27 (2011) 229–236

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Midwifery

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Evaluation of a traditional birth attendant training programme in Bangladesh

Tami Rowen, MD, MS (Resident )a, Ndola Prata, MD, MSc (Assistant Adjunct Professor)b, Paige Passano, MPH (Associate Specialist in )c,Ã a University of California San Francisco School of Medicine, Department of , 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 . 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 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 underutilized across the country. It is Lanka and Malaysia. However, in countries where governments notable that the MMR in GK programme areas (145/100,000 in have been unable to achieve rapid and sustained mobilization of 2005/6) is considerably lower than the nationwide estimate SBAs into rural areas, either no change has occurred in the reported by the DHS in 2004 (320/100,000). While many factors proportion of women receiving professional care or the situation could be responsible for this, there are plausible reasons, detailed has worsened. In countries such as Tanzania, Kenya and Yemen, in Chaudhury and Chowdhury (2008), that could explain such a the proportion of women who had an SBA by their side at the birth low MMR. Other Bangladeshi non-governmental organizations of their last child decreased substantially in the last two (NGOs) such as Rangpur Dinajpur Rural Service (RDRS), in Demographic and Health Surveys. In other countries, such as collaboration with the International Centre for Diarrhoeal Disease Chad and Ethiopia, the proportion of women served by SBAs has Research, Bangladesh also provide training, supervision and remained static over the past 5–10 years (Measure DHS, 2007). For support to TBAs, and have recorded a similarly low MMR. Of the the most part, where governments have been unable to recruit, 97,735 deliveries that took place in 2007 in the area served by train, and retain trained birth attendants in areas of greatest need, RDRS (where nearly 80% of deliveries were managed by trained the MMR has tended to stagnate or increase. The challenge to safe TBAs), the MMR was 100 (Rangpur Dinajpur Rural Service, 2007). motherhood has also been exacerbated by rapid population Considering the time and effort that NGOs, such as RDRS and growth; the countries with the highest fertility rates require a GK, invest in training, formal quantitative and qualitative training greater density of SBAs, but tend to have a more severe shortage assessment tools are essential. A formal evaluation can assess (Dogba and Fournier, 2009). effectiveness and help NGOs to adapt their methodologies to Despite the fact that WHO, UNFPA and UNICEF no longer improve upon existing programmes. The goal of this study was to support the training of TBAs (UNFPA, 2004; WHO, 2007a), some observe GK’s training sessions and provide a quantitative measure experts argue that TBAs should not be overlooked in training of knowledge transfer, taking three important factors into efforts because they are an important part of the maternal health account: (a) content of training, (b) training methodology and infrastructure (Walraven and Weeks, 1999; Chaudhury and (c) background characteristics of TBA trainees that might be Chowdhury, 2008). They insist that time and energy must be associated with knowledge transfer. It also provided a means of invested towards upgrading the skills of active TBAs to avoid comparison between GK’s two training sites. adverse health outcomes among the women who depend on them (Jokhio et al., 2005). Many of the programmes continuing to train Methods TBAs are in South Asia, where home deliveries are still widely prevalent in rural areas, despite improved access to skilled care in Two training sessions at GK were attended during the winter of urban regions (Chaudhury and Chowdhury, 2007). 2005–2006. T. Rowen et al. / Midwifery 27 (2011) 229–236 231

The first training session was conducted at GK’s Sreepur Table 1 training site, 75 km from Dhaka near Gazipur in December 2005. Coded response variables. The Sreepur center is GK’s second largest location and includes a Variable Response ¼ 0 Response ¼ 1 50-room dormitory, a 20-bed hospital and ample land for gardens and livestock. The second training session took place in January Background 2006 in Vatshala, in Sylhet division on the northern Bangladesh– Training history None Any previous training India border. Average number of deliveries One or less per 41/month month Decision to become a TBA Family choice Personal choice Recruitment Form of payment None Money/barter Closest EmOC facility o4km 44km Type of closest EmOC facility Government/private GK’s clinic The TBAs were recruited by GK health workers in the weeks clinic prior to the training sessions. Many of the trainees were known to Knowledge and behavior Less-desired Desired response ¼ 1 health workers prior to recruitment, enabling GK staff to visit the response ¼ 0 TBAs at home to invite them to participate in the training. Clean delivery practices None Wash hands/clean instruments provision No Yes Informed consent Tools used to measure blood None Plastic sheets/clothes Uterine compression to prevent No Yes Gonoshasthaya Kendra health workers obtained informed PPH consent from each TBA. All participants had the option not to Response to PPH No referral to Refer to hospital hospital participate in the survey and/or to refuse to have their photograph Treatment for apneic newborn Shaking and slapping Stimulation and taken. Given the low literacy level of the participants, the training mouth-to-mouth director provided information about the study verbally, and Response to convulsions No referral to Refer to hospital consent was gathered orally, in accordance with UC Berkeley hospital Nutritional needs in pregnancy Normal or less food Extra food required CPHS Protocol #2005-10-6. required

Perceptions and beliefs Less-desired Desired response ¼ 1 Data collection response ¼ 0 Opinion of value of antenatal care Not necessary Necessary The background questionnaire was drafted in English and Opinion of hospital deliveries Worse/no different Better than home than home translated into Bengali. Background questions asked only at Community respects trained TBAs No Yes baseline included: amount of birth experience, training history, who get trained and views on training and hospital vs . Knowledge Feel respected by SBAs No Yes questions asked at baseline and after the training sessions focused on antenatal care, hygiene, eclampsia, haemorrhage and neonatal TBA, traditional birth attendant; EmOC, emergency obstetric care; PPH, post- partum hemorrhage; SBA, skilled birth attendant. care. The survey questions were semi-structured, with the majority of the questions having four pre-written responses to Findings select from in addition to an option for a free-text response. All participants had the freedom to select as many of the pre-written options as they felt were applicable, and their verbal responses Topics and methods of TBA training were written down by their interviewer. Each of the training sessions was carefully observed and Both five-day training programs covered multiple subjects photographed with key sessions translated into English by GK within the area of , with specific topics health workers. There was minimal participation in the training addressed repeatedly such as hygiene and appropriate referral by the observer and all sessions were observed from the back of behaviour. Table 2 summarizes the topics and respective the room. Descriptions of participants, trainers, methods, materi- methodologies used. als and activities were documented comprehensively. Differences in key variables by training location Data analysis Responses to key background variables are summarized in Data analysis was performed using Stata Version 9. The goal of Table 3 with responses stratified by training location. The the analysis was to measure the responses for the questions background of trainees varied substantially because TBAs trainees relating most directly to the major causes of maternal mortality, were recruited from two distinct areas. Questions asked to TBA and to document the largest gaps in knowledge prior to training included their opinion of hospital vs home deliveries, whether they and improvements in knowledge following training. In order to felt respected by trained health providers, and whether the accomplish this goal, each response was labeled as either ‘0’ or ‘1’. communities they serve respected their participation in training The desired response was labelled ‘1’ which matched the best programs. Significant differences between the two sites are high- practices that GK staff taught to TBAs. The coded responses are lighted in bold. The biggest difference in background variables was summarized in Table 1. seen in opinions regarding hospital deliveries, where only 31% of TBAs from Vatshala felt that hospital deliveries were better than home deliveries, compared with 90% of Sreepur TBAs. Significance testing

Due to the small sample size, Fisher’s Exact test was used to Changes in TBAs’ knowledge, attitudes and practices compare the differences in proportions between the two training sites and the differences between pre- and post-training knowl- Mean pre- and post-training responses to knowledge, attitudes edge overall. Statistical significance was established at po0.05. and practices (KAP) questions are summarized in Table 4, with 232 T. Rowen et al. / Midwifery 27 (2011) 229–236

Table 2 combined mean responses, stratification by location, and Topics and methods of traditional birth attendant (TBA) training. measured differences between the two locations. Questions that resulted in significant improvement after training are highlighted Topic Method Specific example in bold with concurrent stratification based on training location. Female physiology Lecture Overheads of reproductive organs in adult There was overall improvement in intended behaviour regarding: Models women and changes during puberty how to treat an apneic newborn, how to respond to heavy Non-pregnant uterus, ovaries and fallopian bleeding or convulsions, and use of a blood measurement tool. tube model passed around training room

Physiology of Lecture Overheads of drawings depicting sexual Influence of background variables on knowledge and reported reproduction intercourse and fertilization practices Normal pregnancy Lecture Overheads of pregnancy changes in Mode reproductive organs and pictures of The study team hypothesized that the changes in knowledge Video abnormal vs normal lie and reported practices might be influenced by background All TBAs examined pregnant uterus model variables, but the majority of variables such as clean birth at 4, 12, 18, 30 and 36 weeks Pictures and diagrams on normal changes practice, perception of antenatal care, and knowledge of nutri- during pregnancy explained in Bengali and tional needs of pregnant women showed no significant change. Hindi However, there were significant improvements in certain vari- ables after stratification by training history, prior experience Antenatal care Lecture Overhead pictures of measuring fundal conducting deliveries, and attitude towards hospital birth Video height, assessing lie, proper nutrition and Role- dangers of drug and cigarette use (Table 5). The before and after columns in Table 5 indicate the play Depictions of a routine antenatal visit at percentage of TBAs who selected the preferred response (‘1’), as Activity home or at local clinic defined in Table 1. The first column in Table 5 highlights the Health workers demonstrated proper significant differences in the two groups before and after training abdominal examination using a doll under the TBA’s sari, followed by the TBAs when stratified by these three background variables. practicing in pairs Paired TBA assessment for tibial oedema and ocular signs of anemia and jaundice Summary of findings

Safe delivery Lecture Overhead pictures of instruments and tools Following the training programme, the TBAs showed a Video Depictions of TBAs boiling instruments, statistically significant improvement in the following four ques- Role- cleaning delivery surface and creating play proper lighting tions: (a) how to treat an apneic newborn, (b) whether they Activity TBAs set out clean cloth and practiced planned to use a tool to measure blood loss, (c) when they setting out tools planned to refer in case of convulsions, and (d) when they planned TBAs practiced bucket hand-washing to refer in case of heavy bleeding. The variables that did not show a significant improvement started out with very high rates of Three stages of Lecture Overhead diagrams of stages of labour, labor Video drawings of fetal and placental desired responses prior to the training. Role- presentation play Depictions of actual woman in labour with recreation of delivery using models and Discussion fake blood TBA pairs used dolls to simulate delivery and demonstrate normal presentation Many TBA training evaluations have been based on measure- ments of maternal mortality and morbidity within a region Post-delivery care Lecture Overhead pictures of cord cutting and following specific training, despite the fact that most TBA training Video breast feeding evaluations lack a baseline, fail to take into account the back- Role- Depictions of proper cord cutting, play wrapping the baby, and proper breast- ground of trainees, and neglect to examine the content and feeding technique methods employed in training programs (Kruske and Barclay, TBA pairs used models to practice cord 2004). In the present authors’ view, it is impossible to state that cutting, wrapping, breast feeding and training has succeeded or failed in achieving its aims without a proper treatment for apneic newborn proper pre–post KAP assessment, including a qualitative compo- Complications Lecture Overhead drawings representing: fever, nent and post-training observations. Background surveys, in Video convulsions, pain and bleeding. Emphasis particular, provide important information about the environment Activity on using vaginal tamponade to control within which TBAs operate. This is essential information which bleeding while transferring woman to can guide the design of a training programme that is centered hospital Depictions of post-partum hemorrhage around the learners, the specific knowledge and skills that need to using models and fake blood be imparted, and the community (Bransford et al., 1999). TBAs paired up to feel for pulse and check In the ethnography ‘Birth in Four Cultures’, Jordan and Davis- temperature. Stress placed on referral in Floyd (1993) observe that the customary mode of skill acquisition case of a major difference between TBA’s own pulse and temperature and that of the by TBAs occurs while watching and gradually helping with small, delivering woman. Thermometer practice practical tasks. Most TBA training programmes, in contrast, have only in Sreepur training primarily used a didactic style of instruction that may be abstract and unintelligible to trainees with low literacy. TBA trainers tend Treatment of Lecture Overhead pictures of necessary to be nurses or with biomedical training, compared neonates and immunizations, nutrition and treatment immunization for diarrhoea with TBAs who operate within indigenous knowledge systems that are often disregarded by medical professionals. Jordan notes that it would behove curriculum designers and trainers of TBAs to make a sincere effort to understand the worldview and existing T. Rowen et al. / Midwifery 27 (2011) 229–236 233

Table 3 Differences in key background variables by training location.

Question Options % Overall n ¼ 45 % Sreepur n ¼ 19 % Vatshala n ¼ 26 Measured difference

Background Training history Any previous training 29 26 31 p ¼ 0.094 Average number of deliveries 41/month 65.9 50 77 po0.001 Decision to become TBA Personal choice 44 58 38.5 po0.001 Form of payment Money/barter 84.4 95 77 po0.001 Closest post-partum hemorrhage facility 44 km 26.7 32 23 p ¼ 0.033

Knowledge and behaviour Family planning provision Yes 91 79 96 po0.001 Perceptions Opinion of hospital deliveries Better than home 54.5 89.5 31 po0.001 Feels community respects TBA training Yes 71 74 69 p ¼ 0.096 Feels respected by trained health providers Yes 86.7 89.5 85 p ¼ 0.0335

TBA, traditional birth attendant.

Table 4 Changes in traditional birth attendants’ knowledge and reported practices.

Question Combined mean response n ¼ 44 Sreepur mean response n ¼ 19 Vatshala mean response n ¼ 25

Before % After % Difference Before % After % Difference Before % After % Difference

Treatment for apnic newborn 23 86 p ¼ o0.001 25 89.9 p ¼ o0.001 23 84 p ¼ o0.001 Response to PPH 33 78 p ¼ o0.001 26.3 73.7 p ¼ 0.0026 38.5 80.0 p ¼ 0.014 Measurement of blood loss 67 91 p ¼ 0.0042 47.4 94.7 p ¼ 0.008 80.0 88.5 p ¼ 0.45 Response to convulsions 86.7 100 p ¼ 0.011 89.7 100 p ¼ 0.14 84.6 100 p ¼ 0.02 Compression of uterus to prevent PPH 76 75 p ¼ 0.53 77.8 63.1 p ¼ 0.771 75 84 p ¼ 0.24 Clean delivery practices 93 98 p ¼ 0.167 84.2 87.4 p ¼ 0.1516 100 100 p ¼ 1 Knowledge of nutritional needs of pregnant women 86 93 p ¼ 0.1483 100 94.7 p ¼ 0.83 76.9 92 p ¼ 0.0722 Perception of the value of antenatal care 93.3 97.8 p ¼ 0.16 100 100 P ¼ 1 88.5 96 p ¼ 0.163

PPH, post-partum hemorrhage.

Table 5 Changes in knowledge and reported practices stratified by background variables.

Question By training history

Difference between groups TBAs without prior training n ¼ 31 TBAs with prior training n ¼ 13

Before After Before After Difference Before After Difference

Treatment for apneic newborn p ¼ 0.0032 p ¼ o0.001 20 90 p ¼ o0.001 31 77 p ¼ 0.016 Response to PPH po0.001 p ¼ 0.02 38 81 p ¼ 0.0002 23 69 p ¼ 0.016 Measurement of blood loss p ¼ 0.98 po0.001 69 97 p ¼ 0.0024 62 77 p ¼ 0.42 Response to convulsions p ¼ 0.0004 N/A 84 100 p ¼ 0.02 92 100 p ¼ 0.32

By average number of deliveries

Difference between groups One delivery/month or less n ¼ 15 More than one delivery/month n ¼ 29

Before After Before After Difference Before After Difference

Treatment for apneic newborn p ¼ 0.14 po0.001 18 100 p ¼ o0.001 23 79 p ¼ o0.001 Response to PPH p ¼ 0.02 po0.001 27 87 p ¼ 0.0004 34 76 p ¼ 0.0012 Measurement of blood loss p ¼ 0.0004 po0.001 60 100 p ¼ 0.0048 72 86 p ¼ 0.2 Response to convulsions p ¼ 0.014 N/A 93.3 100 p ¼ 0.32 86 100 p ¼ 0.04

By opinion of hospital deliveries

Difference between groups Negative/neutral n ¼ 19 Positive n ¼ 25

Before After Before After Difference Before After Difference

Treatment for apneic newborn p ¼ 0.044 p ¼ 0.0036 21 84 p ¼ o0.001 28 91 po0.001 Response to PPH po0.001 p ¼ 0.72 45 80 p ¼ 0.02 25 79 po0.001 Measurement of blood loss po0.001 po0.001 75 85 p ¼ 0.44 58 96 p ¼ 0.001 Response to convulsions po0.001 N/A 80 100 p ¼ 0.04 92 100 p ¼ 0.15

TBA, traditional birth attendant; PPH, post-partum hemorrhage. 234 T. Rowen et al. / Midwifery 27 (2011) 229–236

practices of the group to be trained, as these factors will influence Table 6 how TBAs interpret new ideas, and will ultimately play a role in Unexpected results and possible explanations. determining whether or not the new skills will be incorporated (Jordan and Davis-Floyd, 1993). Background Unexpected result Possible explanation question

Prior training TBAs without training Prior training could lead to Significant post-training improvements more likely to show overconfidence significant improvement in Lack of prior training could There were four areas in which TBAs improved significantly knowledge and intended lead to eagerness to learn behaviour. following training: how to treat an apneic newborn, reported plan Amount of delivery TBAs with less delivery More experience could lead to use a blood measurement tool, and reported plan to respond to experience experience were more to more established habits heavy bleeding or convulsions (Table 4). The most significant likely to show significant or overconfidence difference in pre-/post-training responses was concerning the improvement in Less experience could be knowledge and intended linked to an openness treatment of an apneic newborn. There is no uniform agreement behaviour. towards an improvement on how to treat an apneic newborn at home without a suction in knowledge and skills device (Klein et al., 2004), but GK’s recommendation of stimulat- ing the newborn’s back and providing mouth-to-mouth resuscita- Opinion of hospital After training, TBAs with a Despite their uncertainty tion was chosen as the desired response as it was heavily deliveries negative (or neutral) view about hospitals, they may towards hospital birth at be aware that these emphasized throughout the training and repeatedly practiced in baseline were as likely to complications are beyond role-plays. At baseline, only 23% of the TBAs selected the desired report that they would their capacity to manage, response (stimulation+mouth-to-mouth resuscitation). Following refer women to a health or they may feel that it is the training period, 86% of the trainees in both training locations facility in cases of PPH or their duty to refer in eclampsia compared with emergencies correctly reported how to manage an apneic newborn. TBAs with a positive view. It is generally difficult to measure blood loss during home deliveries, especially in low light conditions. However, the use of materials such as plastic, cloth or garments of a fixed size can assist TBAs in determining if bleeding has been excessive. Prior to Unexpected findings the training sessions, 67% of the TBAs reported using some kind of tool to help them measure blood loss. The proportion of TBAs Several interesting observations emerged from this study in who reported that they planned to use a blood measurement the analysis of background characteristics, knowledge acquisition tool increased significantly to 91% after training (Table 4). In and reported behaviour. First, it was expected that those with less comparing the two sites, the trainees from Sreepur showed a training would start out with lower levels of knowledge and significant improvement, while in Vatshala, there was no would improve significantly. As it turned out, the TBAs with no significant change. In Vatshala, 80% of the TBAs indicated at prior training not only improved more than the TBAs with prior baseline that they use a blood measurement tool, and after training, but they also ended up with higher overall scores training, the proportion was 89%. In Sreepur, on the other hand, (Table 5), except for the scores in ‘response to convulsions’, where less than half of the TBAs used a measurement tool before both groups ended up with an equally high score. training, compared with 95% who reported that they intended to Another surprising finding emerged in the area of prior birth use a blood measurement tool following training. experience. When stratified by amount of experience conducting Another significant finding related to the TBAs’ response to deliveries, the group that had conducted more deliveries im- heavy bleeding. Prior to the training sessions, only 33% reported proved less and ended up with lower overall scores than the group that they recommend immediate referral for heavy bleeding, who had conducted fewer deliveries. This pattern was evident in compared with 78% reporting that they would refer women who three out of the four knowledge variables. The only exception was were bleeding heavily after training. Interestingly, when the in the question regarding convulsions, in which all TBAs reported trainees were stratified into two groups, one with a positive view that they would immediately refer. towards hospital birth and the other with a negative or neutral In terms of opinion of hospital birth, it was expected that TBAs view, the groups started out with very different responses; only with negative or neutral views towards hospital birth might be 25% of the group with the positive view claimed that they less likely to refer in case of heavy bleeding or convulsions. immediately refer in case of heavy bleeding, while 45% of the However, the proportion of TBAs who reported that they would group with a negative or neutral view towards hospital birth said immediately refer women with heavy bleeding improved sig- they immediately refer. After the training sessions, an almost nificantly among all TBAs following training, and by the end of identical proportion of TBAs (79% and 80%) claimed that they training, 100% of TBAs reported that they would immediately refer intended to immediately refer in case of heavy bleeding. This is in case of convulsions. encouraging although it cannot predict the proportion of TBAs Table 6 summarizes these unexpected findings along with who will actually recommend referral when faced with the possible explanations, but definitive explanations cannot be situation in the future. provided until further qualitative research is conducted. The final significant finding related to the importance of referral for convulsions, where prior to training, 87% of TBAs reported that they immediately refer in such cases, compared Qualitative observations with 100% of the trainees reporting that they would do so after training. As there is almost nothing a TBA can do to treat the life- The content of the training sessions was similar in both threatening effects of eclampsia without access to an emergency training locations, but there were slight differences in the amount obstetric care facility, the immediate referral of women with of time spent in particular areas, and in some of the materials signs of eclampsia was an essential component of the training, used. There were also distinct differences in the background and it appears that GK’s efforts to impart this knowledge was experiences and opinions held by the two groups of TBA trainees. successful. While these differences limit the conclusions that can be drawn, T. Rowen et al. / Midwifery 27 (2011) 229–236 235 they clearly illuminate the need to understand the complex range testament to the ongoing training efforts of GK, considering the of factors which may affect changes in KAP when training TBAs or fact that maternal health knowledge is not equally high among other community-based health workers. trained and untrained TBAs in Bangladesh (Rashid et al., 1999). This highlights the need for programme planners to take into The study also provides an example of how an evaluation could account regional differences in belief systems and practices when be developed and implemented by NGOs to assess their own designing and implementing multi-site TBA training programmes. training programmes for community-based birth attendants. It Key differences can be planned for and incorporated into training highlights the importance of collecting data on the background of design for optimal results. If two or more training sessions are to birth attendants prior to the design and implementation of be evaluated together, it is also essential that differences in the training programs. It also reiterates the importance of adult attitude of trainers, training content and methodology should be learning theory in explaining how prior knowledge, attitudes and minimized as much as possible for more accurate comparability. experiences are likely to have a significant impact on how A careful qualitative observation of trainers’ attitudes towards knowledge is acquired and incorporated. TBAs, TBAs’ attitudes towards trainers, and the interpersonal This study focused on successful knowledge transfer within dynamics within the trainee and trainer groups should be noted. the context of a training programme, but GK’s goals are more ambitious. GK aims to improve care for women in the community, Limitations by training TBAs to identify possible problems and refer women to facilities in a more timely manner. To encourage referral, TBAs and An important limitation of this study is the fact that the community members need to understand why referral is so indicators that were measured are simply proxies to determine necessary in certain contexts and when to refer if they witness any what TBAs may be doing; it was beyond the scope of this study to danger signs. Community-based training programs can be an observe TBAs’ actual practices. It is well understood that a desired excellent opportunity to teach TBAs (and the women they serve) response in the post-training survey question does not mean that to prevent adverse outcomes and to recognize key danger signs the training participant will necessarily put this knowledge into during pregnancy and childbirth so appropriate action can be practice. To measure actual effectiveness of a TBA training taken. program, one would have to document the rates of recommended Many maternal health advocates argue that TBAs should be referral by the TBAs following the onset of complications, excluded from training and support because they believe that only although this would be complicated by various measurement SBAs have the skills to save women’s lives. However, in the absence challenges. One important measurement challenge is the fact that of training programmes for birth attendants who fall outside the there is rarely any documentation of TBA and family decision- category of SBAs, harmful practices are likely to continue and an making processes prior to maternal deaths. Second, families do uncooperative divide between the trained and untrained birth not always agree to recommendations by TBAs. Third, weather attendants will persist. Although it is true that SBAs have skills that conditions may prevent TBAs from even mentioning referral if TBAs lack, it is important to find out what TBAs are doing in their they do not see it as a realistic possibility. Fourth, given the rarity communities and offer them an opportunity to enhance their skills. of specific maternal health outcomes, being at the right place at Exclusion of TBAs is not useful at a time when a more trusting the right time to record what happens is logistically difficult. relationship between TBAs, SBAs and other health facility personnel Finally, there are a large number of possible variables that may needs to be built. Greater cooperation will benefit all, because influence TBA behavior and maternal health outcomes. In light of without more effective linkages to underserved communities that all these measurement challenges, it was felt that a simple TBAs can provide, emergency obstetric care facilities are likely to pre–post questionnaire would provide an NGO with useful remain underutilized. information about knowledge transfer and intended behaviour. Sample size is another consideration. This study’s sample size of 45 TBAs was large enough to detect statistically significant Acknowledgements differences in pre- and post-training responses, but was not large enough to be considered representative of TBAs in the regions The authors wish to acknowledge Rizwanul Karim, Go- studied. 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