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1.  Traditional birth attendant training for improving health behaviours and pregnancy outcomes 
Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes.
To assess the effects of TBA training on health behaviours and pregnancy outcomes.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search.
Selection criteria
Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs.
Data collection and analysis
Three authors independently assessed study quality and extracted data in the original and first update review. Three authors and one external reviewer independently assessed study quality and two extracted data in this second update.
Main results
Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).
Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).
Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).
We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01).
Authors’ conclusions
The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.
PMCID: PMC4158424  PMID: 22895949
Health Behavior; Infant Mortality; Infant, Newborn; Maternal Mortality; Midwifery [*education; standards]; Perinatal Mortality; Pregnancy Outcome [*epidemiology]; Randomized Controlled Trials as Topic; Stillbirth [epidemiology]; Female; Humans; Pregnancy
2.  Recognition of and Response to Neonatal Intrapartum-related Complications in Home-birth Settings in Bangladesh 
Intrapartum-related complications (previously called ‘birth asphyxia’) are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites ‘no movement’ and ‘no cry’ were identified as signs of breathing difficulties while ‘prolonged labour’ was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh.
PMCID: PMC4221456  PMID: 25395913
Home-birth; Intrapartum-related complications; Bangladesh
Midwifery  2012;28(5):554-560.
PMCID: PMC3472154  PMID: 22884893
4.  Women’s Social Networks and Birth Attendant Decisions: Application of the Network-Episode Model 
Social science & medicine (1982)  2011;74(3):452-459.
This paper examines the association of women's social networks with the use of skilled birth attendants in uncomplicated pregnancy and childbirth in Matlab, Bangladesh. The Network-Episode Model was applied to determine if network structure variables (density / kinship homogeneity / strength of ties) together with network content (endorsement for or against a particular type of birth attendant) explain the type of birth attendant used by women above and beyond the variance explained by women's individual attributes. Data were collected by interviewing a representative sample of 246 women, 18–45 years of age, using survey and social network methods between October and December 2008. Logistic regression models were used to examine the associations. Results suggest that the structural properties of networks did not add to explanatory value but instead network content or the perceived advice of network members add significantly to the explanation of variation in service use. Testing aggregate network variables at the individual level extends the ability of the individual profile matrix to explain outcomes. Community health education and mobilization interventions attempting to increase demand for skilled attendants need to reflect the centrality of kinship networks to women in Bangladesh and the likelihood of women to heed the advice of their network of advisors with regard to place of birth.
PMCID: PMC3265634  PMID: 22196965
Bangladesh; Network-Episode Model; Social networks; Skilled birth attendants; Health seeking behavior; Utilization; childbirth; Maternal mortality
5.  Association of antenatal care with facility delivery and perinatal survival – a population-based study in Bangladesh 
Antenatal Care (ANC) during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples.
This study was conducted within the Health and Demographic Surveillance System (HDSS) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA) where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH) program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 – 2006) and after (2008–2009) implementation of the MNCH program.
Antenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR) 1.91; 95% confidence intervals (CI): 1.50, 2.42) among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78) to non-significance (OR 0.81; 95% CI: 0.65, 1.01), when comparing cohorts before and after the MNCH program initiation (Sobel test of mediation P < 0.001).
ANC visits are associated with increased uptake of facility-based delivery and improved perinatal survival in the icddr,b SA. Further testing of the icddr,b approach to simultaneously improving quality of ANC and facility delivery care is needed in the existing health system in Bangladesh and in other low-income countries to maximize health benefits to mothers and newborns.
PMCID: PMC3495045  PMID: 23066832
6.  60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths? 
For the world’s 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth.
We present a systematic review of evidence for the effect of community-based cadres–community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)–in improving perinatal and intrapartum-related outcomes.
The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%–47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.
Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.
PMCID: PMC3428830  PMID: 19815200
Birth asphyxia; Community health worker; Community midwife; Hypoxia; Intrapartum; Neonatal mortality; Stillbirth; Traditional birth attendant
7.  Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh 
BMC Public Health  2011;11:914.
Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality.
This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas.
Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018).
The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.
PMCID: PMC3257323  PMID: 22151276
8.  Type, Content, and Source of Social Support Perceived by Women during Pregnancy: Evidence from Matlab, Bangladesh 
Specific and contextualized data on social support during distinct health events are needed to improve social support interventions. This study identified the type, content, and source of social support perceived by women during pregnancy. In-depth interviews with 25 women, aged 18-49 years, living in Matlab, Bangladesh, were conducted. The findings demonstrated that women perceived, the receipt of eight distinct types of support. The four most frequently-mentioned types included: practical help with routine activities, information/advice, emotional support and assurance, as well as the provision of resources and material goods. Sources varied by type of support and most frequently included-—mothers, mothers-in-law, sisters-in-law, and husbands. Examples depicting the content of each type of support revealed culturally-specific issues that can inform community-based social support interventions.
PMCID: PMC3126989  PMID: 21608426
Cross-sectional studies; Pregnancy; Qualitative studies; Reproductive health; Retrospective studies; Social support; Stress; Bangladesh
9.  A Comparison of Excessive Postpartum Blood Loss Estimates Among Three Subgroups of Women Attending Births in Matlab, Bangladesh 
Postpartum hemorrhage (PPH) is the leading cause of maternal death and disability worldwide. Recognition depends on subjective visual quantification. This study sought to assess and compare the thresholds for excessive postpartum blood loss reported by skilled birth attendants (SBA), traditional birth attendants (TBA), and laywomen in Matlab, Bangladesh.
Data from six questions asking about excessive blood loss in the postpartum period were analyzed using analysis of variance (ANOVA), Hochberg test, Kruskal-Wallis and standard descriptive statistics.
Thresholds for excessive blood loss estimated by laywomen and TBAs exceed biomedical standards for PPH. Skilled birth attendant reports are consistent with the definition of severe acute PPH.
Further research on locally validated blood collection devices, in birth kits, for diagnostic aid or referral indication is needed. Areas where coverage and uptake of skilled birth attendance are low should be targeted due to the number of home births attended by TBAs and laywomen in such settings.
A comparison of excessive postpartum blood loss estimates among skilled birth attendants, traditional birth attendants and laywomen in Matlab, Bangladesh.
PMCID: PMC2897753  PMID: 20625452
Bangladesh; Blood Loss; Maternal Mortality; Postpartum Hemorrhage; Childbirth
10.  Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention 
Early recognition can reduce maternal disability and deaths due to postpartum haemorrhage. This study identified cultural theories of postpartum bleeding that may lead to inappropriate recognition and delayed care-seeking. Qualitative and quantitative data obtained through structured interviews with 149 participants living in Matlab, Bangladesh, including women aged 18-49 years, women aged 50+ years, traditional birth attendants (TBAs), and skilled birth attendants (SBAs), were subjected to cultural domain. General consensus existed among the TBAs and lay women regarding signs, causes, and treatments of postpartum bleeding (eigenvalue ratio 5.9, mean competence 0.59, and standard deviation 0.15). Excessive bleeding appeared to be distinguished by flow characteristics, not colour or quantity. Yet, the TBAs and lay women differed significantly from the SBAs in beliefs about normalcy of blood loss, causal role of the retained placenta and malevolent spirits, and care practices critical to survival. Cultural domain analysis captures variation in theories with specificity and representativeness necessary to inform community health intervention.
PMCID: PMC2761798  PMID: 19507753
Anthropometry, Cultural; Maternal mortality; Morbidity; Postpartum haemorrhage; Bangladesh
11.  Transition to Skilled Birth Attendance: Is There a Future Role for Trained Traditional Birth Attendants? 
A brief history of training of traditional birth attendants (TBAs), summary of evidence for effectiveness of TBA training, and consideration of the future role of trained TBAs in an environment that emphasizes transition to skilled birth attendance are provided. Evidence of the effectiveness of TBA training, based on 60 studies and standard meta-analytic procedures, includes moderate-to-large improvements in behaviours of TBAs relating to selected intrapartum and postnatal care practices, small significant increases in women's use of antenatal care and emergency obstetric care, and small significant decreases in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia. Such findings are consistent with the historical focus of TBA training on extending the reach of primary healthcare and a few programmes that have included home-based management of complications of births and the newborns, such as birth asphyxia and pneumonia. Evidence suggests that, in settings characterized by high mortality and weak health systems, trained TBAs can contribute to the Millennium Development Goal 4—a two-thirds reduction in the rate of mortality of children aged less than 14 years by 2015—through participation in key evidence-based interventions.
PMCID: PMC3001151  PMID: 17591344
Traditional birth attendants; Skilled birth attendants; Meta-analysis; Maternal mortality; Perinatal mortality; Training

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