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Evaluation of a Traditional Birth Attendant Training Programme in Bangladesh

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Evaluation of a Traditional Birth Attendant Training Programme in Bangladesh Midwifery 27 (2011) 229–236 Contents lists available at ScienceDirect Midwifery journal homepage: www.elsevier.com/midw Evaluation of a traditional birth attendant training programme in Bangladesh Tami Rowen, MD, MS (Resident Physician)a, Ndola Prata, MD, MSc (Assistant Adjunct Professor)b, Paige Passano, MPH (Associate Specialist in Maternal Health)c,Ã a University of California San Francisco School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 505 Parnassus Avenue – Room 1483, Box 0556, San Francisco, CA 94143-0132, USA b Bixby Center for Population, Health, and Sustainability, School of Public Health, University of California, Berkeley, 229 University Hall, Berkeley, CA 94720-6390, USA c Bixby Center for Population, Health, and Sustainability, School of Public Health, 50 University Hall, University of California, Berkeley, Berkeley, CA 94720-6390, USA article info abstract Article history: Background and context: the 1997 Safe Motherhood Initiative effectively eliminated support for training Received 5 January 2009 traditional birth attendants (TBAs) in safe childbirth. Despite this, TBAs are still active in many countries Received in revised form such as Bangladesh, where 88% of deliveries occur at home. Renewed interest in community-based 21 May 2009 approaches and the urgent need to improve birth care has necessitated a re-examination of how Accepted 7 June 2009 provider training should be conducted and evaluated. Objective: to demonstrate how a simple evaluation tool can provide a quantitative measure of Keywords: knowledge acquisition and intended behaviour following a TBA training program. Traditional birth attendant Design: background data were collected from 45 TBAs attending two separate training sessions Training conducted by Bangladeshi non-governmental organization (NGO) Gonoshasthaya Kendra (GK). A semi- Home births structured survey was conducted before and after each training session to assess the TBAs’ knowledge Skilled birth attendant Bangladesh safe motherhood and reported practices related to home-based management of childbirth. Global maternal health Setting: two training sessions conducted in Vatshala and Sreepur in rural Bangladesh. Participants: 45 active TBAs were recruited for this training evaluation. Findings: there were significant improvements following the training sessions regarding how TBAs reported they would: (a) measure blood loss, (b) handle an apneic newborn, (c) refer women with convulsions and (d) refer women who are bleeding heavily. A greater degree of improvement, and higher scores overall, were observed among TBAs with no prior training and with less birth experience. Key conclusions and recommendations for practice: as the Safe Motherhood community strives to improve safe childbirth care, the quality of care in pregnancy and childbirth for women who rely on less-skilled providers should not be ignored. These communities need assistance from governments and NGOs to help improve the knowledge and skill levels of the providers upon which they depend. Gonoshasthaya Kendra’s extensive efforts to train and involve TBAs, with the aim of improving the quality of care provided to Bangladeshi women, is a good example of how to effectively integrate TBAs into safe motherhood efforts in resource-poor settings. The evaluation methodology described in this paper demonstrates how trainees’ prior experiences and beliefs may affect knowledge acquisition, and highlights the need for more attention to course content and pedagogic style. & 2009 Elsevier Ltd. All rights reserved. Introduction in the prevention of maternal mortality is the fact that 34% of births worldwide still occur without the help of a skilled birth Over half a million women die of maternal causes every year; a attendant (SBA) (WHO, 2008). Given this scenario, inadvertent number that has remained stable in spite of billions of dollars and loss of life occurs when women with serious complications cannot repeated changes in strategies aimed to reduce the global access emergency obstetric care. maternal mortality rate (MMR). In addition to the 536,000 In recognition of the fact that many women give birth at home, women who die in childbirth each year, an additional 10–15 many local and international organizations have made efforts to million women suffer severe, debilitating health problems result- train traditional birth attendants (TBAs) to recognize, refer ing from pregnancy and childbirth (UNFPA, 2007). A major hurdle and manage pregnancy complications during home births (Walraven et al., 2005; Sibley and Sipe, 2006). Over 70 quantitative and qualitative studies have been published, doc- Ã Corresponding author. umenting the impact on knowledge, behaviour and health E-mail address: [email protected] (P. Passano). outcomes following TBA training initiatives. The foci of these 0266-6138/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2009.06.003 230 T. Rowen et al. / Midwifery 27 (2011) 229–236 studies vary considerably—from hygiene practices to referral In contemporary Bangladesh, female relatives and TBAs play a behaviour to changes in maternal health outcomes (Goodburn major role in labour and birth. The 2004 Demographic and Health et al., 2000; Jokhio et al., 2005; Mathole et al., 2005). Survey (DHS) reported that a mere 16% of births were attended by Researchers have faced complex challenges in attempting to SBAs and only 11% of women gave birth in a health facility (Macro isolate and quantify the impact of TBA training. Findings are International Inc., 2004). These figures include both urban and contradictory, and incomplete reporting has limited the ability of rural populations, which have significant differences in educa- researchers conducting meta-analyses to assess whether TBA tional attainment and access to health care. Data from the 2001 training courses has had a significant impact on maternal health Bangladesh Maternal Health Survey indicate that wealth and outcomes (Sibley et al., 2004, 2007). Nevertheless, it cannot be education are associated with demand for a higher quality of care, assumed that the persistently high regional MMR in areas where as rural women from the top wealth quintile were eight times TBAs have been trained is mainly due to the inadequate technical more likely to obtain professional assistance and nine times more competence of TBAs (De Brouwere et al., 1998). Inappropriate likely to give birth in a health facility than women from the lowest training methodologies, minimal follow-up and inadequate economic quintile. However, even in the highest wealth quintile, documentation of inputs, outputs and outcomes may have also rural women continue to use relatives and TBAs; in 2004, only played an important role in outcomes (Jordan and Davis-Floyd, 28% of the wealthiest families utilized SBAs during childbirth, and 1993; Walraven and Weeks, 1999; Kruske and Barclay, 2004; among the remaining four wealth quintiles, SBA usage ranged Mathole et al., 2005). from 3% to 12% (Koenig et al., 2007). A frequent explanation for In recent years, safe motherhood advocates have drawn more such low usage of professional assistance during birth is the attention to structural barriers faced by women during pregnancy, strong cultural preference for home deliveries among Bangladeshi labour and birth. Geographic distance, poverty, poor infrastruc- women. While a small proportion of women request an SBA to ture, low levels of awareness, and limited access to drugs and assist in home deliveries, there are not enough SBAs available to appropriate technologies all contribute to poor maternal out- assist all women who prefer to deliver at home. Other factors comes (Velez et al., 2007). Combined, these factors make inhibiting facility-based births include: long delays in recognizing identification and management of complications extremely obstetric danger signs, fear of hospitals and fear of high costs difficult at the village level. Partly due to these challenges, a shift (Parkhurst and Rahman, 2007; Velez et al., 2007; WHO, 2007b). In in strategy has occurred over the last decade—away from efforts short, although Bangladesh has made significant strides towards to train TBAs and towards the exclusive promotion and training of improving access to SBAs, the vast majority of women throughout SBAs (Starrs, 1997). This shift increased the overall number of the country are still not utilizing professional services. deliveries attended by professionals, but maternal mortality has Given the persistent use of relatives and TBAs to assist in still not decreased to the degree that was hoped for (WHO, 2005). births, several local organizations are training TBAs to provide In sub-Saharan Africa, for example, where conditions for women antenatal care and safer birth services, despite the Bangladeshi during childbirth are arguably the worst, there was no statistically Government’s exclusive focus on the promotion of skilled care. significant reduction in the regional MMR between 1990 and 2005 One such organization is Gonoshasthaya Kendra (GK). Despite the (Hill et al., 2007). fact that GK’s strategy differs from the Government’s approach, its The emphasis on SBAs has worked well in countries and mission is complementary. Gonoshasthaya Kendra’s staff train regions where governments have prioritized the training and TBAs to refer women to the numerous emergency obstetric care deployment of SBAs, such as Cambodia, Thailand, Indonesia, Sri facilities which are currently
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