Open Access Research 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 Babar Tasneem Shaikh, Sharifullah Khan, Ayesha Maab, Sohail Amjad To cite: Shaikh BT, Khan S, ABSTRACT et al Strengths and limitations of this study Maab A, . Emerging role Objectives: This research endeavours to identify the of traditional birth attendants role of traditional birth attendants (TBAs) in supporting ▪ in mountainous terrain: A study, the first of its kind, which has expounded the maternal, newborn and child health (MNCH) care, a qualitative exploratory study on the subject of traditional birth attendants from Chitral District, Pakistan. partnership mechanism with a formal health system (TBAs)’ role and livelihood after the introduction of BMJ Open 2014;4:e006238. and also explored livelihood options for TBAs in the trained maternal, newborn and child health provi- doi:10.1136/bmjopen-2014- health system of Pakistan. ders in Pakistan. 006238 Setting: The study was conducted in district Chitral, ▪ The use of qualitative methods provided rich Khyber Pakhtunkhwa province, covering the areas insight into women’s interpretations and ▸ Prepublication history for where the Chitral Child Survival programme was decision-making regarding healthcare seeking this paper is available online. implemented. during and after pregnancy in a relatively conser- To view these files please Participants: A qualitative exploratory study was vative setting of Pakistan. The study presents the visit the journal online conducted, comprising seven key informant interviews views of all stakeholders involved in the (http://dx.doi.org/10.1136/ with health managers, and four focus group discussions intervention. bmjopen-2014-006238). with community midwives (CMWs), TBAs, members of ▪ The findings represent a specific sample size, Community Based Saving Groups (CBSGs) and study site and sociocultural milieu and therefore Received 27 July 2014 Revised 20 October 2014 members of village health committees (VHCs). may not be generalised for the entire province or Accepted 6 November 2014 Results: The study identified that in the new scenario, country. after the introduction of CMWs in the health system, ▪ Health providers involved in the study were TBAs still have a pivotal role in health promotion mainly from the Aga Khan Health Services http://bmjopen.bmj.com/ activities such as breastfeeding promotion and Pakistan (AKHSP) and government who were vaccination. TBAs can assist CMWs in normal deliveries, already exposed to this intervention. and refer high-risk cases to the formal health system. ▪ Only few TBAs could be gathered for discussion, Generally, TBAs are positive about CMWs’ introduction because most of them were remotely located, and welcome this addition. Yet their livelihood has and weather and family constraints did not allow suffered after CMWs’ deployment. Monetary incentives them to travel. Moreover, the prospective role of to them in recognition of referrals to CMWs could be TBAs is discussed in a special context, whereby one solution. The VHC is an active forum for a community midwife was trained and deployed strengthening co-ordination between the two service in the area for increasing skilled birth on September 27, 2021 by guest. Protected copyright. providers and to ensure an alternate and permanent attendance. livelihood support system for the TBAs. Conclusions: TBAs have assured their continued support in provision of continuum of care for pregnant women, lactating mothers and children under the age of year 6.6 million children die before 5 years 5 years. The district health authorities must figure out of age (44% as newborns) and 289 000 ways to foster a healthy interface vis-à-vis roles and maternal deaths occur, mostly from prevent- responsibilities of TBAs and CMWs. In time it would be able causes.1 This state of affairs has raised worthwhile to do further research to look into the serious global concern over the years in CMWs’ integration in the system, as well as TBAs’ developing countries to ensure the availabil- continued role for provision of MNCH care. Department of Health & Built ity and accessibility of human resources for Environment, Aga Khan ensuring continuum of care for expecting Foundation, Islamabad, mothers. Uniform availability and distribu- Pakistan tion of skilled birth attendants is critical to INTRODUCTION consider while looking at health service util- Correspondence to 2 Dr Babar Tasneem Shaikh; Despite all advances towards Millennium isation trends. The Millennium Declaration [email protected] Development Goals (MDGs) 4 and 5, every in 2000, signed by 189 nations, recognised Shaikh BT, et al. BMJ Open 2014;4:e006238. doi:10.1136/bmjopen-2014-006238 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2014-006238 on 26 November 2014. Downloaded from the proportion of births assisted by trained birth atten- CMWs in some rural parts of the country.18 While some dants as an important indicator to track maternal and maternity care indicators appear to have improved over child survival indicators.34To increase the availability the past two decades, women’s access to prenatal health- and accessibility of maternal and child healthcare ser- care continues to be low in Pakistan. vices, training of traditional birth attendants (TBAs) and Realising the need for a community health workforce, strengthening the partnership between community mid- the Government of Pakistan launched the national wives (CMWs) and TBAs are widely acknowledged world- MNCH programme in 2006 to help the rural women wide.56Nonetheless, the role of the TBAs cannot be deliver safely.19 Although the programme has been suc- effective in a weak primary healthcare system and in an cessful in countries such as Malaysia and Indonesia, the unplanned referral mechanism.7 challenges faced by the CMW programme of Pakistan In order to attain MDG-5, isolated interventions are are multifaceted. These challenges are related to accept- not able to reduce maternal mortality sufficiently. It is ance by the community, competition with other service important to review strategies to maximise the strengths providers, a weak referral system, an inadequate skill set of TBAs and skilled birth attendants. Evidence suggests and a lack of community involvement.20 that skilled birth attendance has increased in regions where TBAs are integrated with the formal health THE INTERVENTION system.8 However, integration of TBAs with the formal To address the health system constraints, the Chitral health system may require the capacity development and Child Survival Program (CCSP) of Aga Khan supervision of TBAs, collaboration skills for health Foundation Pakistan (AKF-P) deployed CMWs, sup- workers, involvement of TBAs at health facilities and ported a community financing scheme, improved refer- improved capacity on communication and referral ral linkages and implemented a behaviour change systems. With this approach, TBAs may positively contrib- communication campaign from 2008 to 2014. CCSP was ute to maternal and child health outcomes.9 Training of implemented in close partnership with the Department TBAs not only enhances their knowledge and skills on of Health, Khyber Pakhtunkhwa, the Aga Khan Health obstetric care and referral mechanism, but also leads to Services Pakistan (AKHSP) and the Aga Khan Rural greater community acceptance and a greater consumer Support Program (AKRSP). The CCSP interventions, satisfaction. They can play a vital role in birth prepared- especially the role of community-based savings groups, ness and identification of danger signs.10 Training of village health committees (VHCs) and community-based TBAs has shown an impact on perinatal and neonatal emergency maternal referral mechanisms to achieve deaths which can be significantly reduced.11 Moreover, project results, showed that CCSP had attempted to TBAs have been a critical contributor in providing engage the TBAs proactively. The project empowered skilled maternal, newborn and child health (MNCH) TBAs on Birth Preparedness and Complications care in the rural population of developing countries due http://bmjopen.bmj.com/ Readiness (BPCR) plans and integrated referral to inadequate numbers of human resource for service mechanisms. The involvement of TBAs in the project delivery.12 Therefore, the role of trained TBAs in health- was meaningful to generate the community acceptability care provision cannot be undermined. Developing coun- for young CMWs, identification of high-risk cases, and tries have used TBAs as a key strategy to improve referrals of complications to CMWs and transporting maternal and child healthcare.13 They have been effect- pregnant women to a health facility in time. ive in improving the referral mechanism and links with This research paper endeavoured to identify the role the formal healthcare system.14 The literature review has of TBAs in supporting the MNCH care, partnership suggested that a TBA is preferred over a midwife who is on September 27, 2021 by guest. Protected copyright. mechanism with the formal health system and also a young, unmarried girl without children. This trend is explored livelihood options for TBAs. more common in countries where fresh CMWs are recently deployed such as Pakistan.15 16 Another reason for the community acceptance of TBAs is that they are a METHODOLOGY more affordable option than