Right-to-Reply results

This has stimulated me to go on line and read the critical sections of WHR 2005. I have also looked at the latest State of the World’s Children Report 2007.

The critical issue is this. What should be done in most of the least developed countries today and over the next decade. In the least developed countries, only 35% of births are attended by a skilled attendant, only 59% of pregnant mothers have access to ante-natal care. It is especially in the rural areas where skilled staff and access are not available. Although it may be ideal to have skilled attendants with full professional training, this is obviously a vision for some years in the future.

This was the challenge for which training of Traditional Birth Attendants was undertaken and seen as a second best and temporary answer. As I read the evidence, it can still be useful. As your advisor cites TBA training can improve “knowledge” and “attitude” and “be associated with small but significant decreases in perinatal mortality and birth asphyxia”, even though it seems to have little impact on maternal mortality. I am glad that your advisor agrees that there are roles which can still be taken care by a TBA/CHW.

So I am not whether or not we are differing. We all agree that well trained professional staff are best, operating in well equipped facilities. But what should be done in the countries where this is available only for a minority of people? I have not consulted my practically-minded UNICEF colleagues, but I would imagine that they would still believe TBAs have a useful and important role in some countries, that in these cases some TBA training important, though avoiding the 1980s error of apparently doing this instead of moving ahead with professional training for midwives and others. I would add that such TBA training ought also to deal with traditional practices that are dangerous and should be avoided –such as cutting the cord with an un-sterile knife or rubbing cow dung on the cord. The WHO Report states that such TBA strategy is increasingly seen as a failure – but the report doesn’t say where or who still disagrees. Perhaps it is these issues of context which I felt the id 21 left out.

I am glad that the important role of individuals, families and communities is also recognized. This presumably would also cover the importance of breastfeeding (and support for mothers in doing this), which was not mentioned in the id21.

Richard Jolly

17 August 2007

Dear Richard,

We really appreciate your feedback.

You raise a very important issue and I thought it was worthwhile having a chat with my guest editor and a couple of contributors before responding.

Evidence shows that training TBAs has had little impact on maternal mortality. It may improve "knowledge" and "attitude", and be associated with small but significant decreases in perinatal mortality and birth asphyxia, but there are no elements to demonstrate that this training is cost-effective. We do agree that there are interventions that can be taken care of by a non-skilled person at home or by a TBA/CHW that benefit the newborn. However, beyond a certain mortality rate level we need clinical services to reduce mortality rates substantially.

As such it was important in this issue of id21 insights to focus on the most effective measure which is to provide professional skilled care, including the possibility to reach a well-equipped hospital if needed. WHO clearly states in the World Health Report 2005 that the TBA strategy is seen as a failure, which has taken 20 years to realise, and that the money spent would perhaps, in the end, have been better used to train professional midwives. However, given that TBAs are a major part of the support structure for women giving birth today in many developing countries it is important to address a realistic phasing out plan that delineates the possible roles and functions of TBA simultaneously with an accelerated production of SBAs within formalised health systems.

We absolutely agree that we have omitted to include a section on this in this id21 insights – although we would say that the issue of TBAs has had a lot of prominence elsewhere and we felt that it was more important to bring out the major constraints to progress at this time. Unfortunately, a full section on this issue would have been too much. We do take your point, however, that mention could have been made of the TBA issue within the human resources piece.

Another piece that you could argue that we have missed relates to the actions that individuals, families and communities can take to support progress towards MDGs 4 and 5 - and indeed we do believe that civil society groups that keep the pressure up on governments to provide services, to provide services that are of a reasonable quality and treat women with respect - are extremely important. If there is an article missing - it is this one - and we would apologise whilst again noting the space constraints within id21 insights. If you would like to read more about this important issue, the guest editor did publish a policy brief while at WHO which accompanied the World Health Report 2005. This brief was peer reviewed by ministers of health and representatives of a wide range of governments as well as academics, other agencies and NGOs in March 2005. It can be accessed at: http://www.who.int/whr/2005/media_centre/pb_4_en.pdf.

Richard, I hope this brief email goes some way to clarifying the direction we took in this issue of id21 insights.

Many thanks and best wishes,

Tom Barker
id21 Health Editor

16 August 2007

Dear id21,

I am glad to see this – so far only on the web. I look forward to reading a full printed version. But am I right, that there insights health makes no mention of TBAs (Traditional Birth Attendants) who provide a major party of the support structure for women giving birth in many poor countries nor of Breastfeeding, ORT and Immunization all critical for the survival, health, growth and development of babies and young children. Without these, the presentation seems to over-emphasise improving health systems as the only action for meeting the MDGs and to underemphasise the importance of what mothers, fathers and families need to do themselves – and how these action can and must be supported.

I hope I am only misreading the text.

Richard Jolly

13 August 2007

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