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Recent efforts to reduce maternal mortality in developing countries have focused primarily on two long-term aims: training and deploying skilled birth attendants and upgrading emergency obstetric care facilities. Given the future population-level benefits, strengthening of health systems makes excellent strategic sense but it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. There are currently 28 countries from four major regions in which fewer than half of all births are attended by skilled birth attendants. Sixty-nine percent of maternal deaths in these four regions can be attributed to these 28 countries, despite the fact that these countries only constitute 34% of the total population in these regions. Trends documenting the change in the proportion of births accompanied by a skilled attendant in these 28 countries over the last 15-20 years offer no indication that adequate change is imminent. To rapidly reduce maternal mortality in regions where births in the home without skilled birth attendants are common, governments and community-based organizations could implement a cost-effective, complementary strategy involving health workers who are likely to be present when births in the home take place. Training community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) will increase the chance that women in the lowest economic quintiles will also benefit from global safe motherhood efforts.

This paper analyses the importance of the services rendered by traditional birth attendants (TBAs) to pregnant women in Zimbabwe. It argues that, though an integral part of the health system, the ambivalence in terms of policy on the part of the government leaves them in a predicament. Sociocultural values as well as tradition imbue TBAs power and authority to manage pregnancies and assist in child deliveries. On the other hand, government policies expounded through the Ministry of Health (MoH) programs and policies appear to be relegating them to the fringes of healthcare provision. However, in a country with a failing health system characterized by mass exodus of qualified personnel, availability of drugs, and understaffing of healthcare centres, among others, TBAs remain the lifeline for many women in the country. Instead of sidelining them in healthcare interventions, I argue that their integration, however, problematic and often noted to be with disastrous consequences for traditional medicine, presents the sole viable solution towards achieving MDGs 4 and 5. The government and MoH should capitalize on the availability of and standing working relations of TBAs with the grassroots for better/positive maternal health outcomes. In a country reeling with high maternal deaths, TBAs' status and position in society make them the best intervention tools.

AbstractOver the twentieth century, Malian families turned to older women reproductive specialists like excisers (who initiated young women into adulthood), nuptial counsellors (who educated women for sex within marriage) and popular midwives. Their work reflected an expansive understanding of health and fertility. In the 1970s, Mali's government sought to incorporate 'traditional medicine' into the health system. State health workers trained popular midwives as 'Traditional Birth Attendants' (TBA). The same health workers defined nuptial counselling and excision as un‐therapeutic and outdated cultural practices. Comparing these responses reveals the role of gender and social status in the making of an African health system.