I have read with great interest your interchange over recommendations for lowering preventable maternal mortality. While Jon’s address from years back, outlining a multi-leveled approach ranging from home-based care by TBA through heath posts and rural clinics to hospitals, makes a lot of sense, it has nevertheless been hard to put into practice. Cultural and economic barriers (often including illicit under-the-table charges by professionals) often make the referrals to “higher” levels of care prohibitive for the families involved.

I therefore agree very much with Nick that training local people — including selected healthworkers and TBAs — to do some of the life-saving procedures usually reserved “for doctors only” would have potentially for significantly lowering child mortality.

Not everything need be or can be done at once. But some simple measures could make a substantial difference. For example “severe” postpartum bleeding is a major cause of maternal mortality in poor communities where up to 70% of women are visibly anemic, many of them severely so. Provision of oxytocics to TBAs, with adequate precautionary training to use only after the baby is delivered, could probably save a large number of women’s lives. (The training of lay providers needs to be better than that of doctors on this issue, where the premature overuse — often to speed up normal delivery — is a common malpractice leading to everything from vaginal tears to ruptured uteri to asphyxiation of the baby. Nevertheless, adequate instruction of TBAs on the proper use and warnings with oxytocics shouldn’t take more than half an hour.)   

The major obstacle to systematically enabling lay practitioners to perform tasks exclusively reserved for titled “professionals” is the resistance from the medical establishment. Years ago I argued with the MOH directors in Colombia about the question of teaching health workers and TBAs to use oxytocin to control postpartum hemorrhage, and they were afraid to even consider it. This was not because they didn’t believe it could save many women’s lives, but because they feared the criticism they would get from the medical establishment if a mother died after a TBA used oxytocin — as was occasional likely to happen even though far more women’s lives would be saved. In short, the decision-makers in the MOH were more concerned about protecting themselves than about protecting the lives of poor rural women.  

Nick is absolutely right that — given the many barriers to taking poor rural women to where they can get the professional care they need — a great many women’s lives could be saved by training local lay service providers to “specialize” in such life-saving techniques as C-sections and transfusions, use of blood thickeners, and the like. As Nick points out, there are many examples of village health workers and birth attendants learning and successfully practicing equally demanding skills. (For example see our Newsletter #76 on how a village boy in Mexico learned eye-surgery from a visiting ophthalmologist, and eventually became a eye-surgeon and professor of ophthalmology: http://web.healthwrights.org/newsletters/nl75-village-boy-to-eye-surgeon/)

In this context, the WHO has been a two edged sword. At least in some countries, it has counseled health ministries not to work with TBAs. When I visited East Timor in 2011 I found this to be the case. In our Newsletter # 69 I wrote:

“The Health Ministry’s failure to officially recognize Traditional Birth Attendants (TBAs) is another big obstacle to mother and child health in Timor-Leste. A graph published by the Health Ministry shows that about 20% of babies are delivered by health professionals in hospitals; nearly 30% are delivered by trained midwives (educated women officially trained in childbirth); and half of all babies are delivered by “other.” “Other” refers mostly to Traditional Birth Attendants, who do deliveries in homes and whom most mothers (including city dwellers) prefer. However, the graph doesn’t refer to them as TBAs because, following a directive of the World Health Organization, they are no longer recognized by the Timorese Health Ministry. Given that TBAs attend the vast majority of births in remote areas where the titled midwives almost never go, the WHO directive makes little sense. If the Ministry of Health provided basic support, back-up, and sterile birth kits to the TBAs, it could have a significant impact on maternal and child health. And the impact could be even greater if TBAs were encouraged to cooperate with Family Health Promoters in pre- and post natal care, including nutrition and immunization.” (http://healthwrights.org/index.php?option=com_content&view=article&layout=edit&id=228)

A Timorese obstetrician worked with upgrading the skills of TBAs in a remote area of the island, resulting in an impressive decline in maternal and neonatal mortality. The Japanese govt. development agency offered the Timorese MOH a million dollar grant to expand the program throughout remote highland areas. However the WHO disapproved, and the project never resulted.

Breaking the monopoly of medical establishment is still a major challenge in achieving adequate health care for the disadvantaged.    

— David Werner