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Background Availability of a Skilled Birth Attendant (SBA) during childbirth is a key indicator for MDG5 and a strategy for reducing maternal and neonatal mortality in Africa. There is limited information on how SBAs and their functions are defined. The aim of this study was to map the cadres of health providers considered SBAs in Sub Saharan Africa (SSA); to describe which signal functions of Essential Obstetric Care (EmOC) they perform and assess whether they are legislated to perform these functions. Methods and Findings Key personnel in the Ministries of Health, teaching institutions, referral, regional and district hospitals completed structured questionnaires in nine SSA countries in 2009–2011. A total of 21 different cadres of health care providers (HCP) were reported to be SBA. Type and number of EmOC signal functions reported to be provided, varied substantially between cadres and countries. Parenteral antibiotics, uterotonic drugs and anticonvulsants were provided by most SBAs. Removal of retained products of conception and assisted vaginal delivery were the least provided signal functions. Except for the cadres of obstetricians, medical doctors and registered nurse-midwives, there was lack of clarity regarding signal functions reported to be performed and whether they were legislated to perform these. This was particularly for manual removal of placenta, removal of retained products and assisted vaginal delivery. In some countries, cadres not considered SBA performed deliveries and provided EmOC signal functions. In other settings, cadres reported to be SBA were able to but not legislated to perform key EmOC signal functions. Conclusions Comparison of cadres of HCPs reported to be SBA across countries is difficult because of lack of standardization in names, training, and functions performed. There is a need for countries to develop clear guidelines defining who is a SBA and which EmOC signal functions each cadre of HCP is expected to provide.

The study was conducted on factors contributing to increased utilisation of traditional birth attendants among pregnant women in Illah community of Oshimili North Local Government Area of Delta State. A descriptive cross-sectional design was adopted for this study. Convenience sampling method was used to select 110 respondents in the nine quarters. A self-designed questionnaire was used for data collection. The research instrument was validated was validated by experts of Nursing Science and Tests & Measurement. Reliability of the instrument was tested using Cronbach's Alpha to determine internal consistency of the instrument. The value of 0.70 was gotten. Descriptive statistics was used to answer the research questions while inferential statistics of chi-square was used to test the hypotheses at 0.05 level of significance. The findings revealed that majority 83(75.5%) had good perception about TBA service utilization while 27(24.5%) had poor perception. Also, 70(63.6%) delivered in a healthcare facility, 25(22.7%) delivered with TBAs, 11(10.0%) delivered in religious centres while 4(3.6%) delivered at home. Regarding factors affecting utilization of TBA services, handling of spiritual attack was identified by respondents 95(86.4%) as the most important factor influencing their utilization of TBA service for delivery followed by cheaper cost which was identified by 82(74.5%) women. Results of hypotheses showed that there was no significant association between respondents' perception, as well as socio-demographic data and their utilization of TBA services for delivery. Also, no significant association existed between respondents' TBA service utilization and perceived factors affecting utilization of TBA services for delivery. It was recommended among others that government should regulate the activities of the TBAs and develop a framework that specify the roles and job descriptions of TBAs as well as instituting sanctions where necessary to prevent any attempt to practice outside their jurisdiction. Keywords: ...

Background: Because of the high under-five mortality rate, the government in Zambia has adopted the World Health Organization (WHO) policy on child delivery which insists on professional maternal care. However, there are scholars who criticize this policy by arguing that although built on good intentions, the policy to ban traditional birth attendants (TBAs) is out of touch with local reality in Zambia. There is lack of evidence to legitimize either of the two positions, nor how the outcome differs between women with HIV and those without HIV. Thus, the aim of this paper is to investigate the effect of using professional maternal care or TBA care by mothers (during antenatal, delivery, and postnatal) on under-five mortality of their children. We also compare these outcomes between HIV-positive and HIV-negative women. Methods: By relying on data from the 2013-2014 Zambia Demographic Health Survey (ZDHS), we carried out propensity score matching (PSM) to investigate the effect of utilization of professional care or TBA during antenatal, childbirth, and postnatal on under-five mortality. This method allows us to estimate the average treatment effect on the treated (ATT). Results: Our results show that the use of professional care as opposed to TBAs in all three stages of maternal care increases the probability of children surviving beyond 5 years old. Specifically for women with HIV, professional care usage during antenatal, at birth, and during postnatal periods increases probability of survival by 0.07 percentage points (p.p), 0.71 p.p, and 0.87 p.p respectively. Similarly, for HIV-negative women, professional care usage during antenatal, at birth, and during postnatal periods increases probability of survival by 0.71 p.p, 0.52 p.p, and 0.37 p.p respectively. However, although there is a positive impact when mothers choose professional care over TBAs, the differences at all three points of maternal care are small. Conclusion: Given our findings, showing small differences in under-five child's mortality between utilizers of professional care and utilizers of TBAs, it may be questioned whether the government's intention of completely excluding TBAs (who despite being outlawed are still being used) without replacement by good quality professional care is the right decision

BACKGROUND: Most low- and middle-income countries are experiencing challenges in maternal health in relation to accessing skilled birth attendants (SBA). The first step in addressing this problem is understanding the current situation. We aimed to understand SBA's availability and distribution in Ituri Province, North Eastern Democratic Republic of the Congo (DRC) from 2013 to 2017. METHODS: We used available data on SBAs (doctors, nurses and midwives) from the Ituri Provincial Human Resource for Health Management Unit's database from 2013 to 2017. The current distribution across and within three categories of district (rural, peri-urban and urban) and characteristics of SBAs as well as 5-year trends and vacancy trends were identified. Data on training outputs for SBA cadres was collected from training schools in the province. Descriptive analysis, disaggregating by district, cadre and gender where possible, was conducted using Excel. RESULTS: The national ratio of SBAs per 1000 population is four times less than the Sustainable Development Goals threshold (4.45) while the Ituri Province ratio is one of the lowest in DRC. There are more doctors and nurses in urban and peri-urban districts compared to posts, and shortages of midwives in all district categories, particularly in rural districts. From 2013 to 2017, occupied posts for doctors and nurses in all three categories of districts increase while midwives decrease in peri-urban and rural districts. There is clear gender and occupational segregation: doctors and nurses are more likely to be male, whereas midwives are more likely to be female. The projections of training outputs show a surplus against authorised posts of doctors and nursing increasing, while the shortfall for midwives remains above 75%. CONCLUSION: This is the first study to use existing human resource data to analyse availability and distribution of SBAs in a DRC province. This has provided insight into the mismatch of supply and demand of SBAs, highlighting the extreme shortage of midwives ...

A consensus emerged in the late 1990s among leaders in global maternal health that traditional birth attendants (TBAs) should no longer be trained in delivery skills and should instead be trained as promoters of facility-based care. Many TBAs continue to be trained in places where home deliveries are the norm and the potential impacts of this training are important to understand. The primary objective of this study was to gain a more nuanced understanding of the full impact of training TBAs to use misoprostol and a blood measurement tool (mat) for the prevention of postpartum haemorrhage (PPH) at home deliveries through the perspective of those involved in the project. This qualitative study, conducted between July 2009 and July 2010 in Bangladesh, was nested within larger operations research, testing the feasibility and acceptability of scaling up community-based provision of misoprostol and a blood measurement tool for prevention of PPH. A total of 87 in-depth interviews (IDIs) were conducted with TBAs, community health workers (CHWs), managers, and government-employed family welfare visitors (FWVs) at three time points during the study. Computer-assisted thematic data analysis was conducted using ATLAS.ti (version 5.2). Four primary themes emerged during the data analysis, which all highlight changes that occurred following the training. The first theme describes the perceived direct changes linked to the two new interventions. The following three themes describe the indirect changes that interviewees perceived: strengthened linkages between TBAs and the formal healthcare system; strengthened linkages between TBAs and the communities they serve; and improved quality of services/service utilization. The data indicate that training TBAs and CHW supervisors resulted in perceived broader and more nuanced changes than simply improvements in TBAs knowledge, attitudes, and practices. Acknowledgeing TBAs important role in the community and in home deliveries and integrating them into the formal healthcare system has the potential to result in changes similar to those seen in this study.

Background: Most low- and middle-income countries are experiencing challenges in maternal health in relation to accessing skilled birth attendants (SBA). The first step in addressing this problem is understanding the current situation. We aimed to understand SBA's availability and distribution in Ituri Province, North Eastern Democratic Republic of the Congo (DRC) from 2013 to 2017. Methods: We used available data on SBAs (doctors, nurses and midwives) from the Ituri Provincial Human Resource for Health Management Unit's database from 2013 to 2017. The current distribution across and within three categories of district (rural, peri-urban and urban) and characteristics of SBAs as well as 5-year trends and vacancy trends were identified. Data on training outputs for SBA cadres was collected from training schools in the province. Descriptive analysis, disaggregating by district, cadre and gender where possible, was conducted using Excel. Results: The national ratio of SBAs per 1000 population is four times less than the Sustainable Development Goals threshold (4.45) while the Ituri Province ratio is one of the lowest in DRC. There are more doctors and nurses in urban and peri-urban districts compared to posts, and shortages of midwives in all district categories, particularly in rural districts. From 2013 to 2017, occupied posts for doctors and nurses in all three categories of districts increase while midwives decrease in peri-urban and rural districts. There is clear gender and occupational segregation: doctors and nurses are more likely to be male, whereas midwives are more likely to be female. The projections of training outputs show a surplus against authorised posts of doctors and nursing increasing, while the shortfall for midwives remains above 75%. Conclusion: This is the first study to use existing human resource data to analyse availability and distribution of SBAs in a DRC province. This has provided insight into the mismatch of supply and demand of SBAs, highlighting the extreme shortage of midwives throughout the province. Further investigations are needed to better understand the situation and develop strategies to ensure a more equitable distribution of SBAs throughout this province and beyond. Without this, DRC will continue to struggle to reduce maternal mortality.

Olufunke M Ebuehi, IA AkintujoyeReproductive and International Health Unit, Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, NigeriaBackground: In developing countries, most childbirth occurs at home and is not assisted by skilled attendants. This situation increases the risk of death for both mother and child and has severe maternal and neonatal health complications. The purpose of this study was to explore pregnant women's perceptions and utilization of traditional birth attendant (TBA) services in a rural Local Government Area (LGA) in Ogun State, southwest Nigeria.Methods: A quantitative design was used to obtain information using a structured questionnaire from 250 pregnant women attending four randomly selected primary health care clinics in the LGA. Data were analyzed using Epi Info (v 3.5.1) statistical software.Results: Almost half (48.8%) of the respondents were in the age group 26–35 years, with a mean age of 29.4 ± 7.33 years. About two-thirds (65.6%) of the respondents had been pregnant 2–4 times before. TBA functions, as identified by respondents, were: "taking normal delivery" (56.7%), "providing antenatal services" (16.5%), "performing caesarean section" (13.0%), "providing family planning services" (8.2%), and "performing gynaecological surgeries" (5.6%). About 6/10 (61.0%) respondents believed that TBAs have adequate knowledge and skills to care for them, however, approximately 7/10 (69.7%) respondents acknowledged that complications could arise from TBA care. Services obtained from TBAs were: routine antenatal care (81.1%), normal delivery (36.1%), "special maternal bath to ward off evil spirits" (1.9%), "concoctions for mothers to drink to make baby strong" (15.1%), and family planning services (1.9%). Reasons for using TBA services were: "TBA services are cheaper" (50.9%), "TBA services are more culturally acceptable in my environment" (34.0%), "TBA services are closer to my house than hospital services" (13.2%), "TBAs provide more compassionate care than orthodox health workers" (43.4%), and "TBA service is the only maternity service that I know" (1.9%). Approximately 8/10 (79.2%) of the users (past or current) opined that TBA services are effective but could be improved with some form of training (78.3%). More than three-quarters (77.1%) opposed the banning of TBA services. Almost 7/10 (74.8%) users were satisfied with TBA services.Conclusion: Study findings revealed a positive perception and use of TBA services by the respondents. This underlines the necessity for TBAs' knowledge and skills to be improved within permissible standards through sustained partnership between TBAs and health systems. It is hoped that such partnership will foster a healthy collaboration between providers of orthodox and traditional maternity services that will translate into improved maternal and neonatal health outcomes in relevant settings.Keywords: traditional birth attendants, TBA services, pregnant women, utilization of TBA services

The Indonesian government has been implementing the National Health Insurance (Jaminan Kesehatan Nasional [JKN]) policy since 2014. This study aimed to evaluate JKN based on equity indicators, especially in skilled birth attendants (SBAs) use. The data were obtained from National Socio-Economic Survey of Indonesia during 2012 to 2016. To analyze the data, χ(2) and logistic regression tests were applied. The respondents were married mothers from 15 to 49 years who had delivered a baby. Deliveries by SBAs increased at the national level, but this achievement showed significant variation according to geographical location. The coverage of deliveries by SBAs in the eastern areas of Indonesia was still much lower than those in the western areas. All factors determining SBAs utilization (health insurance ownership, education, household economic status, and geography factor) indicated the positive correlation (P < .05). The inequity of SBA use in differences in geographical location and socioeconomic status continues to occur after the implementation of JKN.

Skilled birth attendance during delivery is a crucial factor in reducing maternal and newborn morbidity and mortality. This study investigated the factors influencing utilisation of Skilled Birth Attendants (SBA) among women of childbearing age in healthcare facilities in the rural communities of Akpabuyo Local Government Area of Cross River State, Nigeria. The need for this study arose because women attend antenatal care during pregnancy but do not come to the facility to deliver. They were only seen when complications arise. Cross sectional descriptive design was adopted for the study. A multi-staged sampling was used to select a total population of 208 respondents who attended antenatal and child welfare clinic at the time of this study, with the return rate of (207) 99.52% The Cronbach's alpha was used to ascertain the reliability of the instrument and the reliability coefficient was 0.8. Data analysis was done using frequency counts, simple percentages and logistic regression. The study findings revealed that those who utilized SBA were 80.7% and only 19.3% demonstrated low utilisation, hence, a high proportion women of reproductive age utilise SBA in Akpabuyo. The findings also revealed that economic factors such as poverty and husband unemployment (95.1%) influence the utilisation of SBA. Similarly, most participants (66.1%) disagreed that utilisation of SBA is not against their cultural belief while 33.9% agreed that using SBA is against their cultural belief such as use of herbs, husband approval and other traditional practices. Test of the hypothesis also revealed that the proportion of utilisation of SBA is not statistically significant related to economic and cultural factors among women of childbearing age in Akpabuyo LGA. It was recommended that deliberate programs should be put in place to encourage male involvement in reproductive health services in order to encourage and support their spouses financially to utilise the services of SBA.

This article focuses on the current conflict over the role of traditional birth attendants in the assistance to the reproduction (pregnancy, childbirth and puerperium) and the similarities between this and the time in which midwifery was not longer more a women's job. The speeches of international agencies that dictate the public politics on maternal health —UNFPA, WHO— remind us what happened centuries ago in Europe and the United States, at the time that medical practice was consolidated as a profession and universal and official science. Through these questioning about the capabilities of midwives, first expressed to address complications and then for normal deliveries —eutocic—, placing them as outside the formal health system figures. ; Este artículo se centra en el actual conflicto sobre el papel que deben desempeñar las parteras tradicionales en la asistencia a la reproducción y los paralelismos con el momento en que la partería dejó de ser un oficio de mujeres. Los discursos de organismos internacionales nos recuerdan lo sucedido siglos antes, cuando la práctica médica se consolidaba como profesión y ciencia universal y oficial. Éstos cuestionan las capacidades de las parteras, para atender complicaciones y para atender partos normales, lo que coloca a las parteras como figuras externas al sistema sanitario oficial.

This article focuses on the current conflict over the role of traditional birth attendants in the assistance to the reproduction (pregnancy, childbirth and puerperium) and the similarities between this and the time in which midwifery was not longer more a women's job. The speeches of international agencies that dictate the public politics on maternal health —UNFPA, WHO— remind us what happened centuries ago in Europe and the United States, at the time that medical practice was consolidated as a profession and universal and official science. Through these questioning about the capabilities of midwives, first expressed to address complications and then for normal deliveries —eutocic—, placing them as outside the formal health system figures. ; Este artículo se centra en el actual conflicto sobre el papel que deben desempeñar las parteras tradicionales en la asistencia a la reproducción y los paralelismos con el momento en que la partería dejó de ser un oficio de mujeres. Los discursos de organismos internacionales nos recuerdan lo sucedido siglos antes, cuando la práctica médica se consolidaba como profesión y ciencia universal y oficial. Éstos cuestionan las capacidades de las parteras, para atender complicaciones y para atender partos normales, lo que coloca a las parteras como figuras externas al sistema sanitario oficial.

Abstract Background Availability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the community midwifery programme in 2005. The aim of this programme was to increase women's access to skilled care during pregnancy, childbirth and post-partum within their communities. Methods Qualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya. Results Findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options. Conclusions Although the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers.