http://bmjopen.bmj.com/ 35 36 37 “In my village, TBA assists delivery with me and refers cases to me. I have to say that she is of great help 38 39 for me”. (FGDCMWs, Parsan) 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 “They (TBAs) said, they do refer cases to them and in many cases have joined CMWs for conducting 44 45 deliveries.” (KIIAKFP Senior Program Officer) 46 47 48 49 Linkages and coordination mechanisms among TBAs and CMWs 50 51 Mixed responses were recorded with regards to linkages and coordination among TBAs and CMWs. 52 53 There is no formal referral mechanism between TBAs and the CMWs. Lack of role clarity, physical 54 55 inaccessibility, professional rivalry and few income opportunities are key factors for weak linkages 56 between TBAs and CMWs. Some of the CMWs expressed that they encountered problems and 57 58 59 60 11

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 resistance from the TBAs and community during the initial phase of deployment. Village health committee 4 5 shared that they invite both TBAs and CMWs in the VHC meetings. Performance of TBAs vis-à-vis skills 6 7 related to maternal and newborn health is not satisfactory. Therefore, they now go to the CMWs who 8 9 have adequate competency in knowledge and skills about the obstetric care. Some of the members 10 11 shared that TBAs refer complicated expectant mothers to CMWs and health facility. In few instances, TBA 12 13 was seen to be assisting the CMW in deliveries. 14 15 For peer review only 16 17 “Rivalry; both are birth attendants; one is practicing by virtue of folk knowledge and the other is trained 18 19 according to modern guidelines and WHO standards. So that has created a competition. At places, there 20 21 is coordination too, where both are from the same family or where both have realized each other’s 22 23 importance.” (Director Health & Built Environment, AKFP) 24 25 26 27 “In some areas of intervention, the TBA perceived CMW as competitor.” (GM, AKHSP) 28 29 30 31 “Many TBAs are in favor of CMWs because they cannot handle the complicated cases properly; yet some 32 33 are against her. VHC is trying to bring the TBA as member in VHC and told them about the importance of

34 http://bmjopen.bmj.com/ 35 deliveries by skilled hand and hygienic way.” (FGDVHC, Morder) 36 37 38 39 “We feel good about CMWs and think positively about them, majority still contact us, because the fee for 40 41 CMWs is high”. (FGDTBAs, Raman) 42 on September 28, 2021 by guest. Protected copyright. 43 “I am satisfied with the services provided by CMWI referred two cases to CMW”. (FGDTBAs, Brock 44 45 Kalaway) 46 47 48 49 “Introduction of CMWs in the areas will limit the role of TBAs. To cope with this challenge the TBAs were 50 51 included in the VHCs and the roles/responsibilities of the CMWs were communicated through this 52 53 platform”. (KII, AKRSP Manager) 54

55 56 57 58 59 60 12

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 “The TBA in my area helps me in assisting delivery and refers cases to me.” (FGDCMWs, Terich 4 5 Payeen) 6 7 8 9 “I faced resistance from the community at start.TBA was also not happy with my presence”. (FGD 10 11 CMWs, Khuz) 12 13 14 15 “I think role clarity,For distance andpeer community trustreview on TBAs, income opportunityonly etc. are the main barriers 16 17 .These can be effectively dealt if AKHSP works with communities, CMWs and TBAs and set out a proper 18 19 coordination plan and play catalytic role to nurturing that symbiotic relationship.” (KIIAKFP, Senior 20 21 Program Officer) 22 23 24 25 Livelihood and sustainability of TBAs 26 27 Supporting role of TBAs is very important; especially in context of difficult geographical terrains in Chitral. 28 29 Various options as well as mechanisms were identified by the respondents, when asked about livelihood 30 31 prospects of TBAs. Most of the respondents were of opinion that CMWs must pay some incentives to 32 33 TBAs to strengthen referrals and assistance in skilled delivery. Findings of the KII revealed that one of the

34 http://bmjopen.bmj.com/ 35 available forums to decide TBAs incentives is village committee. VHCs and other available forums such 36 37 as Local Support organizations (LSOs) can play pivotal role in taking up such decisive role for supporting 38 39 livelihood options for TBAs. Regarding payment to TBAs, some of the CMWs did not recompense TBAs. 40 41 Some of the TBAs also told that they get in kind contributions and support for her services from the village 42 on September 28, 2021 by guest. Protected copyright. 43 families and not from the CMWs. 44 45 “Let it be the VHC meeting to decide about some incentives to be given to TBAs from CMW fee, because 46 47 she will be referring every case to CMW. CMW should provide some money to TBA”. (KII, AKHSP 48 49 Manager) 50 51 52 53 “One of the CMW referred two cases to CMWs, and in fact she did join her for conducting the deliveries, 54 but in return did not get anything from the CMW and the family too.” (KIIAKFP, Senior Program Officer) 55 56

57 58 59 60 13

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 “TBAs were providing delivery services before CMWs’ deployment; hence CMWs’ services will certainly affect 4 5 their regular income (in cash or in kind). CMW should give incentive from her service fee to TBAs on each 6 7 referral; whereas TBA can continue providing care to mother after delivery”. (KII, Manager, Programs AKHSP) 8 9 10 11 “It is an informal arrangement between the two of them. Officially there is no binding on the CMW to pay TBA for 12 13 referrals.” (Director Health & Built Environment, AKFP) 14 15 For peer review only 16 17 “In our area, CMW is paying Rs200 to the TBA for each referral”. (FGDVHC, Morder) 18 19 20 21 “In two cases, I assisted CMW for delivery of a mother. CMW did not give me any money. I got some 22 23 cash and chicken from the house of delivered mother”. (FGDTBA, Lower Porth) 24 25 26 27 Discussion 28 29 The continued utilization of TBAs’ services in Chitral is attributed to several factors including the TBAs’ 30 31 proximity to several villages, TBAs’ respectful attitude toward the community, and flexible modes of 32 33 payment (22,23). CMWs have been recently deployed in Chitral and experienced challenges and

34 http://bmjopen.bmj.com/ 35 constraints by community based health providers and community itself in delivery of maternal health 36 37 services (24,25,26). Evidence suggests that health management committees at the village level have 38 39 been effective in reducing maternal complications through promoting linkages of health care providers 40 41 with the community (27). The findings of our study also revealed that community forum in the form of VHC 42 on September 28, 2021 by guest. Protected copyright. 43 has played pivotal role in linking TBAs and CMWs with the community members. 44 45 46 47 Results of our study found that TBAs play vital role in improving maternal health such as diagnosing 48 49 labor, assisting clean delivery with CMWs, detecting and referring maternal complications, and promoting 50 51 health messages. While trained TBAs are not considered skilled birth attendants, their potential 52 53 contribution in supporting maternal care has been recognized in low income and middle countries facing 54 issues of human response scarcity (12,Error! Bookmark not defined.). Role of TBAs in administration of 55 56 misoprostol to prevent postpartum hemorrhage in home-births is oft-advocated (28,29). Nevertheless, the 57 58 59 60 14

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 role of TBAs in supporting MNCH care cannot be neglected in settings where skilled birth attendants are 4 5 fewer and new to health system. In the wake of reforms and the novel MNCH program of Pakistan, role of 6 7 TBAs in improving maternal care and transforming health seeking behaviours ought to be promoted (30). 8 9 Defining her role and contribution in the continuum of care is linked to her livelihood and income 10 11 generation. 12 13 14 15 Improved linkagesFor and relationship peer among CMWs review and TBAs is of essence only to flourish referral system from 16 17 community to health facility. Better coordination and collaboration of TBAs with CMWs was promoted 18 19 under CCSP. TBA, who has a long standing link with local community, can act as a bridge to strengthen 20 21 referral mechanism between community and the formal health system (15). Findings of the qualitative 22 23 study follow other studies which demonstrated that a formal partnership program among TBAs and the 24 25 skilled midwives has yet to be seen (5). While the importance of the TBAs role in referral is universally 26 27 acknowledged, most health systems have not developed an effective referral mechanism. The CCSP 28 29 project provided an enabling forum at the village level for CMWs and TBAs to interact and improve 30 31 referral linkages. Such partnership is crucial to improve access to health care services, especially for 32 33 communities living in the remote areas. Nevertheless, training and monitoring TBAs on MNCH care is

34 http://bmjopen.bmj.com/ 35 imperative to minimize chances of malpractices (13). 36 37 38 39 Financial constraints are a major risk to the livelihood of TBAs as evident from the findings of our study. 40 41 Mostly they are receiving in kind payments by the family of expectant mothers; and a nominal payment by 42 on September 28, 2021 by guest. Protected copyright. 43 CMWs for each referral. Where TBAs did not receive any share from the CMWs, we found weak 44 45 coordination mechanisms with the formal health system. Evidence suggests that in kind contributions by 46 47 clients are the most common mode of payment by the clients (8,10). With the increasing use of TBAs in 48 49 MNCH care, the question of compensation has become more pressing because these workers usually 50 51 rely on rewards and in kind contributions by the clients (31). Continuing efforts to define the role of TBAs 52 53 may benefit from an emphasis on their potential as active promoters of essential newborn care (32). In 54 55 the context of Pakistan, the role of TBAs ought to be revisited and redefined, not only for the sake of trust 56 of communities on her services, but also for her own livelihood. 57 58 59 60 15

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 Conclusion 6 7 Prevailing poverty in the area calls for thinking solutions to ensure livelihood of TBAs, and to figure out an 8 9 emerging role for her after the introduction of CMW in the health system. TBAs surely have solutions in 10 11 the continuum of care for pregnant women, lactating mothers and children under five. They continue to 12 13 take pride and see value in their role in the health system to support MNCH care. Health systems 14 15 performance can Forbe amplified peer by having a healthy review interface between only the TBAs and CMWs, and for the 16 17 larger benefit of the communities served. 18 19 20 21 Acknowledgement: 22 23 The authors acknowledge the facilitation and assistance provided by AKF-P, AKHSP and AKRSP to carry 24 25 out field data collection. 26 27 28 29 Ethical consideration: 30 31 Ethics approval for this study was granted by the Institutional Review Board of Aga Khan Health Services, 32 33 Pakistan. Verbal informed consent was obtained from all the study participants, after explaining the

34 http://bmjopen.bmj.com/ 35 objectives of the study. Confidentiality and anonymity was assured to all the participants. Data was kept 36 37 under lock and key with the principal researcher. 38 39 40 41 Authors’ contributions 42 on September 28, 2021 by guest. Protected copyright. 43 BTS and SAK conceived the study design and instruments. AM supervised the data collection and helped 44 45 in analyses. BTS and SAK drafted the successive drafts of paper. SA conducted the critical review and 46 47 added the intellectual content to the paper. All authors read and approved the final draft. 48 49 50 51 Funding: The study was a part of larger project “Chitral Child Survival Program” funded by USAID. 52 53 54 Competing Interests 55 56 The authors declare that they have no competing interests. 57 58 59 60 16

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 References 6 7 8 1. World Health Organization & UNICEF. Countdown to 2015 and beyond: fulfilling the health 9 10 agenda for women and children. Geneva: 2014. 11 12 2. Shaikh BT. Marching toward the Millennium Development Goals: What about health systems, 13 14 health-seeking behaviours and health service utilization in Pakistan? World Health & Popul 2008; 15 For peer review only 16 10(2): 44-52. 17 18 3. United Nations. Road map towards the implementation of the United Nations Millennium 19 20 Declaration: report of the Secretary-General. New York: 2001. 21 22 4. Sachs JD, McArthur JW. The Millennium Project: a plan for meeting the Millennium Development 23 24 Goals. Lancet 2005; 365(9456):347-53. 25 26 5. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth 27 28 attendants and home delivery? A qualitative study on delivery care services in West Java 29 30 Province, Indonesia. BMC Pregnancy Childbirth 2010, 10:43. 31 32 6. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal 33

34 and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst http://bmjopen.bmj.com/ 35 36 Rev 2010; 11: CD007754. 37 38 7. Garces A, McClure EM, Chomba E, Patel A, Pasha O, Tshefu A. Home birth attendants in low 39 40 income countries: who are they and what do they do? BMC Pregnancy Childbirth 2012; 12:34. 41 42 8. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems on September 28, 2021 by guest. Protected copyright. 43 44 can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115(2):127-34. 45 46 9. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth 47 48 attendants and village midwives. J Obstet Gynaecol 2004; 24(1):5-11. 49 50 10. Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication 51 52 readiness among slum women in Indore City, India. J Health Nutr Popul 2010; 28(4): 383-391. 53 54 11. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies 55 56 incorporating training and support of traditional birth attendants on perinatal and maternal 57 58 mortality: meta-analysis. BMJ 2011; 343:d7102. 59 60 17

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 19 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 12. Sibley LM, Sipe TA. Transition to skilled birth attendance: Is there a future role for trained 5 6 traditional birth attendants. J Health Popul Nutr 2006; 24(4):472-8. 7 8 13. Bisika T. The effectiveness of the TBA programme in reducing maternal mortality and morbidity in 9 10 Malawi. East Afr J Public Health 2008; 5(2):103–10. 11 12 14. Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral of high-risk pregnant mothers by 13 14 trained traditional birth attendants in Buikwe County, Mukono District, Uganda. J Obstet Gynaecol 15 For peer review only 16 2005; 25(6):554-7. 17 18 15. Temesgen TM, Umer JY, Buda DS, Haregu TN. Contribution of traditional birth attendants to the 19 20 formal health system in Ethopia: the case of Afar region. Pan Afr Med J 2012; 13(Suppl 1):15. 21 22 16. Wajid A, Rashid Z, Mir AM. Initial assessment of Community Midwives in rural Pakistan. PAIMAN. 23 24 JSI Research and Training Institute, Inc; Islamabad: 2010. 25 26 17. Concern Worldwide. Examining the role of traditional birth attendants in the continuum of care in 27 28 Sierra Leone. Innovations for maternal, newborn and child health. Policy Brief. Concern 29 30 Worldwide; New York: 2013. 31 32 18. National Institute of Population Studies and Macro International Inc. Pakistan Demographic and 33

34 Health Survey (PDHS) 2006–07. Government of Pakistan; Islamabad: 2008. http://bmjopen.bmj.com/ 35 36 19. Government of Pakistan. PC1 National Maternal Newborn & Child health Program 2006-2012. 37 38 Ministry of Health, Government of Pakistan; Islamabad: 2009. 39 40 20. Research and Development Solutions. The community midwives program in Pakistan. Policy 41 42 Brief Series No 20. Islamabad: 2012. on September 28, 2021 by guest. Protected copyright. 43 44 21. Department of Health. District health profile-Chitral. Government of Khyber Pakhtunkhwa; 45 46 Peshawar: 2014. 47 48 22. Chesney M, Davies S. Women’s birth experiences in Pakistan – the importance of the Dai. The 49 50 Royal College of Midwives. Evid Based Midwifery 2005; 3(1):26-32. 51 52 23. Owolabi OO, Glenton C, Lewin S, Pakenham-Walsh N. Stakeholder views on the incorporation of 53 54 traditional birth attendants into the formal health systems of low-and middle-income countries: a 55 56 qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums. BMC Pregnancy 57 58 Childbirth 2014; 14:118. 59 60 18

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 19 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 24. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-experiences of community 5 6 midwives in Pakistan. BMC Pregnancy Childbirth 2014; 14:59. 7 8 25. Research and Development Solutions. The community midwives program in Pakistan. Policy 9 10 Brief Series No 20. Islamabad: USAID; 2012. 11 12 26. Research and Advocacy Fund/Children First. How far can I go? Social mobility of CMWs in Azad 13 14 Kashmir. Islamabad: 2012. 15 For peer review only 16 27. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community 17 18 mobilization and health management committee strengthening to increase birth attendance by 19 20 trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomized 21 22 controlled trial. Trials 2011; 12:128. 23 24 28. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the 25 26 management of the third stage of labour in the home delivery setting in rural Gambia: a 27 28 randomized controlled trial. Br J Obstet Gynaecol 2005; 112: 1277-83. 29 30 29. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, et al. Administration of misoprostol 31 32 by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in 33

34 Pakistan: a randomized placebo-controlled trial. BJOG 2011; 118(3):353-61. http://bmjopen.bmj.com/ 35 36 30. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: Is the 37 38 health care system accessible and responsive in Pakistan? Health Care Women Int 2008; 39 40 29:945-959. 41 42 31. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB. Effect of training on September 28, 2021 by guest. Protected copyright. 43 44 traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): 45 46 randomized controlled study. BMJ 2011; 342:d346. 47 48 32. Falle TY, Mulany LC, Thatte N, Khatry SK, LeClerg SC, Darmstadt GL, et al. Potential role of 49 50 traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 51 52 2009; 27(1): 53–61. 53 54 55 56 57 58 59 60 19

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

Emerging role of traditional birth attendants in mountainous terrain of Chitral District, Pakistan

ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-006238.R1

Article Type: Research

Date Submitted by the Author: 10-Sep-2014

Primary Subject Health services research Heading:

Health policy, Obstetrics and gynaecology, Public health, Qualitative Secondary Subject Heading: research, Reproductive medicine

Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Keywords: Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Public health < INFECTIOUS DISEASES

http://bmjopen.bmj.com/

on September 28, 2021 by guest. Protected copyright.

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Emerging role of traditional birth attendants in mountainous terrain of Chitral District, Pakistan 4 5 6 7 Babar Tasneem Shaikh, MPH, PhD, FRCP Edin 8 9 Sharifullah Khan, MPH 10 11 Ayesha Maab, MSc 12 13 Sohail Amjad, MA-HM, MA-HMPP 14 15 For peer review only 16 17 18 19 Running title: Role of traditional birth attendants 20 21 22 23 24 25 Corresponding author 26 27 Dr Babar Tasneem Shaikh 28 29 Aga Khan Foundation (Pakistan) 30 31 Level Nine, Serena Business Complex 32 33 Khayaban-e-Suharwardy, Islamabad

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Abstract: 4 5 Objectives: This research endeavors to re-define the role of TBAs in supporting the MNCH care now 6 7 provided mainly by the trained community midwives (CMWs), to mainstream TBAs with the formal health 8 9 system and to delineate their livelihood prospects, after the deployment and introduction of CMWs in the 10 11 health system of Pakistan. 12 13 14 15 Setting: The studyFor was conducted peer in District reviewChitral, Khyber Pakhtunkhwa only province, covering the areas 16 17 where Chitral Child Survival programme was implemented. 18 19 20 21 Participants: A qualitative exploratory study was conducted, comprising seven Key informant interviews 22 23 (KIIs) with health managers, and four focus group discussions (FGDs) with CMWs, TBAs and members 24 25 of Village Health Committees (VHCs). 26 27 28 29 Results: The study identified that In the new scenario, after the introduction of CMW in the health 30 31 system, TBAs still have a pivotal role in health promotion activities such as breast feeding promotion and 32 33 vaccination. TBAs can assist CMWs in normal deliveries, and refer high risk cases to formal health

34 http://bmjopen.bmj.com/ 35 system. Generally, TBAs are positive about CMWs’ introduction and welcome this addition. Yet, their 36 37 livelihood has suffered after CMWs deployment. Monetary incentives to them in recognition of referrals to 38 39 CMWs could be one solution. VHC is an active forum for strengthening coordination between the two 40 41 service providers and to ensure an alternate and permanent livelihood support system for the TBAs. 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 Conclusion: TBAs assured their continued support in provision of continuum of care for pregnant 46 47 women, lactating mothers and children under five. The district health authorities must figure out ways to 48 49 foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. After some time, it would 50 51 be worthwhile to do further research to look into the CMW’s integration in the system, as well as TBA’s 52 53 continued role for provision of MNCH care. 54

55 56 57 58 59 60 2

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Keywords: Maternal Newborn & Child Health, Traditional birth attendant, Community midwife, Qualitative 4 5 research, Pakistan. 6 7 8 9 Strengths & Limitations of the study 10 11 A study, first of its kind, which has expounded on the subject of TBAs role and livelihood after the 12 13 introduction of trained MNCH providers in Pakistan. Use of qualitative methods provided rich insight into 14 15 women’s interpretationsFor and decision-makingpeer regardingreview health care seekingonly during and after pregnancy in 16 17 a relatively conservative setting of Pakistan. Study presents views of all stakeholders involved in the 18 19 intervention. 20 21 22 23 The findings represent a specific sample size, study site and socio-cultural milieu and therefore may not 24 25 be generalized for the entire province or country. Health providers involved in the study were mainly from 26 27 AKHSP and government who were already exposed to this intervention. Only few TBAs could be 28 29 gathered for discussion, because most of them were remotely located, and weather and family 30 31 constraints did not allow them to travel. Moreover, the prospective role of TBA is discussed in a special 32 33 context, whereby a CMW was trained and deployed in the area for increasing skilled birth attendance.

34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

34 Evidence suggests that skilled birth attendance has increased in regions where TBAs are integrated with http://bmjopen.bmj.com/ 35 36 the formal health system (8). However, integration of TBAs with the formal health system may require 37 38 capacity development and supervision of TBAs, collaboration skills for health workers, involvement of 39 40 TBAs at health facilities and, improved capacity on communication and referral systems. With this 41 42 approach, TBAs may positively contribute to maternal and child health outcomes (9). Trainings of the on September 28, 2021 by guest. Protected copyright. 43 44 TBAs not only enhance their knowledge and skills on obstetric care and referral mechanism, but also lead 45 46 to greater community acceptance and a greater consumer satisfaction. They can play a vital role in birth 47 48 preparedness and identification of danger signs (10). Training of TBAs has shown impact on perinatal 49 50 and neonatal deaths which can be significantly reduced (11). Moreover, TBAs have been a critical 51 52 contributor in providing skilled maternal, newborn and child health (MNCH) care in rural population of 53 54 developing countries due to inadequate numbers of human resource for service delivery (12). Therefore, 55 56 role of trained TBAs in healthcare provision cannot be undermined. Developing countries have used 57 58 TBAs as a key strategy to improve maternal and child health care (13). They have been effective in 59 60 4

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 improving referral mechanism and links with the formal health care system (14). Literature review has 4 5 suggested that a TBA is preferred over a midwife who is young, unmarried girl and without children. This 6 7 trend is more common in countries where fresh CMWs are recently deployed such as Pakistan (15,16). 8 9 Another reason for the community acceptance of TBAs is that they are affordable option than professional 10 11 midwives and she often accepts payment in kind (17). Moreover, TBAs are always happy to make house 12 13 visits, warranting mother’s privacy. 14 15 For peer review only 16 17 Pakistan is among the few countries in South Asia that continues to have dismal maternal and child 18 19 health indicators. In Pakistan, Maternal Mortality Ratios (MMR) is high, ranging from 240 to 700 per 20 21 100,000 live births. The top three causes of maternal death are postpartum hemorrhage, eclampsia and 22 23 sepsis. Approximately two-thirds of all births (61%) take place at home due to limited access to health 24 25 facilities. Home based deliveries are usually attended by the TBA and now newly deployed community 26 27 midwives in some rural parts of the country (18). While some maternity care indicators appear to have 28 29 improved over the last two decades, women’s access to prenatal health care continues to be low in 30 31 Pakistan18. 32 33

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 (AKHSP), and Aga Khan Rural Support Program (AKRSP). The CCSP interventions, especially the role of 4 5 community based saving groups, village health committees (VHCs) and community based emergency 6 7 maternal referral mechanism to achieve project results showed that CCSP had attempted to engage the 8 9 TBAs proactively. The project empowered TBAs on Birth Preparedness and Complications Readiness 10 11 (BPCR) plans and integrated referral mechanisms. Involvement of TBAs in the project was meaningful to 12 13 generate the community acceptability for young CMWs, identification of high risk cases, and referrals of 14 15 complications to CMWFor and transporting peer pregnant review woman to health facility only in time. 16 17 18 19 This research endeavored to identify the role of TBAs in supporting the MNCH care, partnership 20 21 mechanism with the formal health system and also explored livelihood options for TBAs. 22 23 24 25 Methodology 26 27 a) Study site 28 29 The study was conducted in Chitral district, north western border of Pakistan, from March-April 2014. 30 31 The population of the intervention area is 200,000, about 57% of the total population of the district 32 33 and residing in 243 villages. The government department of health and Aga Khan Health Services

34 http://bmjopen.bmj.com/ 35 Pakistan (AKHSP) are the two primary formal sector healthcare providers in Chitral. The public-sector 36 37 healthcare infrastructure in the district includes 22 civil dispensaries, 21 basic health units; three tehsil 38 39 headquarters and one district headquarter hospital (21). AKHSP operates its own 32 health facilities 40 41 in Chitral which include 17 health centers, eight family health centers, four dispensaries and three 42 on September 28, 2021 by guest. Protected copyright. 43 secondary care facilities, covering 60% of Chitral district. The MMR in the province is 275/100,000 44 45 live births; whereas under five mortality is 75/1000 live births (1819). Despite the presence of skilled 46 47 birth attendants under MNCH program, large proportion of the deliveries is still attended by TBAs in 48 49 Chitral district. 50 51 52 53 b) Study Design and data collection 54 55 The project documents and other relevant studies were thoroughly reviewed and the collated 56 information guided to design the qualitative data collection instruments. A qualitative exploratory 57 58 59 60 6

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 study entailed seven KIIs and four FGDs conducted with different study participants. The questions 4 5 for focus group discussion (FGD) and key informants interview (KIIs) explore the role of TBAs in 6 7 supporting MNCH care and CCSP project activities, community experience with TBAs, TBAs’ 8 9 relationship and coordination with the CMWs, referral of cases; remuneration and livelihood sources 10 11 of TBAs; ways to engage TBAs in continuum of care, working relationships and linkages with the 12 13 formal health system, and sustainability/livelihood of TBAs. Using a participation diagram in FGDs, it 14 15 was ensured For that all the peer participants mustreview speak on each question.only To ensure quality control, 16 17 information collected through note-taking was cross-checked for completeness and consistency 18 19 before and during data processing by the research team. 20 21 22 23 c) Study participants 24 25 All the study participants were purposively sampled from the intervention areas in the district, with the 26 27 help of the implementing agencies on ground. Community based health workers i.e. CMWs and 28 29 TBAs; members of VHC and Community Based Saving Group (CBSG) were included in the 30 31 discussion. The participants were encouraged by the moderator (PI) to interact with each other and 32 33 comment on experiences and perceptions regarding role of TBAs, partnership with formal health

34 http://bmjopen.bmj.com/ 35 system, and livelihood of TBAs. KIIs were conducted with two government health managers, two 36 37 AKF-P managers, and three AKHSP managers. All the FGDs were conducted in the community; 38 39 whereas KIIs were conducted in the respective offices of health managers. Table-1 presents the 40 41 detail of the methods employed for the study. 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 Table-1: Detail of methods employed in qualitative study 46 Total number 47 Cadre Method Village 48 of respondents 49 Mori Lshat, Barini, Awi, Miragarm, Sore 50 Laspoor, Raman, Terich Payeen, Lot Owir CMWs FGD 10 51 Bala, Lot Owir Payeen, Gohkir, Parsan, Owir 52 Lasht Arkari, Besti Arkari, Khuz, Phashk 53 Lower Porth, Brock Kalaway, Porth Bala, TBAs FGD 5 54 Raman, Brock Baraman Deh 55 VHC FGD 8 Morder 56 57 CBSG FGD 10 Morder 58 59 60 7

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Health managers 4 (AKHSP, AKF-P 7 KIIs 07 Chitral city 5 & Government) 6 7 8 Purposive sampling technique was adopted, inviting the participation of those CMWs, and TBAs who had 9 10 been serving actively in their local communities for the last two years. These health workers were 11 12 identified with the help of health managers of AKHSP and government. Likewise, only those members of 13 14 VHC were invited for FGD, who had been active for the last two years. Each participant of the FGD and 15 For peer review only 16 KII was given the verbal information about the study by the research team and was given a consent form 17 18 prior to participation. 19 20 21 22 d) Data analysis 23 24 A qualitative content analysis was applied to analyze the information manually from all the FGDs and 25 26 KIIs. A stepwise approach was adopted for the content analysis. The analysis aimed at finding manifest 27 28 and latent meaning of data. The transcribed data was initially read several times by the principal 29 30 researcher in order to find the sense of the whole. At first stage the segmentation of information was done 31 32 i.e. segments and sub-segments of information were organized. Subsequently the significant information 33

34 was extracted which was related to research questions. At second stage the common views of the http://bmjopen.bmj.com/ 35 36 respondents were put together at one place. At third stage, data was coded (different responses 37 38 highlighted) and then these codes were grouped into categories and abstracted into sub-themes and a 39 40 main theme. At final stage, the meanings of themes/descriptions were interpreted by keeping in view and 41 42 considering the cultural context of the participants. on September 28, 2021 by guest. Protected copyright. 43 44 45 46 Results 47 48 The main theme which came out was the “emerging role of TBAs to improve Maternal, Newborn and 49 50 Child Health”. After content analysis, following sub-themes were identified as shown in Table 2: 51 52 1. Community experience with CMWs and TBAs 53 54 2. View of participants on utilization of TBAs in formal health system 55 56 3. Role of TBAs in supporting obstetric care 57 58 4. Linkages and coordination among TBAs and CMWs 59 60 8

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 5. Livelihood of TBAs 4 5 6 7 Table-2: Matrix of qualitative research analysis 8 9 Nodes Sub-nodes 10 11 Community experience with - Availability of CMWs have empowered women for health care seeking 12 CMWs and TBAs - Community has trust and faith in TBAs and their services 13 14 -TBAs have pivotal role in health promotion activities such as health 15 For peermessages on reviewbreast feeding, mother only and child immunization. 16 Linkage of TBAs with formal 17 -TBAs must assist CMW who is naïve to reproductive health matters. health system 18 -TBAs can be involved in linking high risk cases to CMW and health 19 20 facility. 21 - TBAs assist CMW in delivery, identify expectant mothers with high 22 Role of TBAs in supporting 23 risks, refer such cases to formal health system, and support post-natal obstetric care 24 care 25 26 - Mixed responses in terms of relationship between CMWs and TBAs 27 Linkages and coordination - VHC is an active forum for coordination 28 29 among TBAs and CMWs - Coordination is better at places where TBA gets some share of CMW 30 income 31 32 - CMWs could offer some incentives to TBAs to strengthen referrals and 33 assistance in skilled delivery

34 Livelihood of TBAs http://bmjopen.bmj.com/ 35 - VHCs decide TBA incentive share of CMW income 36 - Community pay in kind contribution to recognize services of TBA 37 38 39 40 Community experience with CMWs and TBAs 41 42 Availability of CMWs and the supportive role of TBAs in obstetric care have benefited communities, by on September 28, 2021 by guest. Protected copyright. 43 and large. Most of the respondents shared that availability of CMWs has empowered women in order to 44 45 seek essential and emergency obstetric care in rural communities. Members of VHC appreciated the 46 47 binding relation of CMWs with TBAs. Despite availability of CMWs, the community members still have 48 49 greater trust and faith in TBAs who live and deals with the village women since ages. Some of the 50 51 respondents told that they avail services of TBAs due to her rich experience as compared to CMWs who 52 53 are young and yet naïve to various reproductive health matters. 54 55 56 57 58 59 60 9

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 “TBA still has the critical role as being more in proximity to the village women. She enjoys far more trust of 4 5 the communities. She has a years’ long rapport with the families. People tend to follow her advice.” 6 7 (Director Health, AKFP) 8 9 10 11 “I consider the role of TBAs important for two reasons; firstly they have been trusted by the communities, 12 13 so they need to be taken on board for enhancing referrals to CMWs. Secondly, if they are not engaged 14 15 properly then theyFor will do more peer harm by doing review deliveries and might only spread negative propaganda too 16 17 about the CMWs”. (KIIAKFP Senior Program Officer) 18 19 20 21 “I take my wife and child to CMW to see for medical help or treatment for maternal and child health 22 23 problems? In our village, Dai (TBA) enjoys good relationship with the CMW”. (FGDVHC, Morder)” 24 25 26 27 “My family often seeks services from a TBAshe has all the experience.” (FGDVHC, Morder) 28 29 30 31 “The TBAs are working since long time and they have developed trust in the communities”. (KII, AKHSP 32 33 Manager)

34 http://bmjopen.bmj.com/ 35 36 37 Linkage of TBAs with formal health system 38 39 TBAs have pivotal role in health promotion activities such as health messages on nutrition, breast 40 41 feeding, and vaccination promotion. Viewpoints of participants revealed that TBAs can be mainstreamed 42 on September 28, 2021 by guest. Protected copyright. 43 in a formal health system by assigning health promotion activities and for referring high risk cases to 44 45 CMW and health facility. 46 47 48 49 “The TBAs have role in referring of high risk cases and expectant mothers for delivery to CMWs. TBAs

50 st 51 are also playing very good role in the community in identifying pregnant mothers during 1 trimester in the 52 53 community, arranging TT vaccinations and providing education on nutrition during pregnancy.” (GM, 54 AKHSP) 55 56

57 58 59 60 10

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 “They (TBAs) must be linked with the formal health system especially for health promotion, referrals and 4 5 assisting deliveries with CMWs, when needed” (FGDVHC, Morder) 6 7 8 9 Role of TBAs in supporting obstetric care 10 11 TBAs have pivotal role in terms of identifying pregnancy related complications and assisting safe obstetric 12 13 care services with CMWs. Traditionally, TBAs have been involved in the promotion of better nutrition 14 15 practices for pregnantFor mothers, peer breastfeeding reviewpractices, TT vaccination only of expectant mothers, prevention 16 17 of neonatal hypothermia, and post-natal care including family planning. TBAs have a crucial role in 18 19 strengthening referral and coordination mechanisms with CMWs and with the health facility. Findings of 20 21 the KIIs and FGDs revealed that some TBAs were even involved in assisting deliveries with CMWs. 22 23 24 25 “Many TBAs, no doubt have a sound folk wisdom, which can be used for various health promotion 26 27 messages, especially where there is no other community health worker. Moreover, TBAs can be trained 28 29 in providing antenatal care, TT vaccine, Misoprostol administration, recognizing the danger signs of 30 31 pregnancy etc. This will give her a feeling that she still has a role to play in saving women’s lives.” 32 33 (Director Health, AKFP)

34 http://bmjopen.bmj.com/ 35 36 37 “TBAs promote breastfeeding and healthy nutritional practices in our community for mother and children; 38 39 and they can keep on doing that”. (FGDVHC, Morder) 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 “In my village, TBA assists delivery with me and refers cases to me. I have to say that she is of great help 44 45 for me”. (FGDCMWs, Parsan) 46 47 48 49 “They (TBAs) said, they do refer cases to them and in many cases have joined CMWs for conducting 50 51 deliveries.” (KIIAKFP Senior Program Officer) 52 53 54 Linkages and coordination mechanisms among TBAs and CMWs 55 56 57 58 59 60 11

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Lack of role clarity, physical inaccessibility, professional rivalry and few income opportunities are key 4 5 factors for weak linkages between TBAs and CMWs. Some of the CMWs expressed that they 6 7 encountered problems and resistance from the TBAs and community during the initial phase of 8 9 deployment. Village health committee shared that they invite both TBAs and CMWs in the VHC meetings. 10 11 Performance of TBAs vis-à-vis skills related to maternal and newborn health is not satisfactory. Therefore, 12 13 they now go to the CMWs who have adequate competency in knowledge and skills about the obstetric 14 15 care. Some of theFor members sharedpeer that TBAs review refer complicated expectant only mothers to CMWs and health 16 17 facility. In few instances, TBA was seen to be assisting the CMW in deliveries. 18 19 20 21 “Rivalry; both are birth attendants; one is practicing by virtue of folk knowledge and the other is trained 22 23 according to modern guidelines and WHO standards. So that has created a competition. At places, there 24 25 is coordination too, where both are from the same family or where both have realized each other’s 26 27 importance.” (Director Health, AKFP) 28 29 30 31 “The issues between TBA and CMW can be effectively dealt if AKHSP works with all stakeholders and set 32 33 out a proper coordination plan, and play catalytic role to nurture a health relationship.” (KIIAKFP, Senior

34 http://bmjopen.bmj.com/ 35 Program Officer) 36 37 38 39 “In some areas of intervention, the TBA perceived CMW as competitor.” (GM, AKHSP) 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 “Introduction of CMWs in the areas will limit the role of TBAs. To cope with this challenge the TBAs were 44 45 included in the VHCs and the roles/responsibilities of the CMWs were communicated through this 46 47 platform”. (KII, AKRSP Manager) 48 49 50 51 “Many TBAs are in favor of CMWs because they cannot handle the complicated cases properly; yet some 52 53 are against her. VHC is trying to bring the TBA as member in VHC and told them about the importance of 54 deliveries by skilled hand and hygienic way.” (FGDVHC, Morder) 55 56

57 58 59 60 12

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 According to CMWs, they have high regard for the TBA, her experience and wisdom. They feel that TBA 4 5 can complement their work. On the other hand, most TBAs are satisfied with CMWs work, skills and 6 7 services rendered to the community women. Very few seem to be unhappy indeed. 8 9 10 11 Livelihood and sustainability of TBAs 12 13 Supporting role of TBAs is very important; especially in context of difficult geographical terrains in Chitral. 14 15 Various options asFor well as mechanisms peer were identifiedreview by the respondents, only when asked about livelihood 16 17 prospects of TBAs. Most of the respondents were of opinion that CMWs must pay some incentives to 18 19 TBAs to strengthen referrals and assistance in skilled delivery. Findings of the KII revealed that one of the 20 21 available forums to decide TBAs incentives is village committee. VHCs and other available forums such 22 23 as Local Support organizations (LSOs) can play pivotal role in taking up such decisive role for supporting 24 25 livelihood options for TBAs. Regarding payment to TBAs, some of the CMWs did not recompense TBAs. 26 27 Some of the TBAs also told that they get in kind contributions and support for her services from the village 28 29 families and not from the CMWs. 30 31 32 33 “It is an informal arrangement between the two of them. Officially there is no binding on the CMW to pay TBA for

34 http://bmjopen.bmj.com/ 35 referrals.” (Director Health, AKFP) 36 37 38 39 “One of the CMW referred two cases to CMWs, and in fact she did join her for conducting the deliveries, but in 40 41 return did not get anything from the CMW and the family too.” (KIIAKFP, Senior Program Officer) 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 “Let it be the VHC meeting to decide about some incentives to be given to TBAs from CMW fee, because 46 47 she will be referring every case to CMW. CMW should provide some money to TBA”. (KII, AKHSP 48 49 Manager) 50 51 “TBAs were providing delivery services before CMWs’ deployment; hence CMWs’ services will certainly affect 52 53 their regular income (in cash or in kind). CMW should give incentive from her service fee to TBAs on each 54 referral; whereas TBA can continue providing care to mother after delivery”. (KII, Manager Programs, AKHSP) 55 56

57 58 59 60 13

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 “In our area, CMW is paying Rs200 to the TBA for each referral”. (FGDVHC, Morder) 4 5 6 7 “In two cases, I assisted CMW for delivery of a mother. CMW did not give me any money. I got some 8 9 cash and chicken from the house of delivered mother”. (FGDTBA, Lower Porth) 10 11 12 13 Discussion 14 15 Though communitiesFor where CMWspeer are deployed review after training are happy,only yet the continued utilization of 16 17 TBAs’ services in Chitral. Fact is attributed to several factors including the TBAs’ proximity to several 18 19 villages, TBAs’ respectful attitude toward the community, and flexible modes of payment (22,23). CMWs 20 21 have been recently deployed in Chitral and experienced challenges and constraints by community based 22 23 health providers and community itself in delivery of maternal health services (24,25). Evidence suggests 24 25 that health management committees at the village level have been effective in reducing maternal 26 27 complications through promoting linkages of health care providers with the community (26). The findings 28 29 of our study also revealed that community forum in the form of VHC has played pivotal role in convincing 30 31 the communities to avail CMW services and motivate the TBA to continue in supportive role in MNCH 32 33 care. Awareness sessions have to be conducted on regular basis and on different forums to better

34 http://bmjopen.bmj.com/ 35 inform the elder women and expecting mothers about the benefits of making use of skilled birth attendant 36 37 i.e. CMW. 38 39 40 41 Results of our study found that TBAs play vital role in improving maternal health such as diagnosing 42 on September 28, 2021 by guest. Protected copyright. 43 labor, assisting clean delivery with CMWs, detecting and referring maternal complications, and promoting 44 45 health messages. While trained TBAs are not considered skilled birth attendants, their potential 46 47 contribution in supporting maternal care has been recognized in low income and middle countries facing 48 49 issues of human response scarcity (12,Error! Bookmark not defined.13). Role of TBAs in administration 50 51 of misoprostol to prevent postpartum hemorrhage in home-births is oft-advocated (27,28). Nevertheless, 52 53 the role of TBAs in supporting MNCH care cannot be neglected in settings where skilled birth attendants 54 55 are fewer and new to health system. In the wake of reforms and the novel MNCH program of Pakistan, 56 role of TBAs in improving maternal care and transforming health seeking behaviours ought to be 57 58 59 60 14

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 promoted (29). Defining her role and contribution in the continuum of care is linked to her livelihood and 4 5 income generation. 6 7 8 9 Improved linkages and relationship among CMWs and TBAs is of essence to flourish referral system from 10 11 community to health facility. Better coordination and collaboration of TBAs with CMWs was promoted 12 13 under CCSP, by sensitizing the CMW on prospective role of TBA which will complement her services and 14 15 will help in buildingFor her rapport peer with the community. review TBA, who hasonly a long standing link with local 16 17 community, can act as a bridge to strengthen referral mechanism between community and the formal 18 19 health system (1521). Findings of the qualitative study follow other studies which demonstrated that a 20 21 formal partnership program among TBAs and the skilled midwives has yet to be seen (56). While the 22 23 importance of the TBAs role in referral is universally acknowledged, most health systems have not 24 25 developed an effective referral mechanism. The CCSP project provided an enabling forum at the village 26 27 level for CMWs and TBAs to interact and improve referral linkages. Such partnership is crucial to improve 28 29 access to health care services, especially for communities living in the remote areas. Nevertheless, 30 31 training and monitoring TBAs on MNCH care is imperative to minimize chances of malpractices (13). 32 33 Therefore, joint monitoring by AKHSP and government, by involving the village health committees could

34 http://bmjopen.bmj.com/ 35 be instrumental in this regard. Moreover, participatory monitoring is always less threatening; and hence 36 37 TBAs should be meaningfully engaged in such type of monitoring. 38 39 40 41 Financial constraints are a major risk to the livelihood of TBAs as evident from the findings of our study. 42 on September 28, 2021 by guest. Protected copyright. 43 Mostly they are receiving in kind payments by the family of expectant mothers; and a nominal payment by 44 45 CMWs for each referral. CMWs must keep a cushion of nominal payment to TBA, after verifying her 46 47 services. That will surely help in building a healthy relationship amongst the two service providers. Where 48 49 TBAs did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 50 51 health system. Evidence suggests that in kind contributions by clients are the most common mode of 52 53 payment by the clients (89,1011). With the increasing use of TBAs in MNCH care, the question of 54 55 compensation has become more pressing because these workers usually rely on rewards and in kind 56 contributions by the clients (30). Continuing efforts to define the role of TBAs may benefit from an 57 58 59 60 15

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 emphasis on their potential as active promoters of essential newborn care (31). In the context of Pakistan, 4 5 the role of TBAs ought to be revisited and redefined, not only for the sake of trust of communities on her 6 7 services, but also for her own livelihood. 8 9 10 11 Conclusion 12 13 Prevailing poverty in the area calls for thinking solutions to ensure livelihood of TBAs, and to figure out an 14 15 emerging role for Forher after the peer introduction of reviewCMW in the health system. only TBAs surely have solutions in 16 17 the continuum of care for pregnant women, lactating mothers and children under five. They continue to 18 19 take pride and see value in their role in the health system to support MNCH care. Health systems 20 21 performance can be amplified by having a healthy interface between the TBAs and CMWs, and for the 22 23 larger benefit of the communities served. 24 25 26 27 Acknowledgement: 28 29 The authors acknowledge the facilitation and assistance provided by AKF-P, AKHSP and AKRSP to carry 30 31 out field data collection. 32 33

34 http://bmjopen.bmj.com/ 35 Ethical consideration: 36 37 Ethics approval for this study was granted by the Institutional Review Board of Aga Khan Health Services, 38 39 Pakistan. Verbal informed consent was obtained from all the study participants, after explaining the 40 41 objectives of the study. Confidentiality and anonymity was assured to all the participants. Data was kept 42 on September 28, 2021 by guest. Protected copyright. 43 under lock and key with the principal researcher. 44 45 46 47 Authors’ contributions 48 49 BTS and SAK conceived the study design and instruments. AM supervised the data collection and helped 50 51 in analyses. BTS and SAK drafted the successive drafts of paper. SA conducted the critical review and 52 53 added the intellectual content to the paper. All authors read and approved the final draft. 54 55 56 Funding: The study was a part of larger project “Chitral Child Survival Program” funded by USAID. 57 58 59 60 16

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 Competing Interests 6 7 The authors declare that they have no competing interests. 8 9 10 11 References 12 13 14 1. World Health Organization & UNICEF. Countdown to 2015 and beyond: fulfilling the health 15 For peer review only 16 agenda for women and children. Geneva: 2014. 17 18 2. Shaikh BT. Marching toward the Millennium Development Goals: What about health systems, 19 20 health-seeking behaviours and health service utilization in Pakistan? World Health & Popul 2008; 21 22 10(2): 44-52. 23 24 3. United Nations. Road map towards the implementation of the United Nations Millennium 25 26 Declaration: report of the Secretary-General. New York: 2001. 27 28 4. Sachs JD, McArthur JW. The Millennium Project: a plan for meeting the Millennium Development 29 30 Goals. Lancet 2005; 365(9456):347-53. 31 32 5. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth 33

34 attendants and home delivery? A qualitative study on delivery care services in West Java http://bmjopen.bmj.com/ 35 36 Province, Indonesia. BMC Pregnancy Childbirth 2010; 10:43. 37 38 6. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal 39 40 and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst 41 42 Rev 2010; 11: CD007754. on September 28, 2021 by guest. Protected copyright. 43 44 7. Garces A, McClure EM, Chomba E, Patel A, Pasha O, Tshefu A. Home birth attendants in low 45 46 income countries: who are they and what do they do? BMC Pregnancy Childbirth 2012; 12:34. 47 48 8. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems 49 50 can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115(2):127-34. 51 52 9. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth 53 54 attendants and village midwives. J Obstet Gynaecol 2004; 24(1):5-11. 55 56 10. Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication 57 58 readiness among slum women in Indore City, India. J Health Nutr Popul 2010; 28(4): 383-391. 59 60 17

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 11. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies 5 6 incorporating training and support of traditional birth attendants on perinatal and maternal 7 8 mortality: meta-analysis. BMJ 2011; 343:d7102. 9 10 12. Sibley LM, Sipe TA. Transition to skilled birth attendance: Is there a future role for trained 11 12 traditional birth attendants. J Health Popul Nutr 2006; 24(4):472-8. 13 14 13. Bisika T. The effectiveness of the TBA programme in reducing maternal mortality and morbidity in 15 For peer review only 16 Malawi. East Afr J Public Health 2008; 5(2):103–10. 17 18 14. Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral of high-risk pregnant mothers by 19 20 trained traditional birth attendants in Buikwe County, Mukono District, Uganda. J Obstet Gynaecol 21 22 2005; 25(6):554-7. 23 24 15. Temesgen TM, Umer JY, Buda DS, Haregu TN. Contribution of traditional birth attendants to the 25 26 formal health system in Ethopia: the case of Afar region. Pan Afr Med J 2012; 13(Suppl 1):15. 27 28 16. Wajid A, Rashid Z, Mir AM. Initial assessment of Community Midwives in rural Pakistan. PAIMAN. 29 30 JSI Research and Training Institute, Inc; Islamabad: 2010. 31 32 17. Concern Worldwide. Examining the role of traditional birth attendants in the continuum of care in 33

34 Sierra Leone. Innovations for maternal, newborn and child health. Policy Brief. Concern http://bmjopen.bmj.com/ 35 36 Worldwide; New York: 2013. 37 38 18. National Institute of Population Studies and Macro International Inc. Pakistan Demographic and 39 40 Health Survey (PDHS) 2006–07. Government of Pakistan; Islamabad: 2008. 41 42 19. Government of Pakistan. PC1 National Maternal Newborn & Child health Program 2006-2012. on September 28, 2021 by guest. Protected copyright. 43 44 Ministry of Health, Government of Pakistan; Islamabad: 2009. 45 46 20. Research and Development Solutions. The community midwives program in Pakistan. Policy 47 48 Brief Series No 20. Islamabad: 2012. 49 50 21. Department of Health. District health profile-Chitral. Government of Khyber Pakhtunkhwa; 51 52 Peshawar: 2014. 53 54 22. Chesney M, Davies S. Women’s birth experiences in Pakistan – the importance of the Dai. The 55 56 Royal College of Midwives. Evid Based Midwifery 2005; 3(1):26-32. 57 58 59 60 18

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 23. Owolabi OO, Glenton C, Lewin S, Pakenham-Walsh N. Stakeholder views on the incorporation of 5 6 traditional birth attendants into the formal health systems of low-and middle-income countries: a 7 8 qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums. BMC Pregnancy 9 10 Childbirth 2014; 14:118. 11 12 24. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-Experiences of community 13 14 midwives in Pakistan. BMC Pregnancy Childbirth 2014; 14:59. 15 For peer review only 16 25. Research and Advocacy Fund/Children First. How far can I go? Social mobility of CMWs in Azad 17 18 Kashmir. Islamabad: 2012. 19 20 26. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community 21 22 mobilization and health management committee strengthening to increase birth attendance by 23 24 trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomized 25 26 controlled trial. Trials 2011; 12:128. 27 28 27. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the 29 30 management of the third stage of labour in the home delivery setting in rural Gambia: a 31 32 randomized controlled trial. Br J Obstet Gynaecol 2005; 112: 1277-83. 33

34 28. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, et al. Administration of misoprostol http://bmjopen.bmj.com/ 35 36 by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in 37 38 Pakistan: a randomized placebo-controlled trial. BJOG 2011; 118(3):353-61. 39 40 29. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: Is the 41 42 health care system accessible and responsive in Pakistan? Health Care Women Int 2008; on September 28, 2021 by guest. Protected copyright. 43 44 29:945-959. 45 46 30. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB. Effect of training 47 48 traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): 49 50 randomized controlled study. BMJ 2011; 342:d346. 51 52 31. Falle TY, Mulany LC, Thatte N, Khatry SK, LeClerg SC, Darmstadt GL, et al. Potential role of 53 54 traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 55 56 2009; 27(1): 53–61. 57 58 59 60 19

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Emerging role of traditional birth attendants in mountainous terrain of Chitral District, Pakistan 10 11 12 Babar Tasneem Shaikh, MPH, PhD, FRCP Edin 13 Sharifullah Khan, MPH 14 15 Ayesha Maab, MSc For peer review only 16 17 Sohail Amjad, MA-HM, MA-HMPP 18 19 20 21 Running title: Role of traditional birth attendants 22 23 24

25 26 Corresponding author 27 28 Dr Babar Tasneem Shaikh 29 Aga Khan Foundation (Pakistan) 30 31 Level Nine, Serena Business Complex 32 Khayaban-e-Suharwardy, Islamabad 33

34 t: +92 51 111-253-254 http://bmjopen.bmj.com/ 35 36 f: +92 51 2072552 37 e: [email protected] 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 1 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Abstract: 10 IntroductionObjectives: Shortage of health workforce is the major impediment in the achievement of 11 12 health related MDGs 4 & 5. It is important to review strategies to maximize strengths of traditional birth 13 attendants (TBAs) and skilled birth attendants in resource limited settings. However, role of TBAs in the 14 15 provision of maternal, newbornFor and child peer health (MNCH) carereview has been a subject of discussion.only This 16 17 research endeavors to identifyre-define the role of TBAs in supporting the MNCH care now provided 18 mainly by the trained community midwives (CMWs), to mainstreaming TBAs with the formal health 19 20 system and to delineate their livelihood prospects, after the deployment and introduction of CMWs in the 21 health system of Pakistan. 22 23 Setting: The study was conducted in District Chitral, Khyber Pakhtunkhwa province, covering the areas Formatted: Font: Not Bold 24 25 where Chitral Child Survival programme was implemented. Formatted: Font: Not Bold 26 MethodsParticipants: A qualitative exploratory study was conducted, comprising in predominantly rural 27 28 district Chitral, Pakistan. About seven Key informant interviews (KIIs) with health managers, and four 29 focus group discussions (FGDs) were conducted with community midwives (CMWs), TBAs and members 30 31 of Village Health Committees (VHCs). 32 Results: The study identified that community has trust and faith in TBAs and her services. In the new 33

34 scenario, after the introduction of CMW in the health system, TBAs still have had a pivotal role in health http://bmjopen.bmj.com/ 35 36 promotion activities such as breast feeding promotion and vaccination. TBAs can assistonduct CMWs in 37 normal deliveries, and refer high risk cases to formal health system. With regard to CMW introduction in 38 39 system, Generally, TBAs are positive about CMWs’ introduction and welcome this addition. Yet, their 40 livelihood has suffered after CMWs deployment. Monetary incentives to them in recognition of referrals to 41 42 CMWs could be one solution. There ought to be a meaningful interaction between the two cadres at the on September 28, 2021 by guest. Protected copyright. 43 village level. VHC is an active forum for strengthening coordination between them two service providers 44 45 and to ensure an alternate and permanent livelihood support system for the TBAs. 46 47 Conclusion: TBAs assured their continuedly support in provision ofthe need for continuum of care for 48 pregnant women, lactating mothers and children under five. The district health authorities must figure out 49 50 ways to foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. After some time, 51 52 53 54 2 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 it would be worthwhile to do further research to look into the CMW’s integration in the system, as well as 10 TBA’s continued role for provision of MNCH care. 11 12 13 Keywords: Maternal Newborn & Child Health, Traditional birth attendant, Community midwife, Qualitative 14 15 research, Pakistan. For peer review only 16 17 18 Strengths & Limitations of the study 19 20 A study, first of its kind, which has expounded on the subject of TBAs role and livelihood after the 21 introduction of trained MNCH providers in Pakistan. Use of qualitative methods provided rich insight into 22 23 women’s interpretations and decision-making regarding health care seeking during and after pregnancy in 24 25 a relatively conservative setting of Pakistan. Study presents views of all stakeholders involved in the 26 intervention. 27 28 29 The findings represent a specific sample size, study site and socio-cultural milieu and therefore may not 30 31 be generalized for the entire province or country. Health providers involved in the study were mainly from 32 AKHSP and government who were already exposed to this intervention. Only few TBAs could be 33

34 gathered for discussion, because most of them were remotely located, and weather and family http://bmjopen.bmj.com/ 35 36 constraints did not allow them to travel. Moreover, the prospective role of TBA is discussed in a special 37 context, whereby a CMW was trained and deployed in the area for increasing skilled birth attendance. 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 3 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Introduction 10

11 Despite all advances toward MDGs 4 & 5, every year 6.6 million children die before five years of age 12 13 (44% as newborns) and 289,000 maternal deaths occur, mostly from preventable causes (1). This state 14 of affairs has raised serious global concern over the years in developing countries to ensure availability 15 For peer review only 16 and accessibility of human resources for ensuring continuum of care for expecting mothers. Uniform 17 18 availability and distribution of skilled birth attendants is critical to consider while looking at health service 19 utilization trends (2). The Millennium Declaration in 2000 signed by 189 nations, recognized proportion of 20 21 births assisted by trained birth as an important indicator to track maternal and child survival indicators 22 (3,4). To increase the availability and accessibility of maternal and child health care services, training of 23 24 TBAs and strengthening the partnership between community midwives (CMWs) and TBAs is widely 25 acknowledged worldwide (5,6). Nonetheless, role of the TBAs cannot be effective in a weak primary 26 27 health care system and in an unplanned referral mechanism (7). 28 29 30 In order to attain MDG-5, isolated interventions are not able to reduce maternal mortality sufficiently. It is 31 32 important to review strategies to maximize strengths of TBAs as well and skilled birth attendants. 33 Evidence suggests that skilled birth attendance has increased in regions where TBAs are integrated with

34 http://bmjopen.bmj.com/ 35 the formal health system (8). However, integration of TBAs with the formal health system may require 36 capacity development and supervision of TBAs, collaboration skills for health workers, involvement of 37 38 TBAs at health facilities and, improved capacity on communication and referral systems. With this 39 40 approach, TBAs may positively contribute to maternal and child health outcomes (9). Trainings of the 41 TBAs not only enhance their knowledge and skills on obstetric care and referral mechanism, but also lead 42 on September 28, 2021 by guest. Protected copyright. 43 to greater community acceptance and a greater consumer satisfaction. They can play a vital role in birth 44 preparedness and identification of danger signs (10). Training of TBAs has shown impact on perinatal 45 46 and neonatal deaths which can be significantly reduced (11). Moreover, TBAs have been a critical 47 contributor in providing skilled maternal, newborn and child health (MNCH) care in rural population of 48 49 developing countries due to inadequate numbers of human resource for service delivery (12). Therefore, 50 51 role of trained TBAs in healthcare provision cannot be undermined. Developing countries have used 52 TBAs as a key strategy to improve maternal and child health care (13). They have been effective in 53 54 4 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 improving referral mechanism and links with the formal health care system (14). Literature review has 10 suggested that a TBA is preferred over a midwife who is young, unmarried girl and without children. This 11 12 trend is more common in countries where fresh CMWs are recently deployed such as Pakistan (15,16). 13 Another reason for the community acceptance of TBAs is that they are affordable option than professional 14 15 midwives and she often acceptsFor payment peerin kind (17). Moreover, review TBAs are always happy toonly make house 16 17 visits, warranting mother’s privacy. 18 19 20 Pakistan is among the few countries in South Asia that continues to have dismal maternal and child 21 health indicators. In Pakistan, Maternal Mortality Ratios (MMR) is high, ranging from 240 to 700 per 22 23 100,000 live births. The top three causes of maternal death are postpartum hemorrhage, eclampsia and 24 25 sepsis. Approximately two-thirds of all births (61%) take place at home due to limited access to health 26 facilities. Home based deliveries are usually attended by the TBA and now newly deployed community 27 28 midwives in some rural parts of the country (18). While some maternity care indicators appear to have 29 improved over the last two decades, women’s access to prenatal health care continues to be low in 30 31 Pakistan18. 32

34 Realizing the need for community health work force, Government of Pakistan launched the national http://bmjopen.bmj.com/ 35 36 MNCH program in 2006 to help the rural women deliver safely (19). Although the program has been 37 successful in countries such as Malaysia and Indonesia, challenges faced by the CMW program of 38 39 Pakistan are multifaceted. These challenges are related to acceptance by community, competition with 40 other service providers, weak referral system, inadequate skill set and lack of community involvement 41 42 (20). on September 28, 2021 by guest. Protected copyright. 43

44 45 The intervention 46 47 To address health system constraints, Chitral Child Survival Program (CCSP) of Aga Khan Foundation 48 Pakistan (AKF-P) deployed CMWs, supported community financing scheme, improved referral linkages 49 50 and implemented a behavior change communication campaign from 2008-2014. CCSP was implemented 51 in close partnership of Department of Health, Khyber Pakhtunkhwa, Aga Khan Health Services (AKHSP), 52 53 54 5 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Pakistan (AKHSP), and Aga Khan Rural Support Program (AKRSP). The CCSP interventions, especially 10 the role of community based saving groups, village health committees (VHCs) and community based 11 12 emergency maternal referral mechanism to achieve project results showed that CCSP had attempted to 13 engage the TBAs proactively. The project empowered TBAs on Birth Preparedness and Complications 14 15 Readiness (BPCR) plans Forand integrated peerreferral mechanisms. review Involvement of TBAs in theonly project was 16 17 meaningful to generate the community acceptability for young CMWs, identification of high risk cases, 18 and referrals of complications to CMW and transporting pregnant woman to health facility in time. 19 20 21 This research endeavored to identify the role of TBAs in supporting the MNCH care, partnership 22 23 mechanism with the formal health system and also explored livelihood options for TBAs. 24 25 26 Methodology 27 28 a) Study site 29 The study was conducted in Chitral district, north western border of Pakistan, from March-April 2014. 30 31 The population of the intervention area is 200,000, about 57% of the total population of the district 32 and residing in 243 villages. The government department of health and Aga Khan Health Services 33

34 Pakistan (AKHSP) are the two primary formal sector healthcare providers in Chitral. The public-sector http://bmjopen.bmj.com/ 35 36 healthcare infrastructure in the district includes 22 civil dispensaries, 21 basic health units; three tehsil 37 headquarters and one district headquarter hospital (21). AKHSP operates its own 32 health facilities 38 39 in Chitral which include 17 health centers, eight family health centers, four dispensaries and three 40 secondary care facilities, covering 60% of Chitral district. The MMR in the province is 275/100,000 41 42 live births; whereas under five mortality is 75/1000 live births (1819). Despite the presence of skilled on September 28, 2021 by guest. Protected copyright. 43 birth attendants under MNCH program, large proportion of the deliveries is still attended by TBAs in 44 45 Chitral district. 46 47 48 b) Study Design and data collection 49 50 The project documents and other relevant studies were thoroughly reviewed and the collated 51 information guided to design the qualitative data collection instruments. A qualitative exploratory 52 53 54 6 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 study entailed seven KIIs and four FGDs conducted with different study participants. The questions 10 for focus group discussion (FGD) and key informants interview (KIIs) explore the Field guides 11 12 included open ended questions, covering topics such as role of TBAs in supporting MNCH care and 13 CCSP project activities, community experience with TBAs, TBAs’ relationship and coordination with 14 15 the CMWs, referral ofFor cases; remuneration peer and livelihood reviewsources of TBAs; ways to engageonly TBAs in 16 17 continuum of care, working relationships and linkages with the formal health system, and 18 sustainability/livelihood of TBAs. Using a participation diagram in FGDs, it was ensured that all the 19 20 participants must speak on each question. To ensure quality control, information collected through 21 note-taking was cross-checked for completeness and consistency before and during data processing 22 23 by the research team. 24 25 26 c) Study participants 27 28 All the study participants were purposively sampled from the intervention areas in the district, with the 29 help of the implementing agencies on ground. Community based health workers i.e. CMWs and 30 31 TBAs; members of VHC and Community Based Saving Group (CBSG) were included in the 32 discussion. The participants were encouraged by the moderator (PI) to interact with each other and 33

34 comment on experiences and perceptions regarding role of TBAs, partnership with formal health http://bmjopen.bmj.com/ 35 36 system, and livelihood of TBAs. KIIs were conducted with two government health managers, two 37 AKF-P managers, and three AKHSP managers. All the FGDs were conducted in the community; 38 39 whereas KIIs were conducted in the respective offices of health managers. Table-1 presents the 40 detail of the methods employed for the study. 41 42 on September 28, 2021 by guest. Protected copyright. 43 Table-1: Detail of methods employed in qualitative study 44 45 Total number Cadre Method AreaVillage 46 of respondents 47 Mori Lshat, Barini, Awi, Miragarm, Sore Laspoor, Raman, Terich Payeen, Lot Owir 48 CMWs FGD 10 Bala, Lot Owir Payeen, Gohkir, Parsan, Owir 49 Lasht Arkari, Besti Arkari, Khuz, Phashk 50 Lower Porth, Brock Kalaway, Porth Bala, TBAs FGD 5 51 Raman, Brock Baraman Deh 52 VHC FGD 8 Morder 53 54 7 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 CBSG FGD 10 Morder 10 Health managers (AKHSP, AKF-P 11 7 KIIs 07 Chitral city & 12 DHDGovernment) 13 14 15 Purposive sampling techniqueFor was adopted, peer inviting the participation review of those CMWs, and onlyTBAs who had 16 been serving actively in their local communities for the last two years. These health workers were 17 18 identified with the help of health managers of AKHSP and government. Likewise, only those members of 19 VHC were invited for FGD, who had been active for the last two years. Each participant of the FGD and 20 21 KII was given the verbal information about the study by the research team and was given a consent form 22 23 prior to participation. 24 25 26 d) Data analysis 27 A qualitative content analysis was applied to analyze the information manually from all the FGDs and 28 29 KIIs. A stepwise approach was adopted for the content analysis. The analysis aimed at finding manifest 30 and latent meaning of data. The transcribed data was initially read several times by the principal 31 32 researcher in order to find the sense of the whole. At first stage the segmentation of information was done 33 i.e. segments and sub-segments of information were organized. Subsequently the significant information

34 http://bmjopen.bmj.com/ 35 was extracted which was related to research questions. At second stage the common views of the 36 37 respondents were put together at one place. At third stage, data was coded (different responses 38 highlighted) and then these codes were grouped into categories and abstracted into sub-themes and a 39 40 main theme. At final stage, the meanings of themes/descriptions were interpreted by keeping in view and 41 considering the cultural context of the participants. 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 Results 46 The main theme which came out was the “emerging role of TBAs to improve Maternal, Newborn and 47 48 Child Health”. After content analysis, following sub-themes were identified as shown in Table 2: 49 1. Community experience with CMWs and TBAs 50 51 2. View of participants on utilization of TBAs in formal health system 52 53 54 8 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 3. Role of TBAs in supporting obstetric care 10 4. Linkages and coordination among TBAs and CMWs 11 12 5. Livelihood of TBAs 13

14 15 Table-2: Matrix of qualitativeFor research analysispeer review only Formatted: Left, Space After: 10 pt, Line 16 spacing: Multiple 1.15 li, Adjust space between Nodes Sub-nodes Latin and Asian text, Adjust space between 17 Asian text and numbers 18 Community experience with - Availability of CMWs have empowered women for health care seeking 19 CMWs and TBAs - Community has trust and faith in TBAs and their services 20 -TBAs have pivotal role in health promotion activities such as health 21 messages on breast feeding, mother and child immunization. 22 Linkage of TBAs with formal -TBAs must assist CMW who is naïve to reproductive health matters. 23 health system 24 -TBAs can be involved in linking high risk cases to CMW and health 25 facility. 26 - TBAs promote health messages for expecting mothers, assist CMW in 27 Role of TBAs in supporting delivery, identify expectant mothers with high risks, refer such cases to 28 obstetric care 29 formal health system, and support post-natal care 30 - Mixed responses in terms of relationship between CMWs and TBAs 31 Linkages and coordination - VHC is an active forum for coordination 32 among TBAs and CMWs - Coordination is better at places where TBA gets some share of CMW 33 income

34 http://bmjopen.bmj.com/ 35 - CMWs could offer some incentives to TBAs to strengthen referrals and assistance in skilled delivery 36 Livelihood of TBAs 37 - VHCs decide TBA incentive share of CMW income 38 - Community pay in kind contribution to recognize services of TBA 39 40 41 Community experience with CMWs and TBAs 42 Availability of CMWs and the supportive role of TBAs in obstetric care hashave benefited communities, by on September 28, 2021 by guest. Protected copyright. 43 44 and large. Most of the respondents shared that availability of CMWs has empowered women in order to 45 46 seek essential and emergency obstetric care in rural communities. Members of VHC appreciated the 47 binding relation of CMWs with TBAs. Despite availability of CMWs, the community members still have 48 49 greater trust and faith in TBAs who live and deals with the village women since ages. Some of the 50 respondents told that they avail services of TBAs due to her rich experience as compared to CMWs who 51 52 are young and yet naïve to various reproductive health matters. 53 54 9 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 “TBA still has the critical role as being more in proximity to the village women. She enjoys far more trust of 11 12 the communities. She has a years’ long rapport with the families. People tend to follow her advice.” 13 (Director Health, AKFP) 14 15 For peer review only 16 17 “I consider the role of TBAs important for two reasons; firstly they have been trusted by the communities, 18 so they need to be taken on board for enhancing referrals to CMWs. Secondly, if they are not engaged 19 20 properly then they will do more harm by doing deliveries and might spread negative propaganda too 21 about the CMWs”. (KIIAKFP Senior Program Officer) 22 23 24 “I take my wife and child to CMW to see for medical help or treatment for maternal and child health 25 26 problems? In our village, Dai (TBA) enjoys good relationship with the CMW”. (FGDVHC, Morder)” 27 28 29 “My family often seeks services from a TBAshe has all the experience.” (FGDVHC, Morder) 30 31 32 “The TBAs are working since long time and they have developed trust in the communities”. (KII, AKHSP 33

34 Manager) http://bmjopen.bmj.com/ 35 36 37 Linkage of TBAs with formal health system 38 39 TBAs have pivotal role in health promotion activities such as health messages on nutrition, breast 40 feeding, and vaccination promotion. Viewpoints of participants revealed that TBAs can be mainstreamed 41 42 in a formal health system by assigning health promotion activities and for referring high risk cases to on September 28, 2021 by guest. Protected copyright. 43 CMW and health facility. 44 45 46 47 “The TBAs have role in referring of high risk cases and expectant mothers for delivery to CMWs. TBAs 48 are also playing very good role in the community in identifying pregnant mothers during 1st trimester in the 49 50 community, arranging TT vaccinations and providing education on nutrition during pregnancy.” (GM, 51 AKHSP) 52 53 54 10 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 “They (TBAs) must be linked with the formal health system especially for health promotion, referrals and 11 12 assisting deliveries with CMWs, when needed” (FGDVHC, Morder) 13

14 15 Role of TBAs in supportingFor obstetric carepeer review only 16 17 TBAs have pivotal role in terms of identifying pregnancy related complications and assisting safe obstetric 18 care services with CMWs. Traditionally, TBAs have been involved in the promotion of better nutrition 19 20 practices for pregnant mothers, breastfeeding practices, TT vaccination of expectant mothers, prevention 21 of neonatal hypothermia, and post-natal care including family planning. TBAs have a crucial role in 22 23 strengthening referral and coordination mechanisms with CMWs and with the health facility. Findings of 24 25 the KIIs and FGDs revealed that some TBAs were even involved in assisting deliveries with CMWs. 26 27 28 “Many TBAs, no doubt have a sound folk wisdom, which can be used for various health promotion 29 messages, especially where there is no other community health worker. Moreover, TBAs can be trained 30 31 in providing antenatal care, TT vaccine, Misoprostol administration, recognizing the danger signs of 32 pregnancy etc. This will give her a feeling that she still has a role to play in saving women’s lives.” 33

34 (Director Health, AKFP) http://bmjopen.bmj.com/ 35 36 37 “TBAs promote breastfeeding and healthy nutritional practices in our community for mother and children; 38 39 and they can keep on doing that”. (FGDVHC, Morder) 40 41 42 “In my village, TBA assists delivery with me and refers cases to me. I have to say that she is of great help on September 28, 2021 by guest. Protected copyright. 43 for me”. (FGDCMWs, Parsan) 44 45 46 47 “They (TBAs) said, they do refer cases to them and in many cases have joined CMWs for conducting 48 deliveries.” (KIIAKFP Senior Program Officer) 49 50 51 Linkages and coordination mechanisms among TBAs and CMWs 52 53 54 11 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Mixed responses were recorded with regards to linkages and coordination among TBAs and CMWs. 10 There is no formal referral mechanism between TBAs and the CMWs. Lack of role clarity, physical 11 12 inaccessibility, professional rivalry and few income opportunities are key factors for weak linkages 13 between TBAs and CMWs. Some of the CMWs expressed that they encountered problems and 14 15 resistance from the TBAs Forand community peerduring the initial phase review of deployment. Village healthonly committee 16 17 shared that they invite both TBAs and CMWs in the VHC meetings. Performance of TBAs vis-à-vis skills 18 related to maternal and newborn health is not satisfactory. Therefore, they now go to the CMWs who 19 20 have adequate competency in knowledge and skills about the obstetric care. Some of the members 21 shared that TBAs refer complicated expectant mothers to CMWs and health facility. In few instances, TBA 22 23 was seen to be assisting the CMW in deliveries. 24 25 26 “Rivalry; both are birth attendants; one is practicing by virtue of folk knowledge and the other is trained 27 28 according to modern guidelines and WHO standards. So that has created a competition. At places, there 29 is coordination too, where both are from the same family or where both have realized each other’s 30 31 importance.” (Director Health, AKFP) 32

34 “The issues between TBA and CMW can be effectively dealt if AKHSP works with all stakeholders and set http://bmjopen.bmj.com/ 35 36 out a proper coordination plan, and play catalytic role to nurture a health relationship.” (KIIAKFP, Senior 37 Program Officer) 38 39 40 “In some areas of intervention, the TBA perceived CMW as competitor.” (GM, AKHSP) 41 42 on September 28, 2021 by guest. Protected copyright. 43 “Introduction of CMWs in the areas will limit the role of TBAs. To cope with this challenge the TBAs were 44 45 included in the VHCs and the roles/responsibilities of the CMWs were communicated through this 46 47 platform”. (KII, AKRSP Manager) 48 49 50 51 52 53 54 12 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 “Many TBAs are in favor of CMWs because they cannot handle the complicated cases properly; yet some 10 are against her. VHC is trying to bring the TBA as member in VHC and told them about the importance of 11 12 deliveries by skilled hand and hygienic way.” (FGDVHC, Morder) 13

14 15 According to CMWs, they Forhave high regard peer for the TBA, her experiencereview and wisdom. They only feel that TBA 16 17 can complement their work. On the other hand, most TBAs are satisfied with CMWs work, skills and 18 services rendered to the community women. Very few seem to be unhappy indeed. 19 20 21 Livelihood and sustainability of TBAs 22 23 Supporting role of TBAs is very important; especially in context of difficult geographical terrains in Chitral. 24 25 Various options as well as mechanisms were identified by the respondents, when asked about livelihood 26 prospects of TBAs. Most of the respondents were of opinion that CMWs must pay some incentives to 27 28 TBAs to strengthen referrals and assistance in skilled delivery. Findings of the KII revealed that one of the 29 available forums to decide TBAs incentives is village committee. VHCs and other available forums such 30 31 as Local Support organizations (LSOs) can play pivotal role in taking up such decisive role for supporting 32 livelihood options for TBAs. Regarding payment to TBAs, some of the CMWs did not recompense TBAs. 33

34 Some of the TBAs also told that they get in kind contributions and support for her services from the village http://bmjopen.bmj.com/ 35 36 families and not from the CMWs. 37 38 39 “It is an informal arrangement between the two of them. Officially there is no binding on the CMW to pay TBA for 40 referrals.” (Director Health, AKFP) 41 42 on September 28, 2021 by guest. Protected copyright. 43 “One of the CMW referred two cases to CMWs, and in fact she did join her for conducting the deliveries, but in 44 45 return did not get anything from the CMW and the family too.” (KIIAKFP, Senior Program Officer) 46 47 48 “Let it be the VHC meeting to decide about some incentives to be given to TBAs from CMW fee, because 49 50 she will be referring every case to CMW. CMW should provide some money to TBA”. (KII, AKHSP 51 Manager) 52 53 54 13 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 “TBAs were providing delivery services before CMWs’ deployment; hence CMWs’ services will certainly affect 10 their regular income (in cash or in kind). CMW should give incentive from her service fee to TBAs on each 11 12 referral; whereas TBA can continue providing care to mother after delivery”. (KII, Manager Programs, AKHSP) 13

14 15 “In our area, CMW is payingFor Rs200 to the peer TBA for each referral”. review (FGDVHC, Morder) only 16 17 18 “In two cases, I assisted CMW for delivery of a mother. CMW did not give me any money. I got some 19 20 cash and chicken from the house of delivered mother”. (FGDTBA, Lower Porth) 21 22 23 Discussion 24 25 Though communities where CMWs are deployed after training are happy, yet tThe continued utilization of 26 TBAs’ services in Chitral. Fact is attributed to several factors including the TBAs’ proximity to several 27 28 villages, TBAs’ respectful attitude toward the community, and flexible modes of payment (22,23). CMWs 29 have been recently deployed in Chitral and experienced challenges and constraints by community based 30 31 health providers and community itself in delivery of maternal health services (24,25). Evidence suggests 32 that health management committees at the village level have been effective in reducing maternal 33

34 complications through promoting linkages of health care providers with the community (26). The findings http://bmjopen.bmj.com/ 35 36 of our study also revealed that community forum in the form of VHC has played pivotal role in convincing 37 the communities to avail CMW services and motivate the TBA to continue in supportive role in MNCH 38 39 care. linking TBAs and CMWs with the community members. Awareness sessions have to be conducted 40 on regular basis and on different forums to better inform the elder women and expecting mothers about 41 42 the benefits of making use of skilled birth attendant i.e. CMW. on September 28, 2021 by guest. Protected copyright. 43

44 45 Results of our study found that TBAs play vital role in improving maternal health such as diagnosing 46 47 labor, assisting clean delivery with CMWs, detecting and referring maternal complications, and promoting 48 health messages. While trained TBAs are not considered skilled birth attendants, their potential 49 50 contribution in supporting maternal care has been recognized in low income and middle countries facing 51 issues of human response scarcity (12,Error! Bookmark not defined.13). Role of TBAs in administration 52 53 54 14 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 of misoprostol to prevent postpartum hemorrhage in home-births is oft-advocated (27,28). Nevertheless, 10 the role of TBAs in supporting MNCH care cannot be neglected in settings where skilled birth attendants 11 12 are fewer and new to health system. In the wake of reforms and the novel MNCH program of Pakistan, 13 role of TBAs in improving maternal care and transforming health seeking behaviours ought to be 14 15 promoted (29). Defining herFor role and contribution peer in the continuum review of care is linked to her only livelihood and 16 17 income generation. 18 19 20 Improved linkages and relationship among CMWs and TBAs is of essence to flourish referral system from 21 community to health facility. Better coordination and collaboration of TBAs with CMWs was promoted 22 23 under CCSP, by sensitizing the CMW on prospective role of TBA which will complement her services and 24 25 will help in building her rapport with the community. TBA, who has a long standing link with local 26 community, can act as a bridge to strengthen referral mechanism between community and the formal 27 28 health system (1521). Findings of the qualitative study follow other studies which demonstrated that a 29 formal partnership program among TBAs and the skilled midwives has yet to be seen (56). While the 30 31 importance of the TBAs role in referral is universally acknowledged, most health systems have not 32 developed an effective referral mechanism. The CCSP project provided an enabling forum at the village 33

34 level for CMWs and TBAs to interact and improve referral linkages. Such partnership is crucial to improve http://bmjopen.bmj.com/ 35 36 access to health care services, especially for communities living in the remote areas. Nevertheless, 37 training and monitoring TBAs on MNCH care is imperative to minimize chances of malpractices (13). 38 39 Therefore, joint monitoring by AKHSP and government, by involving the village health committees could 40 be instrumental in this regard. Moreover, participatory monitoring is always less threatening; and hence 41 42 TBAs should be meaningfully engaged in such type of monitoring. on September 28, 2021 by guest. Protected copyright. 43

44 45 Financial constraints are a major risk to the livelihood of TBAs as evident from the findings of our study. 46 47 Mostly they are receiving in kind payments by the family of expectant mothers; and a nominal payment by 48 CMWs for each referral. CMWs must keep a cushion of nominal payment to TBA, after verifying her 49 50 services. That will surely help in building a healthy relationship amongst the two service providers. Where 51 TBAs did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 52 53 54 15 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 health system. Evidence suggests that in kind contributions by clients are the most common mode of 10 payment by the clients (89,1011). With the increasing use of TBAs in MNCH care, the question of 11 12 compensation has become more pressing because these workers usually rely on rewards and in kind 13 contributions by the clients (30). Continuing efforts to define the role of TBAs may benefit from an 14 15 emphasis on their potentialFor as active promoters peer of essential newbornreview care (31). In the context only of Pakistan, 16 17 the role of TBAs ought to be revisited and redefined, not only for the sake of trust of communities on her 18 services, but also for her own livelihood. 19 20 21 Conclusion 22 23 Prevailing poverty in the area calls for thinking solutions to ensure livelihood of TBAs, and to figure out an 24 25 emerging role for her after the introduction of CMW in the health system. TBAs surely have solutions in 26 the continuum of care for pregnant women, lactating mothers and children under five. They continue to 27 28 take pride and see value in their role in the health system to support MNCH care. Health systems 29 performance can be amplified by having a healthy interface between the TBAs and CMWs, and for the 30 31 larger benefit of the communities served. 32

34 Acknowledgement: http://bmjopen.bmj.com/ 35 36 The authors acknowledge the facilitation and assistance provided by AKF-P, AKHSP and AKRSP to carry 37 out field data collection. 38 39 40 Ethical consideration: 41 42 Ethics approval for this study was granted by the Institutional Review Board of Aga Khan Health Services, on September 28, 2021 by guest. Protected copyright. 43 Pakistan. Verbal informed consent was obtained from all the study participants, after explaining the 44 45 objectives of the study. Confidentiality and anonymity was assured to all the participants. Data was kept 46 47 under lock and key with the principal researcher. 48 49 50 Authors’ contributions 51 52 53 54 16 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 BTS and SAK conceived the study design and instruments. AM supervised the data collection and helped 10 in analyses. BTS and SAK drafted the successive drafts of paper. SA conducted the critical review and 11 12 added the intellectual content to the paper. All authors read and approved the final draft. 13

14 15 Funding: The study was aFor part of larger projectpeer “Chitral Child Survivalreview Program” funded by onlyUSAID. 16 17 18 Competing Interests 19 20 The authors declare that they have no competing interests. 21 22 23 References 24 25 1. World Health Organization & UNICEF. Countdown to 2015 and beyond: fulfilling the health 26 27 agenda for women and children. Geneva: 2014. 28 29 2. Shaikh BT. Marching toward the Millennium Development Goals: What about health systems, 30 health-seeking behaviours and health service utilization in Pakistan? World Health & Popul 2008; 31 32 10(2): 44-52. 33 3. United Nations. Road map towards the implementation of the United Nations Millennium

34 http://bmjopen.bmj.com/ 35 Declaration: report of the Secretary-General. New York: 2001. 36 4. Sachs JD, McArthur JW. The Millennium Project: a plan for meeting the Millennium Development 37 38 Goals. Lancet 2005; 365(9456):347-53. 39 40 5. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth 41 attendants and home delivery? A qualitative study on delivery care services in West Java 42 on September 28, 2021 by guest. Protected copyright. 43 Province, Indonesia. BMC Pregnancy Childbirth 2010; 10:43. 44 6. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal 45 46 and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst 47 Rev 2010; 11: CD007754. 48 49 7. Garces A, McClure EM, Chomba E, Patel A, Pasha O, Tshefu A. Home birth attendants in low 50 51 income countries: who are they and what do they do? BMC Pregnancy Childbirth 2012; 12:34. 52 53 54 17 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 8. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems 11 can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115(2):127-34. 12 13 9. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth 14 attendants and village midwives. J Obstet Gynaecol 2004; 24(1):5-11. 15 For peer review only 16 10. Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication 17 18 readiness among slum women in Indore City, India. J Health Nutr Popul 2010; 28(4): 383-391. 19 11. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies 20 21 incorporating training and support of traditional birth attendants on perinatal and maternal 22 mortality: meta-analysis. BMJ 2011; 343:d7102. 23 24 12. Sibley LM, Sipe TA. Transition to skilled birth attendance: Is there a future role for trained 25 traditional birth attendants. J Health Popul Nutr 2006; 24(4):472-8. 26 27 13. Bisika T. The effectiveness of the TBA programme in reducing maternal mortality and morbidity in 28 29 Malawi. East Afr J Public Health 2008; 5(2):103–10. 30 14. Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral of high-risk pregnant mothers by 31 32 trained traditional birth attendants in Buikwe County, Mukono District, Uganda. J Obstet Gynaecol 33 2005; 25(6):554-7.

34 http://bmjopen.bmj.com/ 35 15. Temesgen TM, Umer JY, Buda DS, Haregu TN. Contribution of traditional birth attendants to the 36 formal health system in Ethopia: the case of Afar region. Pan Afr Med J 2012; 13(Suppl 1):15. 37 38 16. Wajid A, Rashid Z, Mir AM. Initial assessment of Community Midwives in rural Pakistan. PAIMAN. 39 40 JSI Research and Training Institute, Inc; Islamabad: 2010. 41 17. Concern Worldwide. Examining the role of traditional birth attendants in the continuum of care in 42 on September 28, 2021 by guest. Protected copyright. 43 Sierra Leone. Innovations for maternal, newborn and child health. Policy Brief. Concern 44 Worldwide; New York: 2013. 45 46 18. National Institute of Population Studies and Macro International Inc. Pakistan Demographic and 47 Health Survey (PDHS) 2006–07. Government of Pakistan; Islamabad: 2008. 48 49 19. Government of Pakistan. PC1 National Maternal Newborn & Child health Program 2006-2012. 50 51 Ministry of Health, Government of Pakistan; Islamabad: 2009. 52 53 54 18 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 39 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 20. Research and Development Solutions. The community midwives program in Pakistan. Policy 11 Brief Series No 20. Islamabad: 2012. 12 13 21. Department of Health. District health profile-Chitral. Government of Khyber Pakhtunkhwa; 14 Peshawar: 2014. 15 For peer review only 16 22. Chesney M, Davies S. Women’s birth experiences in Pakistan – the importance of the Dai. The 17 18 Royal College of Midwives. Evid Based Midwifery 2005; 3(1):26-32. 19 23. Owolabi OO, Glenton C, Lewin S, Pakenham-Walsh N. Stakeholder views on the incorporation of 20 21 traditional birth attendants into the formal health systems of low-and middle-income countries: a 22 qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums. BMC Pregnancy 23 24 Childbirth 2014; 14:118. 25 24. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-Experiences of community 26 27 midwives in Pakistan. BMC Pregnancy Childbirth 2014; 14:59. 28 29 25. Research and Advocacy Fund/Children First. How far can I go? Social mobility of CMWs in Azad 30 Kashmir. Islamabad: 2012. 31 32 26. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community 33 mobilization and health management committee strengthening to increase birth attendance by

34 http://bmjopen.bmj.com/ 35 trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomized 36 controlled trial. Trials 2011; 12:128. 37 38 27. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the 39 40 management of the third stage of labour in the home delivery setting in rural Gambia: a 41 randomized controlled trial. Br J Obstet Gynaecol 2005; 112: 1277-83. 42 on September 28, 2021 by guest. Protected copyright. 43 28. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, et al. Administration of misoprostol 44 by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in 45 46 Pakistan: a randomized placebo-controlled trial. BJOG 2011; 118(3):353-61. 47 29. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: Is the 48 49 health care system accessible and responsive in Pakistan? Health Care Women Int 2008; 50 51 29:945-959. 52 53 54 19 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 39 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 30. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB. Effect of training 11 traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): 12 13 randomized controlled study. BMJ 2011; 342:d346. 14 31. Falle TY, Mulany LC, Thatte N, Khatry SK, LeClerg SC, Darmstadt GL, et al. Potential role of 15 For peer review only 16 traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 17 18 2009; 27(1): 53–61. 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 20 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

Emerging role of traditional birth attendants in mountainous terrain: A qualitative exploratory study from Chitral District, Pakistan

For peer review only Journal: BMJ Open

Manuscript ID: bmjopen-2014-006238.R2

Article Type: Research

Date Submitted by the Author: 20-Oct-2014

Primary Subject Health services research Heading:

Health policy, Obstetrics and gynaecology, Public health, Qualitative Secondary Subject Heading: research, Reproductive medicine

Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Keywords: Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Public health < INFECTIOUS DISEASES http://bmjopen.bmj.com/

on September 28, 2021 by guest. Protected copyright.

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Emerging role of traditional birth attendants in mountainous terrain: A qualitative exploratory 4 5 study from Chitral District, Pakistan 6 7 8 9 Babar Tasneem Shaikh, MPH, PhD, FRCP Edin 10 11 Sharifullah Khan, MPH 12 13 Ayesha Maab, MSc 14 15 Sohail Amjad, MA-HM,For MA-HMPP peer review only 16 17 18 19 20 21 Running title: Role of traditional birth attendants 22 23 24 25 26 27 Corresponding author 28 29 Dr Babar Tasneem Shaikh 30 31 Aga Khan Foundation (Pakistan) 32 33 Level Nine, Serena Business Complex

34 http://bmjopen.bmj.com/ 35 Khayaban-e-Suharwardy, Islamabad 36 37 t: +92 51 111-253-254 38 39 f: +92 51 2072552 40 41 e: [email protected] 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Abstract: 4 5 Objectives: This research endeavors to to identify the role of TBAs in supporting the MNCH care, 6 7 partnership mechanism with the formal health system and also explored livelihood options for TBAs in the 8 9 health system of Pakistan. 10 11 12 13 Setting: The study was conducted in District Chitral, Khyber Pakhtunkhwa province, covering the areas 14 15 where Chitral ChildFor Survival programme peer was implemented.review only 16 17 18 19 Participants: A qualitative exploratory study was conducted, comprising seven Key informant interviews 20 21 (KIIs) with health managers, and four focus group discussions (FGDs) with CMWs, TBAs, members of 22 23 CBSG and members of Village Health Committees (VHCs). 24 25 26 27 Results: The study identified that In the new scenario, after the introduction of CMW in the health 28 29 system, TBAs still have a pivotal role in health promotion activities such as breast feeding promotion and 30 31 vaccination. TBAs can assist CMWs in normal deliveries, and refer high risk cases to formal health 32 33 system. Generally, TBAs are positive about CMWs’ introduction and welcome this addition. Yet, their

34 http://bmjopen.bmj.com/ 35 livelihood has suffered after CMWs deployment. Monetary incentives to them in recognition of referrals to 36 37 CMWs could be one solution. VHC is an active forum for strengthening coordination between the two 38 39 service providers and to ensure an alternate and permanent livelihood support system for the TBAs. 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 Conclusion: TBAs assured their continued support in provision of continuum of care for pregnant 44 45 women, lactating mothers and children under five. The district health authorities must figure out ways to 46 47 foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. After some time, it would 48 49 be worthwhile to do further research to look into the CMW’s integration in the system, as well as TBA’s 50 51 continued role for provision of MNCH care. 52 53 54 Keywords: Maternal Newborn & Child Health, Traditional birth attendant, Community midwife, Qualitative 55 56 research, Pakistan. 57 58 59 60 2

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 Strengths & Limitations of the study 6 7 A study, first of its kind, which has expounded on the subject of TBAs role and livelihood after the 8 9 introduction of trained MNCH providers in Pakistan. Use of qualitative methods provided rich insight into 10 11 women’s interpretations and decision-making regarding health care seeking during and after pregnancy in 12 13 a relatively conservative setting of Pakistan. Study presents views of all stakeholders involved in the 14 15 intervention. For peer review only 16 17 18 19 The findings represent a specific sample size, study site and socio-cultural milieu and therefore may not 20 21 be generalized for the entire province or country. Health providers involved in the study were mainly from 22 23 AKHSP and government who were already exposed to this intervention. Only few TBAs could be 24 25 gathered for discussion, because most of them were remotely located, and weather and family 26 27 constraints did not allow them to travel. Moreover, the prospective role of TBA is discussed in a special 28 29 context, whereby a CMW was trained and deployed in the area for increasing skilled birth attendance. 30 31 32 33

34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

34 Evidence suggests that skilled birth attendance has increased in regions where TBAs are integrated with http://bmjopen.bmj.com/ 35 36 the formal health system (8). However, integration of TBAs with the formal health system may require 37 38 capacity development and supervision of TBAs, collaboration skills for health workers, involvement of 39 40 TBAs at health facilities and, improved capacity on communication and referral systems. With this 41 42 approach, TBAs may positively contribute to maternal and child health outcomes (9). Trainings of the on September 28, 2021 by guest. Protected copyright. 43 44 TBAs not only enhance their knowledge and skills on obstetric care and referral mechanism, but also lead 45 46 to greater community acceptance and a greater consumer satisfaction. They can play a vital role in birth 47 48 preparedness and identification of danger signs (10). Training of TBAs has shown impact on perinatal 49 50 and neonatal deaths which can be significantly reduced (11). Moreover, TBAs have been a critical 51 52 contributor in providing skilled maternal, newborn and child health (MNCH) care in rural population of 53 54 developing countries due to inadequate numbers of human resource for service delivery (12). Therefore, 55 56 role of trained TBAs in healthcare provision cannot be undermined. Developing countries have used 57 58 TBAs as a key strategy to improve maternal and child health care (13). They have been effective in 59 60 4

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 study entailed seven KIIs and four FGDs conducted with different study participants. The questions 4 5 for focus group discussion (FGD) and key informants interview (KIIs) explore the role of TBAs in 6 7 supporting MNCH care and CCSP project activities, community experience with TBAs, TBAs’ 8 9 relationship and coordination with the CMWs, referral of cases; remuneration and livelihood sources 10 11 of TBAs; ways to engage TBAs in continuum of care, working relationships and linkages with the 12 13 formal health system, and sustainability/livelihood of TBAs. Using a participation diagram in FGDs, it 14 15 was ensured Forthat nobody ispeer missed out and review that all the participants only must speak on each question. To 16 17 ensure quality control, information collected through note-taking was cross-checked for completeness 18 19 and consistency before and during data processing by the research team. 20 21 22 23 c) Study participants 24 25 All the study participants were purposively sampled from the intervention areas in the district, with the 26 27 help of the implementing agencies on ground. Community based health workers i.e. CMWs and 28 29 TBAs; members of VHC and Community Based Saving Group (CBSG) were included in the 30 31 discussion. The participants were encouraged by the moderator (PI) to interact with each other and 32 33 comment on experiences and perceptions regarding role of TBAs, partnership with formal health

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

34 http://bmjopen.bmj.com/ 35 36 37 Linkage of TBAs with formal health system 38 39 Viewpoints of participants revealed that TBAs can be mainstreamed in a formal health system by 40 41 assigning health promotion activities and for referring high risk cases to CMW and health facility. 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 “The TBAs have role in referring of high risk cases and expectant mothers for delivery to CMWs. TBAs

46 st 47 are also playing very good role in the community in identifying pregnant mothers during 1 trimester in the 48 49 community, arranging TT vaccinations and providing education on nutrition during pregnancy.” (GM, 50 51 AKHSP) 52 53 54 “They (TBAs) must be linked with the formal health system especially for health promotion, referrals and 55 56 assisting deliveries with CMWs, when needed” (FGDVHC, Morder) 57 58 59 60 10

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 Role of TBAs in supporting obstetric care 6 7 TBAs have pivotal role in terms of identifying pregnancy related complications and assisting safe obstetric 8 9 care services with CMWs. Traditionally, TBAs have been involved in the promotion of better nutrition 10 11 practices for pregnant mothers, breastfeeding practices, TT vaccination of expectant mothers, prevention 12 13 of neonatal hypothermia, and post-natal care including family planning. TBAs have a crucial role in 14 15 strengthening referralFor and coordination peer mechanisms review with CMWs and only with the health facility. Findings of 16 17 the KIIs and FGDs revealed that some TBAs were even involved in assisting deliveries with CMWs. 18 19 20 21 “Many TBAs, no doubt have a sound folk wisdom, which can be used for various health promotion 22 23 messages, especially where there is no other community health worker. Moreover, TBAs can be trained 24 25 in providing antenatal care, TT vaccine, Misoprostol administration, recognizing the danger signs of 26 27 pregnancy etc. This will give her a feeling that she still has a role to play in saving women’s lives.” 28 29 (Director Health, AKFP) 30 31 32 33 “TBAs promote breastfeeding and healthy nutritional practices in our community for mother and children;

34 http://bmjopen.bmj.com/ 35 and they can keep on doing that”. (FGDVHC, Morder) 36 37 38 39 “In my village, TBA assists delivery with me and refers cases to me. I have to say that she is of great help 40 41 for me”. (FGDCMWs, Parsan) 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 “They (TBAs) said, they do refer cases to them and in many cases have joined CMWs for conducting 46 47 deliveries.” (KIIAKFP Senior Program Officer) 48 49 50 51 Linkages and coordination mechanisms among TBAs and CMWs 52 53 Lack of role clarity, physical inaccessibility, professional rivalry and few income opportunities are key 54 55 factors for weak linkages between TBAs and CMWs. Some of the CMWs expressed that they 56 57 58 59 60 11

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 encountered problems and resistance from the TBAs and community during the initial phase of 4 5 deployment. Village health committee shared that they invite both TBAs and CMWs in the VHC meetings. 6 7 “Rivalry; both are birth attendants; one is practicing by virtue of folk knowledge and the other is trained 8 9 according to modern guidelines and WHO standards. So that has created a competition. At places, there 10 11 is coordination too, where both are from the same family or where both have realized each other’s 12 13 importance.” (Director Health, AKFP) 14 15 For peer review only 16 17 “The issues between TBA and CMW can be effectively dealt if AKHSP works with all stakeholders and set 18 19 out a proper coordination plan, and play catalytic role to nurture a health relationship.” (KIIAKFP, Senior 20 21 Program Officer) 22 23 24 25 “In some areas of intervention, the TBA perceived CMW as competitor.” (GM, AKHSP) 26 27 28 29 “Introduction of CMWs in the areas will limit the role of TBAs. To cope with this challenge the TBAs were 30 31 included in the VHCs and the roles/responsibilities of the CMWs were communicated through this 32 33 platform”. (KII, AKRSP Manager)

34 http://bmjopen.bmj.com/ 35 36 37 Performance of TBAs vis-à-vis skills related to maternal and newborn health is not satisfactory. Therefore, 38 39 they now go to the CMWs who have adequate competency in knowledge and skills about the obstetric 40 41 care. Some of the members shared that TBAs refer complicated expectant mothers to CMWs and health 42 on September 28, 2021 by guest. Protected copyright. 43 facility. In few instances, TBA was seen to be assisting the CMW in deliveries. Nonetheless, where TBAs 44 45 did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 46 47 health system. 48 49 50 51 “Many TBAs are in favor of CMWs because they cannot handle the complicated cases properly; yet some 52 53 are against her. VHC is trying to bring the TBA as member in VHC and told them about the importance of 54 deliveries by skilled hand and hygienic way.” (FGDVHC, Morder) 55 56

57 58 59 60 12

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

57 58 59 60 13

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

34 http://bmjopen.bmj.com/ 35 the elder women and expecting mothers about the benefits of making use of skilled birth attendant i.e. 36 37 CMW. 38 39 40 41 Results of our study found that TBAs play vital role in improving maternal health such as diagnosing 42 on September 28, 2021 by guest. Protected copyright. 43 labor, assisting clean delivery with CMWs, detecting and referring maternal complications, and promoting 44 45 health messages. While trained TBAs are not considered skilled birth attendants, their potential 46 47 contribution in supporting maternal care has been recognized in low income and middle countries facing 48 49 issues of human response scarcity (12,Error! Bookmark not defined.). Role of TBAs in administration of 50 51 misoprostol to prevent postpartum hemorrhage in home-births is oft-advocated (27,28). Nevertheless, the 52 53 role of TBAs in supporting MNCH care cannot be neglected in settings where skilled birth attendants are 54 55 fewer and new to health system. In the wake of reforms and the novel MNCH program of Pakistan, role of 56 TBAs in improving maternal care and transforming health seeking behaviours ought to be promoted (29). 57 58 59 60 14

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 Defining her role and contribution in the continuum of care is linked to her livelihood and income 4 5 generation. 6 7 8 9 Improved linkages and relationship among CMWs and TBAs is of essence to flourish referral system from 10 11 community to health facility. Better coordination and collaboration of TBAs with CMWs was promoted 12 13 under CCSP, by sensitizing the CMW on prospective role of TBA which will complement her services and 14 15 will help in buildingFor her rapport peer with the community. review TBA, who hasonly a long standing link with local 16 17 community, can act as a bridge to strengthen referral mechanism between community and the formal 18 19 health system (15). Findings of the qualitative study follow other studies which demonstrated that a formal 20 21 partnership program among TBAs and the skilled midwives has yet to be seen (5). While the importance 22 23 of the TBAs role in referral is universally acknowledged, most health systems have not developed an 24 25 effective referral mechanism. The CCSP project provided an enabling forum at the village level for CMWs 26 27 and TBAs to interact and improve referral linkages. Such partnership is crucial to improve access to 28 29 health care services, especially for communities living in the remote areas. Nevertheless, training and 30 31 monitoring TBAs on MNCH care is imperative to minimize chances of malpractices (13). Nevertheless, 32 33 this training should be imparted by the government in its public sector nursing and midwifery schools.

34 http://bmjopen.bmj.com/ 35 However, joint monitoring by AKHSP and government, by involving the village health committees could 36 37 be instrumental in this regard. Moreover, participatory monitoring is always less threatening; and hence 38 39 TBAs should be meaningfully engaged in such type of monitoring. A systematic recording and periodic 40 41 analysis of information could be conducted by the TBAs themselves, with the help of public health 42 on September 28, 2021 by guest. Protected copyright. 43 experts. The aim is to measure progress and to make any corrections en route. 44 45 46 47 Financial constraints are a major risk to the livelihood of TBAs as evident from the findings of our study. 48 49 Mostly they are receiving in kind payments by the family of expectant mothers; and a nominal payment by 50 51 CMWs for each referral. CMWs must keep a cushion of nominal payment to TBA, after verifying her 52 53 services. That will surely help in building a healthy relationship amongst the two service providers. Where 54 55 TBAs did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 56 health system. Evidence suggests that in kind contributions by clients are the most common mode of 57 58 59 60 15

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 payment by the clients (8,10). With the increasing use of TBAs in MNCH care, the question of 4 5 compensation has become more pressing because these workers usually rely on rewards and in kind 6 7 contributions by the clients (30). Continuing efforts to define the role of TBAs may benefit from an 8 9 emphasis on their potential as active promoters of essential newborn care (31). In the context of Pakistan, 10 11 the role of TBAs ought to be revisited and redefined, not only for the sake of trust of communities on her 12 13 services, but also for her own livelihood. 14 15 For peer review only 16 17 Conclusion 18 19 Prevailing poverty in the area calls for thinking solutions to ensure livelihood of TBAs, and to figure out an 20 21 emerging role for her after the introduction of CMW in the health system. TBAs surely have solutions in 22 23 the continuum of care for pregnant women, lactating mothers and children under five. They continue to 24 25 take pride and see value in their role in the health system to support MNCH care. Health systems 26 27 performance can be amplified by having a healthy interface between the TBAs and CMWs, and for the 28 29 larger benefit of the communities served. 30 31 32 33 Acknowledgement:

34 http://bmjopen.bmj.com/ 35 The authors acknowledge the facilitation and assistance provided by AKF-P, AKHSP and AKRSP to carry 36 37 out field data collection. 38 39 40 41 Ethical consideration: 42 on September 28, 2021 by guest. Protected copyright. 43 Ethics approval for this study was granted by the Institutional Review Board of Aga Khan Health Services, 44 45 Pakistan. Verbal informed consent was obtained from all the study participants, after explaining the 46 47 objectives of the study. Confidentiality and anonymity was assured to all the participants. Data was kept 48 49 under lock and key with the principal researcher. 50 51 52 53 Authors’ contributions 54 55 56 57 58 59 60 16

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 BTS and SAK conceived the study design and instruments. AM supervised the data collection and helped 4 5 in analyses. BTS and SAK drafted the successive drafts of paper. SA conducted the critical review and 6 7 added the intellectual content to the paper. All authors read and approved the final draft. 8 9 10 11 Funding: The study was a part of larger project “Chitral Child Survival Program” funded by USAID. 12 13 14 15 Competing InterestsFor peer review only 16 17 The authors declare that they have no competing interests. 18 19 20 21 References 22 23 24 1. World Health Organization & UNICEF. Countdown to 2015 and beyond: fulfilling the health 25 26 agenda for women and children. Geneva: 2014. 27 28 2. Shaikh BT. Marching toward the Millennium Development Goals: What about health systems, 29 30 health-seeking behaviours and health service utilization in Pakistan? World Health & Popul 2008; 31 32 10(2): 44-52. 33

34 3. United Nations. Road map towards the implementation of the United Nations Millennium http://bmjopen.bmj.com/ 35 36 Declaration: report of the Secretary-General. New York: 2001. 37 38 4. Sachs JD, McArthur JW. The Millennium Project: a plan for meeting the Millennium Development 39 40 Goals. Lancet 2005; 365(9456):347-53. 41 42 5. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth on September 28, 2021 by guest. Protected copyright. 43 44 attendants and home delivery? A qualitative study on delivery care services in West Java 45 46 Province, Indonesia. BMC Pregnancy Childbirth 2010; 10:43. 47 48 6. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal 49 50 and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst 51 52 Rev 2010; 11: CD007754. 53 54 7. Garces A, McClure EM, Chomba E, Patel A, Pasha O, Tshefu A. Home birth attendants in low 55 56 income countries: who are they and what do they do? BMC Pregnancy Childbirth 2012; 12:34. 57 58 59 60 17

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 8. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems 5 6 can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115(2):127-34. 7 8 9. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth 9 10 attendants and village midwives. J Obstet Gynaecol 2004; 24(1):5-11. 11 12 10. Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication 13 14 readiness among slum women in Indore City, India. J Health Nutr Popul 2010; 28(4): 383-391. 15 For peer review only 16 11. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies 17 18 incorporating training and support of traditional birth attendants on perinatal and maternal 19 20 mortality: meta-analysis. BMJ 2011; 343:d7102. 21 22 12. Sibley LM, Sipe TA. Transition to skilled birth attendance: Is there a future role for trained 23 24 traditional birth attendants. J Health Popul Nutr 2006; 24(4):472-8. 25 26 13. Bisika T. The effectiveness of the TBA programme in reducing maternal mortality and morbidity in 27 28 Malawi. East Afr J Public Health 2008; 5(2):103–10. 29 30 14. Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral of high-risk pregnant mothers by 31 32 trained traditional birth attendants in Buikwe County, Mukono District, Uganda. J Obstet Gynaecol 33

34 2005; 25(6):554-7. http://bmjopen.bmj.com/ 35 36 15. Temesgen TM, Umer JY, Buda DS, Haregu TN. Contribution of traditional birth attendants to the 37 38 formal health system in Ethopia: the case of Afar region. Pan Afr Med J 2012; 13(Suppl 1):15. 39 40 16. Wajid A, Rashid Z, Mir AM. Initial assessment of Community Midwives in rural Pakistan. PAIMAN. 41 42 JSI Research and Training Institute, Inc; Islamabad: 2010. on September 28, 2021 by guest. Protected copyright. 43 44 17. Concern Worldwide. Examining the role of traditional birth attendants in the continuum of care in 45 46 Sierra Leone. Innovations for maternal, newborn and child health. Policy Brief. Concern 47 48 Worldwide; New York: 2013. 49 50 18. National Institute of Population Studies and Macro International Inc. Pakistan Demographic and 51 52 Health Survey (PDHS) 2006–07. Government of Pakistan; Islamabad: 2008. 53 54 19. Government of Pakistan. PC1 National Maternal Newborn & Child health Program 2006-2012. 55 56 Ministry of Health, Government of Pakistan; Islamabad: 2009. 57 58 59 60 18

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 20. Research and Development Solutions. The community midwives program in Pakistan. Policy 5 6 Brief Series No 20. Islamabad: 2012. 7 8 21. Department of Health. District health profile-Chitral. Government of Khyber Pakhtunkhwa; 9 10 Peshawar: 2014. 11 12 22. Chesney M, Davies S. Women’s birth experiences in Pakistan – the importance of the Dai. The 13 14 Royal College of Midwives. Evid Based Midwifery 2005; 3(1):26-32. 15 For peer review only 16 23. Owolabi OO, Glenton C, Lewin S, Pakenham-Walsh N. Stakeholder views on the incorporation of 17 18 traditional birth attendants into the formal health systems of low-and middle-income countries: a 19 20 qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums. BMC Pregnancy 21 22 Childbirth 2014; 14:118. 23 24 24. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-Experiences of community 25 26 midwives in Pakistan. BMC Pregnancy Childbirth 2014; 14:59. 27 28 25. Research and Advocacy Fund/Children First. How far can I go? Social mobility of CMWs in Azad 29 30 Kashmir. Islamabad: 2012. 31 32 26. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community 33

34 mobilization and health management committee strengthening to increase birth attendance by http://bmjopen.bmj.com/ 35 36 trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomized 37 38 controlled trial. Trials 2011; 12:128. 39 40 27. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the 41 42 management of the third stage of labour in the home delivery setting in rural Gambia: a on September 28, 2021 by guest. Protected copyright. 43 44 randomized controlled trial. Br J Obstet Gynaecol 2005; 112: 1277-83. 45 46 28. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, et al. Administration of misoprostol 47 48 by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in 49 50 Pakistan: a randomized placebo-controlled trial. BJOG 2011; 118(3):353-61. 51 52 29. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: Is the 53 54 health care system accessible and responsive in Pakistan? Health Care Women Int 2008; 55 56 29:945-959. 57 58 59 60 19

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 30. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB. Effect of training 5 6 traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): 7 8 randomized controlled study. BMJ 2011; 342:d346. 9 10 31. Falle TY, Mulany LC, Thatte N, Khatry SK, LeClerg SC, Darmstadt GL, et al. Potential role of 11 12 traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 13 14 2009; 27(1): 53–61. 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 20

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Emerging role of traditional birth attendants in mountainous terrain: A qualitative exploratory 10 study ofrom Chitral District, Pakistan 11 12 13 Babar Tasneem Shaikh, MPH, PhD, FRCP Edin 14 15 Sharifullah Khan, MPH For peer review only 16 17 Ayesha Maab, MSc

18 Sohail Amjad, MA-HM, MA-HMPP 19 20 21 22 23 Running title: Role of traditional birth attendants 24

25 26 27 28 Corresponding author 29 Dr Babar Tasneem Shaikh 30 31 Aga Khan Foundation (Pakistan) 32 Level Nine, Serena Business Complex 33

34 Khayaban-e-Suharwardy, Islamabad http://bmjopen.bmj.com/ 35 36 t: +92 51 111-253-254 37 f: +92 51 2072552 38 39 e: [email protected] 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 1 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Abstract: 10 Objectives: This research endeavors to to identify the role of TBAs in supporting the MNCH care, 11 12 partnership mechanism with the formal health system and also explored livelihood options for TBAsre- 13 define the role of Traditional Birth Attendants (TBAs) in supporting the Maternal Newborn & Child Health 14 15 (MNCH) care now providedFor mainly by the peertrained community midwivesreview (CMWs), to mainstream only TBAs with 16 17 the formal health system and to delineate their livelihood prospects, after the deployment and introduction 18 of CMWs in the health system of Pakistan. 19 20 21 Setting: The study was conducted in District Chitral, Khyber Pakhtunkhwa province, covering the areas 22 23 where Chitral Child Survival programme was implemented. 24

25 26 Participants: A qualitative exploratory study was conducted, comprising seven Key informant interviews 27 28 (KIIs) with health managers, and four focus group discussions (FGDs) with CMWs, TBAs, members of 29 CBSG and members of Village Health Committees (VHCs). 30 31 32 Results: The study identified that In the new scenario, after the introduction of CMW in the health 33

34 system, TBAs still have a pivotal role in health promotion activities such as breast feeding promotion and http://bmjopen.bmj.com/ 35 36 vaccination. TBAs can assist CMWs in normal deliveries, and refer high risk cases to formal health 37 system. Generally, TBAs are positive about CMWs’ introduction and welcome this addition. Yet, their 38 39 livelihood has suffered after CMWs deployment. Monetary incentives to them in recognition of referrals to 40 CMWs could be one solution. VHC is an active forum for strengthening coordination between the two 41 42 service providers and to ensure an alternate and permanent livelihood support system for the TBAs. on September 28, 2021 by guest. Protected copyright. 43

44 45 Conclusion: TBAs assured their continued support in provision of continuum of care for pregnant 46 47 women, lactating mothers and children under five. The district health authorities must figure out ways to 48 foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. After some time, it would 49 50 be worthwhile to do further research to look into the CMW’s integration in the system, as well as TBA’s 51 continued role for provision of MNCH care. 52 53 54 2 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 Keywords: Maternal Newborn & Child Health, Traditional birth attendant, Community midwife, Qualitative 11 12 research, Pakistan. 13

14 15 Strengths & Limitations Forof the study peer review only 16 17 A study, first of its kind, which has expounded on the subject of TBAs role and livelihood after the 18 introduction of trained MNCH providers in Pakistan. Use of qualitative methods provided rich insight into 19 20 women’s interpretations and decision-making regarding health care seeking during and after pregnancy in 21 a relatively conservative setting of Pakistan. Study presents views of all stakeholders involved in the 22 23 intervention. 24 25 26 The findings represent a specific sample size, study site and socio-cultural milieu and therefore may not 27 28 be generalized for the entire province or country. Health providers involved in the study were mainly from 29 AKHSP and government who were already exposed to this intervention. Only few TBAs could be 30 31 gathered for discussion, because most of them were remotely located, and weather and family 32 constraints did not allow them to travel. Moreover, the prospective role of TBA is discussed in a special 33

34 context, whereby a CMW was trained and deployed in the area for increasing skilled birth attendance. http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 28, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 3 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Introduction 10

34 http://bmjopen.bmj.com/ 35 the formal health system (8). However, integration of TBAs with the formal health system may require 36 capacity development and supervision of TBAs, collaboration skills for health workers, involvement of 37 38 TBAs at health facilities and, improved capacity on communication and referral systems. With this 39 40 approach, TBAs may positively contribute to maternal and child health outcomes (9). Trainings of the 41 TBAs not only enhance their knowledge and skills on obstetric care and referral mechanism, but also lead 42 on September 28, 2021 by guest. Protected copyright. 43 to greater community acceptance and a greater consumer satisfaction. They can play a vital role in birth 44 preparedness and identification of danger signs (10). Training of TBAs has shown impact on perinatal 45 46 and neonatal deaths which can be significantly reduced (11). Moreover, TBAs have been a critical 47 contributor in providing skilled maternal, newborn and child health (MNCH) care in rural population of 48 49 developing countries due to inadequate numbers of human resource for service delivery (12). Therefore, 50 51 role of trained TBAs in healthcare provision cannot be undermined. Developing countries have used 52 TBAs as a key strategy to improve maternal and child health care (13). They have been effective in 53 54 4 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

44 45 The intervention 46 47 To address health system constraints, Chitral Child Survival Program (CCSP) of Aga Khan Foundation 48 Pakistan (AKF-P) deployed CMWs, supported community financing scheme, improved referral linkages 49 50 and implemented a behavior change communication campaign from 2008-2014. CCSP was implemented 51 in close partnership of Department of Health, Khyber Pakhtunkhwa, Aga Khan Health Services Pakistan 52 53 54 5 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 (AKHSP), and Aga Khan Rural Support Program (AKRSP). The CCSP interventions, especially the role of 10 community based saving groups, village health committees (VHCs) and community based emergency 11 12 maternal referral mechanism to achieve project results showed that CCSP had attempted to engage the 13 TBAs proactively. The project empowered TBAs on Birth Preparedness and Complications Readiness 14 15 (BPCR) plans and integratedFor referral mechanisms. peer Involvement review of TBAs in the project was only meaningful to 16 17 generate the community acceptability for young CMWs, identification of high risk cases, and referrals of 18 complications to CMW and transporting pregnant woman to health facility in time. 19 20 21 This research endeavored to identify the role of TBAs in supporting the MNCH care, partnership 22 23 mechanism with the formal health system and also explored livelihood options for TBAs. 24 25 26 Methodology 27 28 a) Study site 29 The study was conducted in Chitral district, north western border of Pakistan, from March-April 2014. 30 31 The population of the intervention area is 200,000, about 57% of the total population of the district 32 and residing in 243 villages. The government department of health and Aga Khan Health Services 33

34 Pakistan (AKHSP) are the two primary formal sector healthcare providers in Chitral. The public-sector http://bmjopen.bmj.com/ 35 36 healthcare infrastructure in the district includes 22 civil dispensaries, 21 basic health units; three tehsil 37 headquarters and one district headquarter hospital (21). AKHSP operates its own 32 health facilities 38 39 in Chitral which include 17 health centers, eight family health centers, four dispensaries and three 40 secondary care facilities, covering 60% of Chitral district. The MMR in the province is 275/100,000 41 42 live births; whereas under five mortality is 75/1000 live births (1819). Despite the presence of skilled on September 28, 2021 by guest. Protected copyright. 43 birth attendants under MNCH program, large proportion of the deliveries is still attended by TBAs in 44 45 Chitral district. 46 47 48 b) Study Design and data collection 49 50 The project documents and other relevant studies were thoroughly reviewed and the collated 51 information guided to design the qualitative data collection instruments. A qualitative exploratory 52 53 54 6 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 study entailed seven KIIs and four FGDs conducted with different study participants. The questions 10 for focus group discussion (FGD) and key informants interview (KIIs) explore the role of TBAs in 11 12 supporting MNCH care and CCSP project activities, community experience with TBAs, TBAs’ 13 relationship and coordination with the CMWs, referral of cases; remuneration and livelihood sources 14 15 of TBAs; ways to engageFor TBAs in continuumpeer of care, workingreview relationships and linkages only with the 16 17 formal health system, and sustainability/livelihood of TBAs. Using a participation diagram in FGDs, it 18 was ensured that nobody is missed out and that all the participants must speak on each question. To 19 20 ensure quality control, information collected through note-taking was cross-checked for completeness 21 and consistency before and during data processing by the research team. 22 23 24 c) Study participants 25 26 All the study participants were purposively sampled from the intervention areas in the district, with the 27 28 help of the implementing agencies on ground. Community based health workers i.e. CMWs and 29 TBAs; members of VHC and Community Based Saving Group (CBSG) were included in the 30 31 discussion. The participants were encouraged by the moderator (PI) to interact with each other and 32 comment on experiences and perceptions regarding role of TBAs, partnership with formal health 33

34 system, and livelihood of TBAs. KIIs were conducted with two government health managers, two http://bmjopen.bmj.com/ 35 36 AKF-P managers, and three AKHSP managers. All the FGDs were conducted in the community; 37 whereas KIIs were conducted in the respective offices of health managers. Table-1 presents the 38 39 detail of the methods employed for the study. 40 41 42 Table-1: Detail of methods employed in qualitative study on September 28, 2021 by guest. Protected copyright. 43 Total number Cadre Method Village 44 of respondents 45 Mori Lshat, Barini, Awi, Miragarm, Sore 46 Laspoor, Raman, Terich Payeen, Lot Owir CMWs FGD 10 47 Bala, Lot Owir Payeen, Gohkir, Parsan, Owir 48 Lasht Arkari, Besti Arkari, Khuz, Phashk Lower Porth, Brock Kalaway, Porth Bala, TBAs FGD 5 49 Raman, Brock Baraman Deh 50 VHC FGD 8 Morder 51 CBSG FGD 10 Morder 52 53 54 7 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Health managers 10 (AKHSP, AKF-P 7 KIIs 07 Chitral city & Government) 11 12 13 Purposive sampling technique was adopted, inviting the participation of those CMWs, and TBAs who had 14 been serving actively in their local communities for the last two years. These health workers were 15 For peer review only 16 identified with the help of health managers of AKHSP and government. Likewise, only those members of 17 VHC were invited for FGD, who had been active for the last two years. Each participant of the FGD and 18 19 KII was given the verbal information about the study by the research team and was given a consent form 20 21 prior to participation. 22 23 24 d) Data analysis 25 A qualitative content analysis was applied to analyze the information manually from all the FGDs and 26 27 KIIs. A stepwise approach was adopted for the content analysis. The analysis aimed at finding manifest 28 29 and latent meaning of data. The transcribed data was initially read several times by the principal 30 researcher in order to find the sense of the whole. At first stage the segmentation of information was done 31 32 i.e. segments and sub-segments of information were organized. Subsequently the significant information 33 was extracted which was related to research questions. At second stage the common views of the

34 http://bmjopen.bmj.com/ 35 respondents were put together at one place. At third stage, data was coded (different responses 36 highlighted) and then these codes were grouped into categories and abstracted into sub-themes and a 37 38 main theme. At final stage, the meanings of themes/descriptions were interpreted by keeping in view and 39 40 considering the cultural context of the participants. 41 42 on September 28, 2021 by guest. Protected copyright. 43 Results 44 The main theme which came out was the “emerging role of TBAs to improve Maternal, Newborn and 45 46 Child Health”. After content analysis, following sub-themes were identified as shown in Table 2: 47 1. Community experience with CMWs and TBAs 48 49 2. View of participants on utilization of TBAs in formal health system 50 51 3. Role of TBAs in supporting obstetric care 52 4. Linkages and coordination among TBAs and CMWs 53 54 8 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 5. Livelihood of TBAs 10 11 12 Table-2: Matrix of qualitative research analysis 13 14 Nodes Sub-nodes 15 Community experience For with - Availability peer of CMWs have empoweredreview women for health onlycare seeking 16 CMWs and TBAs - Community has trust and faith in TBAs and their services 17 -TBAs have pivotal role in health promotion activities such as health 18 messages on breast feeding, mother and child immunization. 19 Linkage of TBAs with formal -TBAs must assist CMW who is naïve to reproductive health matters. 20 health system 21 -TBAs can be involved in linking high risk cases to CMW and health 22 facility. 23 - TBAs assist CMW in delivery, identify expectant mothers with high Role of TBAs in supporting 24 risks, refer such cases to formal health system, and support post-natal 25 obstetric care care 26 27 - Mixed responses in terms of relationship between CMWs and TBAs 28 Linkages and coordination - VHC is an active forum for coordination 29 among TBAs and CMWs - Coordination is better at places where TBA gets some share of CMW 30 income 31 - CMWs could offer some incentives to TBAs to strengthen referrals and 32 assistance in skilled delivery 33 Livelihood of TBAs - VHCs decide TBA incentive share of CMW income 34 http://bmjopen.bmj.com/ 35 - Community pay in kind contribution to recognize services of TBA 36 37 38 Community experience with CMWs and TBAs 39 Availability of CMWs and the supportive role of TBAs in obstetric care have benefited communities, by 40 41 and large. Most of the respondents shared that availability of CMWs has empowered women in order to 42 seek essential and emergency obstetric care in rural communities. Members of VHC appreciated the on September 28, 2021 by guest. Protected copyright. 43 44 binding relation of CMWs with TBAs. Despite availability of CMWs, the community members still have 45 46 greater trust and faith in TBAs who live and deals with the village women since ages. Some of the 47 respondents told that they avail services of TBAs due to her rich experience as compared to CMWs who 48 49 are young and yet naïve to various reproductive health matters. 50 51 52 53 54 9 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 “TBA still has the critical role as being more in proximity to the village women. She enjoys far more trust of 10 the communities. She has a years’ long rapport with the families. People tend to follow her advice.” 11 12 (Director Health, AKFP) 13

14 15 “I consider the role of TBAsFor important for peertwo reasons; firstly theyreview have been trusted by theonly communities, 16 17 so they need to be taken on board for enhancing referrals to CMWs. Secondly, if they are not engaged 18 properly then they will do more harm by doing deliveries and might spread negative propaganda too 19 20 about the CMWs”. (KIIAKFP Senior Program Officer) 21 22 23 “I take my wife and child to CMW to see for medical help or treatment for maternal and child health 24 problems? In our village, Dai (TBA) enjoys good relationship with the CMW”. (FGDVHC, Morder)” 25 26 27 28 “My family often seeks services from a TBAshe has all the experience.” (FGDVHC, Morder) 29 30 31 “The TBAs are working since long time and they have developed trust in the communities”. (KII, AKHSP 32 Manager) 33

34 http://bmjopen.bmj.com/ 35 36 Linkage of TBAs with formal health system 37 TBAs have pivotal role in health promotion activities such as health messages on nutrition, breast 38 39 feeding, and vaccination promotion. Viewpoints of participants revealed that TBAs can be mainstreamed 40 in a formal health system by assigning health promotion activities and for referring high risk cases to 41 42 CMW and health facility. on September 28, 2021 by guest. Protected copyright. 43

44 45 “The TBAs have role in referring of high risk cases and expectant mothers for delivery to CMWs. TBAs

46 st 47 are also playing very good role in the community in identifying pregnant mothers during 1 trimester in the 48 community, arranging TT vaccinations and providing education on nutrition during pregnancy.” (GM, 49 50 AKHSP) 51 52 53 54 10 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 “They (TBAs) must be linked with the formal health system especially for health promotion, referrals and 10 assisting deliveries with CMWs, when needed” (FGDVHC, Morder) 11 12 13 Role of TBAs in supporting obstetric care 14 15 TBAs have pivotal role in termsFor of identifying peer pregnancy related review complications and assisting only safe obstetric 16 17 care services with CMWs. Traditionally, TBAs have been involved in the promotion of better nutrition 18 practices for pregnant mothers, breastfeeding practices, TT vaccination of expectant mothers, prevention 19 20 of neonatal hypothermia, and post-natal care including family planning. TBAs have a crucial role in 21 strengthening referral and coordination mechanisms with CMWs and with the health facility. Findings of 22 23 the KIIs and FGDs revealed that some TBAs were even involved in assisting deliveries with CMWs. 24 25 26 “Many TBAs, no doubt have a sound folk wisdom, which can be used for various health promotion 27 28 messages, especially where there is no other community health worker. Moreover, TBAs can be trained 29 in providing antenatal care, TT vaccine, Misoprostol administration, recognizing the danger signs of 30 31 pregnancy etc. This will give her a feeling that she still has a role to play in saving women’s lives.” 32 (Director Health, AKFP) 33

34 http://bmjopen.bmj.com/ 35 36 “TBAs promote breastfeeding and healthy nutritional practices in our community for mother and children; 37 and they can keep on doing that”. (FGDVHC, Morder) 38 39 40 “In my village, TBA assists delivery with me and refers cases to me. I have to say that she is of great help 41 42 for me”. (FGDCMWs, Parsan) on September 28, 2021 by guest. Protected copyright. 43

44 45 “They (TBAs) said, they do refer cases to them and in many cases have joined CMWs for conducting 46 47 deliveries.” (KIIAKFP Senior Program Officer) 48 49 50 Linkages and coordination mechanisms among TBAs and CMWs 51 52 53 54 11 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Lack of role clarity, physical inaccessibility, professional rivalry and few income opportunities are key 10 factors for weak linkages between TBAs and CMWs. Some of the CMWs expressed that they 11 12 encountered problems and resistance from the TBAs and community during the initial phase of 13 deployment. Village health committee shared that they invite both TBAs and CMWs in the VHC meetings. 14 15 Performance of TBAs vis-à-visFor skills related peer to maternal and newbornreview health is not satisfactory. only Therefore, 16 17 they now go to the CMWs who have adequate competency in knowledge and skills about the obstetric 18 care. Some of the members shared that TBAs refer complicated expectant mothers to CMWs and health 19 20 facility. In few instances, TBA was seen to be assisting the CMW in deliveries. 21 22 23 “Rivalry; both are birth attendants; one is practicing by virtue of folk knowledge and the other is trained 24 according to modern guidelines and WHO standards. So that has created a competition. At places, there 25 26 is coordination too, where both are from the same family or where both have realized each other’s 27 28 importance.” (Director Health, AKFP) 29 30 31 “The issues between TBA and CMW can be effectively dealt if AKHSP works with all stakeholders and set 32 out a proper coordination plan, and play catalytic role to nurture a health relationship.” (KIIAKFP, Senior 33

34 Program Officer) http://bmjopen.bmj.com/ 35 36 37 “In some areas of intervention, the TBA perceived CMW as competitor.” (GM, AKHSP) 38 39 40 “Introduction of CMWs in the areas will limit the role of TBAs. To cope with this challenge the TBAs were 41 42 included in the VHCs and the roles/responsibilities of the CMWs were communicated through this on September 28, 2021 by guest. Protected copyright. 43 platform”. (KII, AKRSP Manager) 44 45 46 47 Performance of TBAs vis-à-vis skills related to maternal and newborn health is not satisfactory. Therefore, 48 they now go to the CMWs who have adequate competency in knowledge and skills about the obstetric 49 50 care. Some of the members shared that TBAs refer complicated expectant mothers to CMWs and health 51 facility. In few instances, TBA was seen to be assisting the CMW in deliveries. Nonetheless, where TBAs 52 53 54 12 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 10 health system. 11 12 13 “Many TBAs are in favor of CMWs because they cannot handle the complicated cases properly; yet some 14 15 are against her. VHC is tryingFor to bring the peerTBA as member in VHCreview and told them about the only importance of 16 17 deliveries by skilled hand and hygienic way.” (FGDVHC, Morder) 18 19 20 According to CMWs, they have high regard for the TBA, her experience and wisdom. They feel that TBA 21 can complement their work. On the other hand, most TBAs are satisfied with CMWs work, skills and 22 23 services rendered to the community women. Very few seem to be unhappy indeed. 24

25 26 Livelihood and sustainability of TBAs 27 28 Supporting role of TBAs is very important; especially in context of difficult geographical terrains in Chitral. 29 Various options as well as mechanisms were identified by the respondents, when asked about livelihood 30 31 prospects of TBAs. Most of the respondents were of opinion that CMWs must pay some incentives to 32 TBAs to strengthen referrals and assistance in skilled delivery. Findings of the KII revealed that one of the 33

34 available forums to decide TBAs incentives is village committee. VHCs and other available forums such http://bmjopen.bmj.com/ 35 36 as Local Support organizations (LSOs) can play pivotal role in taking up such decisive role for supporting 37 livelihood options for TBAs. Regarding payment to TBAs, some of the CMWs did not recompense TBAs. 38 39 Some of the TBAs also told that they get in kind contributions and support for her services from the village 40 families and not from the CMWs. 41 42 on September 28, 2021 by guest. Protected copyright. 43 “It is an informal arrangement between the two of them. Officially there is no binding on the CMW to pay TBA for 44 45 referrals.” (Director Health, AKFP) 46 47 48 “One of the CMW referred two cases to CMWs, and in fact she did join her for conducting the deliveries, but in 49 50 return did not get anything from the CMW and the family too.” (KIIAKFP, Senior Program Officer) 51 52 53 54 13 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 “Let it be the VHC meeting to decide about some incentives to be given to TBAs from CMW fee, because 10 she will be referring every case to CMW. CMW should provide some money to TBA”. (KII, AKHSP 11 12 Manager) 13 “TBAs were providing delivery services before CMWs’ deployment; hence CMWs’ services will certainly affect 14 15 their regular income (in cashFor or in kind). peer CMW should give review incentive from her service only fee to TBAs on each 16 17 referral; whereas TBA can continue providing care to mother after delivery”. (KII, Manager Programs, AKHSP) 18 19 20 “In our area, CMW is paying Rs200 to the TBA for each referral”. (FGDVHC, Morder) 21 22 23 “In two cases, I assisted CMW for delivery of a mother. CMW did not give me any money. I got some 24 cash and chicken from the house of delivered mother”. (FGDTBA, Lower Porth) 25 26 27 28 Discussion 29 Though communities where CMWs are deployed after training are happy, yet the continued utilization of 30 31 TBAs’ services in Chitral. Fact is attributed to several factors including the TBAs’ proximity to several 32 villages, TBAs’ respectful attitude toward the community, and flexible modes of payment (22,23). CMWs 33

34 have been recently deployed in Chitral and experienced challenges and constraints by community based http://bmjopen.bmj.com/ 35 36 health providers and community itself in delivery of maternal health services (24,25). Evidence suggests 37 that health management committees at the village level have been effective in reducing maternal 38 39 complications through promoting linkages of health care providers with the community (26). The findings 40 of our study also revealed that community forum in the form of VHC has played pivotal role in convincing 41 42 the communities to avail CMW services and motivate the TBA to continue in supportive role in MNCH on September 28, 2021 by guest. Protected copyright. 43 care. Awareness sessions have to be conducted on regular basis and on different forums to better inform 44 45 the elder women and expecting mothers about the benefits of making use of skilled birth attendant i.e. 46 47 CMW. 48 49 50 Results of our study found that TBAs play vital role in improving maternal health such as diagnosing 51 labor, assisting clean delivery with CMWs, detecting and referring maternal complications, and promoting 52 53 54 14 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 health messages. While trained TBAs are not considered skilled birth attendants, their potential 10 contribution in supporting maternal care has been recognized in low income and middle countries facing 11 12 issues of human response scarcity (12,Error! Bookmark not defined.13). Role of TBAs in administration 13 of misoprostol to prevent postpartum hemorrhage in home-births is oft-advocated (27,28). Nevertheless, 14 15 the role of TBAs in supportingFor MNCH care peer cannot be neglected review in settings where skilled birthonly attendants 16 17 are fewer and new to health system. In the wake of reforms and the novel MNCH program of Pakistan, 18 role of TBAs in improving maternal care and transforming health seeking behaviours ought to be 19 20 promoted (29). Defining her role and contribution in the continuum of care is linked to her livelihood and 21 income generation. 22 23 24 25 Improved linkages and relationship among CMWs and TBAs is of essence to flourish referral system from 26 community to health facility. Better coordination and collaboration of TBAs with CMWs was promoted 27 28 under CCSP, by sensitizing the CMW on prospective role of TBA which will complement her services and 29 will help in building her rapport with the community. TBA, who has a long standing link with local 30 31 community, can act as a bridge to strengthen referral mechanism between community and the formal 32 health system (1521). Findings of the qualitative study follow other studies which demonstrated that a 33 .

34 formal partnership program among TBAs and the skilled midwives has yet to be seen (56) While the http://bmjopen.bmj.com/ 35 36 importance of the TBAs role in referral is universally acknowledged, most health systems have not 37 developed an effective referral mechanism. The CCSP project provided an enabling forum at the village 38 39 level for CMWs and TBAs to interact and improve referral linkages. Such partnership is crucial to improve 40 access to health care services, especially for communities living in the remote areas. Nevertheless, 41 42 training and monitoring TBAs on MNCH care is imperative to minimize chances of malpractices (13). on September 28, 2021 by guest. Protected copyright. 43 Nevertheless, this training should be imparted by the government in its public sector nursing and 44 45 midwifery schools. ThereforeHowever, joint monitoring by AKHSP and government, by involving the 46 47 village health committees could be instrumental in this regard. Moreover, participatory monitoring is 48 always less threatening; and hence TBAs should be meaningfully engaged in such type of monitoring. A 49 50 systematic recording and periodic analysis of information could be conducted by the TBAs themselves, Formatted: Font: (Default) Arial, 10 pt 51 Formatted: Font: (Default) Arial, 10 pt 52 Formatted: Font: (Default) Arial, 10 pt 53 54 15 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 with the help of public health experts. The aim is to measure progress and to make any corrections en 10 route. 11 12 13 Financial constraints are a major risk to the livelihood of TBAs as evident from the findings of our study. 14 15 Mostly they are receiving inFor kind payments peer by the family of expectant review mothers; and a nominal only payment by 16 17 CMWs for each referral. CMWs must keep a cushion of nominal payment to TBA, after verifying her 18 services. That will surely help in building a healthy relationship amongst the two service providers. Where 19 20 TBAs did not receive any share from the CMWs, we found weak coordination mechanisms with the formal 21 health system. Evidence suggests that in kind contributions by clients are the most common mode of 22 23 payment by the clients (89,1011). With the increasing use of TBAs in MNCH care, the question of 24 25 compensation has become more pressing because these workers usually rely on rewards and in kind 26 contributions by the clients (30). Continuing efforts to define the role of TBAs may benefit from an 27 28 emphasis on their potential as active promoters of essential newborn care (31). In the context of Pakistan, 29 the role of TBAs ought to be revisited and redefined, not only for the sake of trust of communities on her 30 31 services, but also for her own livelihood. 32

34 Conclusion http://bmjopen.bmj.com/ 35 36 Prevailing poverty in the area calls for thinking solutions to ensure livelihood of TBAs, and to figure out an 37 emerging role for her after the introduction of CMW in the health system. TBAs surely have solutions in 38 39 the continuum of care for pregnant women, lactating mothers and children under five. They continue to 40 take pride and see value in their role in the health system to support MNCH care. Health systems 41 42 performance can be amplified by having a healthy interface between the TBAs and CMWs, and for the on September 28, 2021 by guest. Protected copyright. 43 larger benefit of the communities served. 44 45 46 47 Acknowledgement: 48 The authors acknowledge the facilitation and assistance provided by AKF-P, AKHSP and AKRSP to carry 49 50 out field data collection. 51 52 53 54 16 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 Ethical consideration: 10 Ethics approval for this study was granted by the Institutional Review Board of Aga Khan Health Services, 11 12 Pakistan. Verbal informed consent was obtained from all the study participants, after explaining the 13 objectives of the study. Confidentiality and anonymity was assured to all the participants. Data was kept 14 15 under lock and key with theFor principal researcher. peer review only 16 17 18 Authors’ contributions 19 20 BTS and SAK conceived the study design and instruments. AM supervised the data collection and helped 21 in analyses. BTS and SAK drafted the successive drafts of paper. SA conducted the critical review and 22 23 added the intellectual content to the paper. All authors read and approved the final draft. 24 25 26 Funding: The study was a part of larger project “Chitral Child Survival Program” funded by USAID. 27 28 29 Competing Interests 30 31 The authors declare that they have no competing interests. 32

34 References http://bmjopen.bmj.com/ 35 36 1. World Health Organization & UNICEF. Countdown to 2015 and beyond: fulfilling the health 37 38 agenda for women and children. Geneva: 2014. 39 40 2. Shaikh BT. Marching toward the Millennium Development Goals: What about health systems, 41 health-seeking behaviours and health service utilization in Pakistan? World Health & Popul 2008; 42 on September 28, 2021 by guest. Protected copyright. 43 10(2): 44-52. 44 3. United Nations. Road map towards the implementation of the United Nations Millennium 45 46 Declaration: report of the Secretary-General. New York: 2001. 47 4. Sachs JD, McArthur JW. The Millennium Project: a plan for meeting the Millennium Development 48 49 Goals. Lancet 2005; 365(9456):347-53. 50 51 52 53 54 17 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 5. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth 11 attendants and home delivery? A qualitative study on delivery care services in West Java 12 13 Province, Indonesia. BMC Pregnancy Childbirth 2010; 10:43. 14 6. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal 15 For peer review only 16 and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst 17 18 Rev 2010; 11: CD007754. 19 7. Garces A, McClure EM, Chomba E, Patel A, Pasha O, Tshefu A. Home birth attendants in low 20 21 income countries: who are they and what do they do? BMC Pregnancy Childbirth 2012; 12:34. 22 8. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems 23 24 can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115(2):127-34. 25 9. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth 26 27 attendants and village midwives. J Obstet Gynaecol 2004; 24(1):5-11. 28 29 10. Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication 30 readiness among slum women in Indore City, India. J Health Nutr Popul 2010; 28(4): 383-391. 31 32 11. Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies 33 incorporating training and support of traditional birth attendants on perinatal and maternal

34 http://bmjopen.bmj.com/ 35 mortality: meta-analysis. BMJ 2011; 343:d7102. 36 12. Sibley LM, Sipe TA. Transition to skilled birth attendance: Is there a future role for trained 37 38 traditional birth attendants. J Health Popul Nutr 2006; 24(4):472-8. 39 40 13. Bisika T. The effectiveness of the TBA programme in reducing maternal mortality and morbidity in 41 Malawi. East Afr J Public Health 2008; 5(2):103–10. 42 on September 28, 2021 by guest. Protected copyright. 43 14. Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral of high-risk pregnant mothers by 44 trained traditional birth attendants in Buikwe County, Mukono District, Uganda. J Obstet Gynaecol 45 46 2005; 25(6):554-7. 47 15. Temesgen TM, Umer JY, Buda DS, Haregu TN. Contribution of traditional birth attendants to the 48 49 formal health system in Ethopia: the case of Afar region. Pan Afr Med J 2012; 13(Suppl 1):15. 50 51 16. Wajid A, Rashid Z, Mir AM. Initial assessment of Community Midwives in rural Pakistan. PAIMAN. 52 JSI Research and Training Institute, Inc; Islamabad: 2010. 53 54 18 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 40 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 17. Concern Worldwide. Examining the role of traditional birth attendants in the continuum of care in 11 Sierra Leone. Innovations for maternal, newborn and child health. Policy Brief. Concern 12 13 Worldwide; New York: 2013. 14 18. National Institute of Population Studies and Macro International Inc. Pakistan Demographic and 15 For peer review only 16 Health Survey (PDHS) 2006–07. Government of Pakistan; Islamabad: 2008. 17 18 19. Government of Pakistan. PC1 National Maternal Newborn & Child health Program 2006-2012. 19 Ministry of Health, Government of Pakistan; Islamabad: 2009. 20 21 20. Research and Development Solutions. The community midwives program in Pakistan. Policy 22 Brief Series No 20. Islamabad: 2012. 23 24 21. Department of Health. District health profile-Chitral. Government of Khyber Pakhtunkhwa; 25 Peshawar: 2014. 26 27 22. Chesney M, Davies S. Women’s birth experiences in Pakistan – the importance of the Dai. The 28 29 Royal College of Midwives. Evid Based Midwifery 2005; 3(1):26-32. 30 23. Owolabi OO, Glenton C, Lewin S, Pakenham-Walsh N. Stakeholder views on the incorporation of 31 32 traditional birth attendants into the formal health systems of low-and middle-income countries: a 33 qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums. BMC Pregnancy

34 http://bmjopen.bmj.com/ 35 Childbirth 2014; 14:118. 36 24. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-Experiences of community 37 38 midwives in Pakistan. BMC Pregnancy Childbirth 2014; 14:59. 39 40 25. Research and Advocacy Fund/Children First. How far can I go? Social mobility of CMWs in Azad 41 Kashmir. Islamabad: 2012. 42 on September 28, 2021 by guest. Protected copyright. 43 26. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community 44 mobilization and health management committee strengthening to increase birth attendance by 45 46 trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomized 47 controlled trial. Trials 2011; 12:128. 48 49 27. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the 50 51 management of the third stage of labour in the home delivery setting in rural Gambia: a 52 randomized controlled trial. Br J Obstet Gynaecol 2005; 112: 1277-83. 53 54 19 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from

1 2 3 4 5 6 7 8 9 10 28. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, et al. Administration of misoprostol 11 by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in 12 13 Pakistan: a randomized placebo-controlled trial. BJOG 2011; 118(3):353-61. 14 29. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: Is the 15 For peer review only 16 health care system accessible and responsive in Pakistan? Health Care Women Int 2008; 17 18 29:945-959. 19 30. Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB. Effect of training 20 21 traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): 22 randomized controlled study. BMJ 2011; 342:d346. 23 24 31. Falle TY, Mulany LC, Thatte N, Khatry SK, LeClerg SC, Darmstadt GL, et al. Potential role of 25 traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr 26 27 2009; 27(1): 53–61. 28 29 30 31 32 33