Traditional Birth Attendants Can Be Trained To Manage Hemorrhage
Training traditional birth attendants in the utilization of two "safe motherhood" tools—misoprostol and an absorbent delivery mat designed to measure postpartum blood loss—is feasible and may improve their ability to manage postpartum hemorrhage.1 In an intervention study conducted in Bangladesh in 2009–2011, the vast majority of traditional birth attendants retained correct knowledge of the function, dosing and timing of administration of misoprostol and of the use of the delivery mat 18 months after training, and women whose deliveries were assisted by these providers were more likely than those using other or no providers to have used misoprostol and a delivery mat. Notably, although trained traditional birth attendants assisted with 43% of the births in the region during the study period, they took part in only 12 of the 113 deliveries (11%) that resulted in maternal death; none of these 12 deaths were attributable to postpartum hemorrhage.
Increasing women’s access to skilled birth attendants is critical to achieving the goal of reducing maternal mortality worldwide. In low-resource settings such as Bangladesh, where fewer than 20% of births were attended by a skilled provider in the five years before 2007, teaching traditional birth attendants how to manage postpartum hemorrhage—the leading cause of maternal mortality—may help to achieve the goal. To assess the feasibility and acceptability of training traditional birth attendants in the use of the two safe motherhood technologies, researchers conducted an evaluation study in six rural districts of Bangladesh’s Rangpur Division. In 2009, 696 traditional birth attendants completed a two-day, hands-on training session on the use of misoprostol to prevent and treat postpartum hemorrhage (including dosing, timing of administration and management of side effects) and the use of the delivery mat (which is designed to absorb 500 ml of blood, the threshold for defining postpartum hemorrhage). The attendents’ background characteristics and preintervention knowledge were assessed at baseline; changes in knowledge were identified through follow-up assessments immediately after training and six and 18 months later. The birth attendants’ delivery practices were evaluated through postpartum interviews with 3,016 randomly selected women who had given birth during the study period; all women in the region had had access to birthing kits containing misoprostol and a delivery mat, although women, their families and providers other than those who took part in the intervention had not received training on their use. The investigators used two-tailed z tests to assess changes in birth attendants’ knowledge and to compare misoprostol and mat use between the trained birth attendants and the providers in the community (including birth attendants, nurses and doctors) who had not received the training.
On average, the traditional birth attendants were 47 years old, had had less than two years of formal schooling, had been attending births for almost 12 years and assisted with six deliveries per month. At baseline, only 12% of the birth attendants knew a method to prevent excessive bleeding during delivery. This figure increased to 94% right after training and remained high at the six-month (99%) and 18-month (97%) follow-ups. Measures of misoprostol and mat knowledge showed a similar pattern: Respondents had little baseline knowledge of either intervention, but rapidly acquired and retained the relevant information. For example, the proportion of participants who identified misoprostol as a way to prevent excessive bleeding increased from 3% before the intervention to 85% immediately after training and to 97% at 18 months; the proportion who knew that three tablets of misoprostol should be given to prevent hemorrhage rose from 1% before training to 100% immediately afterward and remained nearly universal (98%) at 18 months; the proportion who knew that misoprostol helps with placental delivery rose from 1% at baseline to 86% immediately after training and to 100% at the 18-month follow-up; and the proportion who knew that the degree of blood loss was best estimated by observing the delivery mat’s absorption increased from fewer than 1% before training to 93% right after training and to 97% at 18 months.
Forty-three percent of mothers interviewed after delivery reported having been assisted by a traditional birth attendant trained to use misoprostol and the delivery mat. Use of the delivery mat was greater among trained traditional birth attendants (80%) than among untrained traditional birth attendants (68%), nurses (33%), doctors (8%) or women who had delivered alone or with the aid of relatives (63–66%); results were similar for misoprostol use. There were 113 maternal deaths in the region during the study period (out of 77,337 home deliveries); of these, 36 were the result of postpartum hemorrhage. However, only 12 (11%) of the deliveries that resulted in death had been assisted by traditional birth attendants who had received the training, and none of these deaths were caused by postpartum hemorrhage.
The researchers cite a number of study limitations: Patient and birth attendant records could not be matched; data on delivery practices were from women’s reports, rather than from direct observation; the use of one intervention may have influenced the use of the other; and women and providers were not randomized. Despite these limitations, the researchers conclude that both safe motherhood interventions "were acceptable to traditional birth attendants and clients, and that traditional birth attendants used the interventions appropriately and effectively in the field." They suggest that their program be used "as a model to be adapted to other regions of the world where, unfortunately, high coverage of skilled birth attendants remains a distant goal."—L. Melhado
1. Prata N et al., Training traditional birth attendants to use misoprostol and an absorbent delivery mat in home births, Social Science & Medicine, 2012, 75(11):2021–2027.