Maternal and Child Health Training of Traditional Birth Attendants and Pregnancy Outcomes: A Systematic Review and Meta-analysis.

INTRODUCTION: In remote communities, maternal and child health is often compromised due to limited access to healthcare. Simultaneously, these communities historically rely greatly on traditional birth attendants (TBAs). However, optimal integration of these traditional methods with modern healthcare practices remains a topic of debate. We assessed the effect of maternal and child health training of traditional birth attendants on adverse pregnancy outcomes. METHODS: We conducted a systematic review and meta-analysis to answer the above research question. We independently screened studies using databases like PubMed, Scopus, and CENTRAL, extracted data, and assessed the study quality. Due to fewer original studies in this field, we considered both pre-post and between-group differences to assess the effect of differences. These were synthesised separately, assessed against a p-value function, and subjected to sensitivity analyses. RESULTS: We included six interventional studies. Training TBAs reduced the risk of perinatal mortality [0.69, 0.61-0.78] and 7-day neonatal mortality [0.65, 0.53-0.80] but not stillbirth [0.70, 0.39-1.26]. In randomized controlled trials, there is a lower risk of perinatal mortality [0.73, 0.67-0.79] and neonatal mortality [0.70, 0.62-0.80] but not stillbirth [0.81, 0.56-1.18] with trained traditional birth attendants. There are methodological concerns with most existing studies, including domains like allocation concealment. DISCUSSION: There is some evidence of the benefit of training TBAs, though of a low to very low certainty. Due to fewer studies, inconsistent estimates for different critical outcomes, and concerns with the existing studies, further well-designed studies can give more insights. They can also help optimize the contents of TBA training interventions. PROTOCOL: CRD42023412935 (PROSPERO).

Factors Associated with Use of Traditional Birth Attendants for Child Delivery: A Cross-Sectional Study.

Background: Even though the use of skilled birth attendants at birth reduces the risk of maternal mortality and associated complications, some pregnant women prefer to use either traditional birth attendants (TBAs) or deliver at home. Although the use of assisted delivery was reduced between 2014 and 2016 in North Tongu, the rate of TBA use among pregnant women in the district was increasing. There is, therefore, the need to establish the reason for this increase in TBA use. We conducted a study to assess factors that influence the use of TBAs in the North Tongu district. Methods: A retrospective cross-sectional facility-based survey was conducted among 449 women who delivered within the past 12 months and were accessing postnatal care services in the North Tongu district. A simple random sampling method was used to select women who attend child welfare clinics. Bivariate and multivariate analyses were conducted to determine the factors that were significantly associated with use of TBAs. All statistical analyses were done at a 95% confidence level with statistical significance at p ≤ 0.05. Results: The mean age of the respondents was 27.0 years ± 6.2 SD. The prevalence of use of TBA during childbirth among women was 26.5%. Factors that significantly influenced use of TBAs during childbirth were age, religion, educational status, and parity. Other significant factors included several antenatal care visits and the attitude of health workers toward pregnant women. Conclusion: Use of TBA services at birth in the study district remains relatively high. Women who use antenatal and postnatal care services should be educated on the importance of skilled delivery. There is also a need to equip TBAs and reposition them as link agents to facilitate referrals of pregnant women to health facilities where there is a need for additional birth attendants.

Serological profile of hepatitis B virus infection among traditional birth attendants and the attending pregnant women in Ibadan, Nigeria.

Although a sizable number of pregnant women patronize Traditional Birth Attendants (TBAs) for deliveries in Nigeria, efforts to prevent or reduce the risk of HBV transmission are not targeted at the TBAs and the pregnant women patronizing them. This may be linked to the dearth of information on the serological profiles of HBV among this cohort. We, therefore, show the serological profiles of HBV among the cohort. One hundred and seventy pregnant women and 91 TBAs participated in this study between May and July 2019. Serological markers of HBV infection were assayed using ELISA. A prevalence of, 8.0% (95% CI: 5.0% - 11.5%) for HBsAg, 0.8% (95% CI: 0.0% - 1.9%) for HBeAg, 2.7% (95% CI: 0.8% - 5.0%) for HBcIgM, 26.1% (95% CI: 20.7% - 31.4%) for anti-HBs, 21.5% (95% CI: 16.5% - 25.4%) for anti-HBe and 67.0% (95% CI: 60.9% - 72.8%) for anti-HBc was found indicating a high percentage of carriers. Although 32 (12.3%) of the entire participants claimed to be fully vaccinated, serological evidence was only detected in 4 (12.5%). The high percentage of carriers and low evidence of vaccination necessitate intensified efforts to ensure that adequate interventions are made available and accessible to the TBAs and the pregnant women patronizing them (including newborn babies).

Infection Prevention and Control: Baseline Knowledge and Practices of TBAs in Rural Kano, Northwestern Nigeria.

BACKGROUND: Maternal infections remain a significant contributor to maternal mortality worldwide. Majority of births in northern Nigeria occur at home and are attended by Traditional Birth Attendants (TBAs). Little has been documented about their knowledge and practice on infection prevention and control practices in Kano, northern Nigeria. OBJECTIVES: This study evaluated the level as well as factors associated with TBAs' infection prevention and control knowledge and practices. METHODS: The study is the baseline phase of a quasi-experimental study, conducted in a rural LGA in Kano State, Nigeria. Using an adapted tool, 163 eligible TBAs were surveyed. Knowledge and practice of IPC were scored, aggregated, and dichotomized into good or poor. Binary logistic regression analysis was used to predict knowledge and practice of IPC. RESULTS: Majority (79.1%) of the TBAs exhibited poor IPC knowledge but many (78.5%) reported good practice. Good knowledge of IPC was predicted by the TBAs' age: a six-fold increased likelihood (AOR=6.25, 95% CI: 1.02- 38.53) and almost five-fold increased likelihood (AOR=4.75, 95% CI: 1.39- 16.24) for those in their second and fourth decades of life. TBAs who reported poor practice of IPC were 83% less likely (AOR=0.17, 95% CI: 0.03- 0.92) to have good knowledge of IPC. TBAs' practice was only linked to previous training (AOR=0.17, 95% CI: 0.04- 0.76). CONCLUSION: TBAs knowledge of IPC was low although reported practice was good. The need for tailored training interventions to enhance knowledge and skills for safe delivery care is paramount to improve maternal and neonatal outcomes.

CONTEXTE: Les infections maternelles restent une contribution significative à la mortalité maternelle dans le monde. La majorité des accouchements dans le nord du Nigeria ont lieu à domicile et sont assistés par des TBA. Peu de choses ont été documentées sur leurs connaissances et leurs pratiques en matière de prévention et de contrôle des infections à Kano, dans le nord du Nigeria. OBJECTIFS: Cette étude a évalué le niveau de connaissances et de pratiques des TBA en matière de prévention et de contrôle des infections, ainsi que les facteurs associés. MÉTHODES: L'étude est la phase de base d'une étude quasiexpérimentale, menée dans une LGA rurale de l'État de Kano, au Nigeria. En utilisant un outil adapté, 163 TBA éligibles ont été interrogés. Les connaissances et les pratiques en matière de PCI ont été évaluées, agrégées et dichotomisées en bonnes ou mauvaises. Une analyse de régression logistique binaire a été utilisée pour prédire les connaissances et les pratiques en matière de PCI. RÉSULTATS: La majorité (79,1 %) des TBA présentaient des connaissances médiocres en PCI, mais beaucoup (78,5 %) ont déclaré avoir de bonnes pratiques. De bonnes connaissances en PCI étaient prédites par l'âge des TBA : une probabilité multipliée par six (AOR=6,25, IC à 95 % : 1,02-38,53) et presque multipliée par cinq (AOR=4,75, IC à 95 % : 1,39-16,24) pour ceux dans leur deuxième et quatrième décennies de vie. Les TBA qui ont déclaré une mauvaise pratique de la PCI étaient 83 % moins susceptibles (AOR=0,17, IC à 95 % : 0,03-0,92) d'avoir de bonnes connaissances en PCI. La pratique des TBA était uniquement liée à une formation antérieure (AOR=0,17, IC à 95 % : 0,04­0,76). CONCLUSION: Les connaissances des TBA en matière de PCI étaient faibles bien que les pratiques déclarées étaient bonnes. La nécessité d'interventions de formation sur mesure pour améliorer les connaissances et les compétences en matière de soins de l'accouchement sécurisés est primordiale pour améliorer les résultats maternels et néonatals. MOTS-CLÉS: Accoucheuses Traditionnelles, Mortalité Maternelle, Infection Maternelle, Nigeria.

" He's not beating me"-Socio-cultural construction of intimate partner violence and traditional birth attendants: implications for maternal & child health in rural communities in Hohoe, Ghana.

Introduction: Most research on Intimate Partner Violence (IPV) focuses on the physical, sexual and psychological abuse, with less focus on the financial abuse. This study explores nursing mothers' experiences and perceptions of financial and material support from their significant others and traditional birth attendants' (TBA) observations of support to nursing mothers in their communities. Methods: Using purposive sampling, focus groups and interviews were conducted primarily in Ewe language among nursing mothers and TBAs in rural communities in Hohoe, Volta region, Ghana. All discussions were audio-recorded and transcribed for analysis. Thematic analysis guided by the social constructivist framework was used in data analysis. Results: Twenty-seven women participated in the study, ranging in ages from 19 to 82 (20 nursing mothers; 7 TBAs). Most participants were married (19) and about 65% reported working outside the home (10 nursing mothers; 7 TBAs). Two themes emerged from the data analysis: Lack of support from partners for housekeeping chores and finances; and TBAs as mediators. Nursing mothers who reported lack of financial support did not perceive it as abuse, rather as hinderance to their efforts to care for their children. TBAs act as mediators interceding on behalf of nursing mothers with their husbands and fathers of their children, while also seeking resources to support them. Discussion: Understanding the perceptions and socio-cultural meanings women attached to IPV experience is essential for effective intervention to reduce IPV. In addition, TBAs can be a resource in intervening to alleviate IPV in their communities, thereby improving maternal and child health.

Impact of training and case manager support for traditional birth attendants in the linkage of care among HIV-positive pregnant women in Southwest Nigeria: a 3-arm cluster randomized control trial.

BACKGROUND: Mother-to-child transmission (MTCT) accounts for 90% of all new paediatric HIV infections in Nigeria and for approximately 30% of the global burden. This study aimed to determine the effectiveness of a training model that incorporated case managers working closely with traditional birth attendants (TBAs) to ensure linkage to care for HIV-positive pregnant women. METHODS: This study was a 3-arm parallel design cluster randomized controlled trial in Ifo and Ado-Odo Ota, Ogun State, Nigeria. The study employed a random sampling technique to allocate three distinct TBA associations as clusters. Cluster 1 received training exclusively; Cluster 2 underwent training in addition to the utilization of case managers, and Cluster 3 served as a control group. In total, 240 TBAs were enrolled in the study, with 80 participants in each of the intervention and control groups. and were followed up for a duration of 6 months. We employed a one-way analysis of variance (ANOVA) statistical test to evaluate the differences between baseline and endline HIV knowledge scores and PMTCT practices. Additionally, bivariate analysis using the chi-square test was used to investigate linkage to care. Furthermore, logistic regression analysis was utilized to identify TBA characteristics associated with various PMTCT interventions, including the receipt of HIV test results and repeat testing at term for HIV-negative pregnant women. The data analysis was performed using Stata version 16.1.877, and we considered results statistically significant when p values were less than 0.05. RESULTS: At the end of this study, there were improvements in the TBAs' HIV and PMTCT-related knowledge within the intervention groups, however, it did not reach statistical significance (p > 0.05). The referral of pregnant clients for HIV testing was highest (93.5%) within cluster 2 TBAs, who received both PMTCT training and case manager support (p ≤ 0.001). The likelihood of HIV-negative pregnant women at term repeating an HIV test was approximately 4.1 times higher when referred by TBAs in cluster 1 (AOR = 4.14; 95% CI [2.82-5.99]) compared to those in the control group and 1.9 times in cluster 2 (AOR = 1.93; 95% CI [1.3-2.89]) compared to the control group. Additionally, older TBAs (OR = 1.62; 95% CI [1.26-2.1]) and TBAs with more years of experience in their practice (OR = 1.45; 95% CI [1.09-1.93]) were more likely to encourage retesting among HIV-negative women at term. CONCLUSIONS: The combination of case managers and PMTCT training was more effective than training alone for TBAs in facilitating the linkage to care of HIV-positive pregnant women, although this effect did not reach statistical significance. Larger-scale studies to further investigate the benefits of case manager support in facilitating the linkage to care for PMTCT of HIV are recommended. TRIAL REGISTRATION: The study was retrospectively registered in the Pan African Clinical Trial Registry, and it was assigned the unique identification number PACTR202206622552114.

Can Clean Delivery Kits Prevent Infections? Lessons from Traditional Birth Attendants in Nigeria.

Background: In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria. Methods: The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests. Results: CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively. Conclusion: CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.

Mothers' experiences and perceptions about care provided during home deliveries in Alwa sub county, Kaberamaido district, Uganda- a qualitative study.

Introduction: In Uganda 27% of deliveries take place outside a health facility. The existing gaps in quality of maternal and newborn health care must be addressed for Uganda to attain its health targets and consequently its economic targets. Some of the gaps include but are not limited to; ill-equipped healthcare facilities in rural settings, inadequate client/customer care skills by healthcare providers, and health worker absenteeism especially in the night hours. In Kaberamaido District, only 38.3% of the deliveries in Alwa sub county took place at a health facility. Despite the district local government and stakeholder efforts to promote health facility-based deliveries, sadly, a very low proportion of women use the health facilities for delivery. We sought to explore mothers' experiences and perceptions about care provided during home deliveries in Alwa sub county, Kaberamaido district. Methods: The study adopted a cross-sectional descriptive qualitative design. We purposively included 115 mothers who delivered outside the health facility and consented to participate and those who lost their babies within the last 24 months preceding the study. Other participants included in the study were village health team (VHT), traditional birth attendants (TBA) and older women. The main instruments used to collect data were focus group discussion (FGD) and in-depth interview (IDI) guides. All voice recordings from FGDs and interviews were transcribed and translated from the local language (Kumam) into English. Thematic content analysis was used to synthesize data by applying codes to segments of the transcripts upon which major domains were derived. Key findings were synthesized and quotes were carefully selected based on their relevance and representativeness to the analysis and study objective. Results: Our findings indicated general satisfaction with the care provided during and after home delivery by TBAs as expressed by mothers. Motivation to seek services from TBAs was attributable to their vast experience spanning decades with history of safe delivery. Few mothers expressed discontent with TBA services citing abuse and rudeness. Discussion: Our study underscored the common view that TBAs effectively managed home deliveries, providing satisfactory care to mothers. However, concerns emerged on TBAs' capacity to manage complications, emphasizing a need for their reintegration into formal healthcare systems, alongside further training, and standardization in maternal care practices.

"Don't use herbs in labor!": Plants, pharmaceuticals, and the unmaking of traditional birth attendants in Ghana, 1970-2000.

This article considers efforts in the West African country of Ghana to improve maternal care through a network of trained "Traditional Birth Attendants," or TBAs in the late twentieth century. It reconsiders the rise and fall of TBAs through the lens of increasing global access to essential medicines like oxytocin and misoprostol which reduced confidence in herbal medications for pregnancy complications. Interviews with policy makers and birth attendants reflecting on their involvement in TBA programs from the 1970s as well as analysis of archival documents and training manuals shows how pharmaceuticals rose in prominence at the same time birth attendants maintained medicinal plant knowledge. Over time, Ghanaian policymakers encouraged TBAs to avoid using herbs while caring for women during pregnancy. By the early 2000s, government went so far as to ban TBAs, and urged everyone to deliver with a skilled birth attendant (SBA) such as a nurse midwife or obstetrician more conversant in biomedical interventions including pharmaceuticals. This retrospective account of TBAs across several decades suggests that once Ghanaian officials had strengthened access to standardized pharmaceuticals, they lost confidence in traditional birth attendants and the herbal remedies they cultivated. Access to pharmaceuticals shaped the difference between skilled and- "unskilled" or "traditional"-birth attendants.

Exploring experiences with sensitivity to cultural practices among birth attendants in Kenya: A phenomenological study.

BACKGROUND:  Sensitivity to women's cultural needs and expectations by care providers is essential. Skilled birth services for women are as essential as traditional birth services. Therefore, collaborative skilled and cultural care optimises childbearing experiences. AIM:  This study explored the experiences of birth attendants (BAs) with sensitivity to cultural practices (CPs) during pregnancy and birth among the Keiyo community in Kenya. SETTING:  The study was conducted in the purposively selected public health centres and dispensaries offering maternity services and the villages in Keiyo South Sub County in Kenya. METHODS:  A qualitative interpretive phenomenological study of BAs was conducted. Iterative and inductive interviews using a semistructured guide were conducted with 11 skilled BAs (SBAs) and eight traditional BAs (TBAs). Audio-recorded interviews were transcribed and analysed using ATLAS.ti software version 8.4.4 (1135), following Van Manen's five thematic analysis steps. RESULTS:  Three themes emerged: birth attendants' cultural encounters, response to cultural encounters and collaboration. Birth attendants' responses to different cultural encounters revealed their awareness of CPs. The response was experienced as a sensitivity to the need for a triad (woman, TBAs and SBAs) collaborative care, enabling collaborative, woman-centred and culturally safe care. CONCLUSION:  Birth attendants are exposed to cultural encounters, and their responses determine their awareness of enabling sensitive care for optimal childbearing experiences. The study illuminated the need for further collaborative engagements between the BAs and the community to facilitate positive experiences by women through woman-centred, culturally safe care.

Women's use of non-conventional herbal uterotonic in pregnancy and labour: evidence from birth attendants.

BACKGROUND: Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs' services, including herbal uterotonics. This has attempted to defeat stakeholders' campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana. METHODS: This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers' (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants. RESULTS: Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth. CONCLUSION: The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of 'mansugo' and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.

Perceptions and experiences of maternity care workers during COVID-19 pandemic in Lagos State, Nigeria; a qualitative study.

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic challenges provision and access to essential maternity care in low-resilience health systems. The aim of this study was to explore maternity healthcare workers' experiences of, and perceptions about providing maternity care during the COVID-19 outbreak in Lagos State, Nigeria. METHODS: This qualitative study conducted individual, remote, semi-structured interviews with midwives and traditional birth attendants (TBAs). Eligible participants spoke English, and provided maternity care during COVID-19 in Lagos, Nigeria. Participants were recruited via purposive and snowball sampling, from primary health facilities in seven Local Government Areas of Lagos State. Interview transcripts were analysed thematically following the framework method. RESULTS: Sixteen midwives (n = 11) and TBAs (n = 5) were interviewed from March to April 2021. Two overarching themes were identified from the data. 'Maternity care workers' willingness and ability to work during the COVID-19 pandemic' outlined negative influences (fear and uncertainty, risk of infection, burnout, transport difficulties), and positive influences (professional duty, faith, family and employer support). Suggestions to improve ability to work included adequate protective equipment, training, financial support, and workplace flexibility. 'Perceived impact of COVID-19 on women's access and uptake of maternity care' highlighted reduced access and uptake of antenatal and immunisation services by women. Challenges included overstretched health services, movement and cost barriers, and community fear of health facilities. Participants reported delayed healthcare seeking and unattended home births. Midwives and TBAs identified a need for community outreach to raise awareness for women to safely access maternity services. Participants highlighted the responsibility of the government to improve staff welfare, and to implement public health campaigns. CONCLUSIONS: Despite disruption to maternity care access and delivery due to COVID-19, midwives and TBAs in Lagos remained committed to their role in caring for women and babies. Nevertheless, participants highlighted issues of understaffing and mistrust in Lagos' underfunded maternity care system. Our findings suggest that future resilience during outbreaks depends on equipping maternity care workers with adequate working conditions and training, to rebuild public trust and improve access to maternity care.

Care-Seeking Behavior for Newborns in Rural Zambia.

OBJECTIVES: Mothers in resource-limited areas face barriers in initiating care for ill newborns, leading to delays that may contribute to newborn mortality. This qualitative study conducted in rural Lufwanyama District in Zambia aimed to (1) explore mothers' healthcare-seeking related to newborn illness and (2) identify reasons for delaying care-seeking for ill newborns. METHODS: We examined the perspectives of 60 mothers and 77 grandmothers of children under three years of age in 14 focus group discussions as part of the Lufwanyama Integrated Neonatal and Child Health Program study. We conducted a thematic analysis of verbatim transcripts using dedicated software. RESULTS: Mothers and grandmothers were generally able to identify newborn danger signs and established a hierarchy of care-seeking based on the perceived severity of danger signs. However, inability to afford transportation, inaccessible health care facilities, high costs of medication prescribed at the health clinics, lack of respectful treatment and fear of newborns dying in the hospital prevented participants from seeking timely care. As traditional birth attendants (TBAs) and community health care workers (CHWs) have limited roles in newborns care beyond the immediate delivery setting, mothers often resorted to traditional healers for newborn care. CONCLUSIONS: Based on cultural beliefs and influenced by traditions, mothers in Lufwanyama have developed hierarchical strategies to seek care for ill newborns. Barriers to treatment at health facilities often resulted in traditional care. Training both TBAs and CHWs in providing community-based newborn care and appropriate referrals could improve care-seeking and prevent newborn mortality in rural Zambia.

The Addition of Traditional Birth Attendant Care to a Home-Based Skilled Nursing Program in Rural Guatemala: A Secondary Analysis from a Quality Improvement Database.

INTRODUCTION: The use of traditional birth attendants (TBAs) in low- and middle-income countries remains controversial. The aim of this secondary analysis was to observe factors associated with visiting a TBA in addition to a skilled nurse for antepartum care and how this additional care was associated with birth characteristics and outcomes. METHODS: The study included a convenience sample of women living in Southwestern Guatemala enrolled in a community nursing program between October 1, 2018, and December 3, 2019. This analysis describes the sociodemographic characteristics, antepartum care, birth outcomes, and postpartum behaviors of women who received antepartum care with skilled nurses only compared with women who received antepartum care with skilled nurses and a TBA. RESULTS: Of the 316 enrollees, 259 had given birth and completed their postpartum visit at the time of analysis. Three women were excluded because of missing data. The majority of women in the study sample reported visiting a TBA over the course of their pregnancies (80.9%). Women who saw a TBA in addition to the nurse were similar to the comparator sample except that they were almost 3 times more likely to have 8 or more prenatal contacts with the nurse. In separate multivariable logistic regression models adjusted for number of prenatal visits, women who saw a TBA in addition to nurses had a reduced likelihood of cesarean birth, increased likelihood of birth with a TBA, and increased likelihood of breastfeeding within one hour of birth compared with women who only received antenatal care from nurses. Patient-reported adverse outcomes were not included in the analysis because of low prevalence and concern about data quality and missing data. DISCUSSION: Among a convenience sample of women in the Trifinio community in rural Guatemala, a large proportion of women continued to seek the care of a TBA in pregnancy while using a skilled nursing program for antenatal care. Intentionally integrating the TBA into the maternity care workforce may be beneficial for improving pregnancy care quality measures.

Why women utilize traditional rather than skilled birth attendants for maternity care in rural Nigeria: Implications for policies and programs.

OBJECTIVE: Data from the Nigeria Demographic and Health Survey indicate that many pregnant women in rural Nigeria use traditional birth attendants (TBAs) rather than skilled birth attendants (SBAs) for maternal health care. This is one factor that accounts for the persistently high rate of maternal mortality in Nigeria. The objective of this study was to identify the pervading reasons that women use TBAs for pregnancy care in rural Nigeria and to make recommendations for policy and programmatic reform. DESIGN: Qualitative research design consisting of focus group discussions, key informant interviews, and community conversations, followed by inductive thematic analysis. SETTING: Twenty rural communities (villages) in Etsako East, and Esan South East Local Government Areas of Edo State, South-South, Nigeria. PARTICIPANTS: Twenty focus group discussions with men and women in a marital union; 15 key informant interviews with policymakers, senior health providers, and women leaders; and 10 community conversations with key community leaders. FINDINGS: Some reasons proffered for using TBAs included perceptions of higher efficacy of traditional medicines; age-long cultural practices; ease of access to TBAs as compared to SBAs; higher costs of services in health facilities; and friendly attitude of TBAs. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The continued use of TBA is a major challenge in efforts to achieve the Sustainable Development Goal 3 in Nigeria. We conclude that efforts to address the factors identified by community stakeholders as inhibiting the use of SBAs will promote skilled birth attendance and reduce maternal mortality in rural Nigeria.

Exploring experiences with sensitivity to cultural practices among birth attendants in Kenya: A phenomenological study

Background: Sensitivity to women's cultural needs and expectations by care providers is essential. Skilled birth services for women are as essential as traditional birth services. Therefore, collaborative skilled and cultural care optimises childbearing experiences. Aim: This study explored the experiences of birth attendants (BAs) with sensitivity to cultural practices (CPs) during pregnancy and birth among the Keiyo community in Kenya. Setting: The study was conducted in the purposively selected public health centres and dispensaries offering maternity services and the villages in Keiyo South Sub County in Kenya. Methods: A qualitative interpretive phenomenological study of BAs was conducted. Iterative and inductive interviews using a semistructured guide were conducted with 11 skilled BAs (SBAs) and eight traditional BAs (TBAs). Audio-recorded interviews were transcribed and analysed using ATLAS.ti software version 8.4.4 (1135), following Van Manen's five thematic analysis steps. Results: Three themes emerged: birth attendants' cultural encounters, response to cultural encounters and collaboration. Birth attendants' responses to different cultural encounters revealed their awareness of CPs. The response was experienced as a sensitivity to the need for a triad (woman, TBAs and SBAs) collaborative care, enabling collaborative, woman-centred and culturally safe care. Conclusion: Birth attendants are exposed to cultural encounters, and their responses determine their awareness of enabling sensitive care for optimal childbearing experiences. The study illuminated the need for further collaborative engagements between the BAs and the community to facilitate positive experiences by women through woman-centred, culturally safe care.

What Mother, Midwives, and Traditional Birth Helper Said About Early Initiation of Breastfeeding in Buginese-Bajo Culture.

INTRODUCTION: The aim of this study is to investigate how mothers, families, midwives, and traditional birth attendants in the Buginese-Bajo culture understanding breastfeeding and early initiation of breastfeeding (EIBF). Also to assess what support mothers receive from families, midwives, and traditional birth attendants during pregnancy, birth, and EIBF. METHODS: This qualitative study included 21 subjects (11 pregnant women, three midwives, and seven traditional birth attendants). Recorded interviews with the three groups of participants were transcribed verbatim and analyzed separately, using latent content analysis. The study started in December 2014 and ended in July 2015. RESULTS: Some mothers understood the meaning of EIBF, but engaged in it for different reasons. The midwives interpreted the principle of EIBF differently from a duration perspective. Traditional birth attendants explained it as a way to strengthen the relationship between mothers, and babies; they believed that prolonging breastfeeding until 2 years would change babies into caring children. According to them, this skin-to-skin contact has been practice for a century by traditional birth helpers. The philosophy of breastfeeding, according to the Buginese-Bajo, is creating "peru" relationships for mothers and babies each other for their whole lives. CONCLUSION: These findings show a connection between established science and cultural beliefs. The concept of peru is the central philosophy to be achieved in EIBF. Breast-feeding's psychological value is known and passed from generation to generation; this essential fact needs to be preserved as local capital for changing breastfeeding behavior. The government should pay more attention to this opportunity to increase awareness and promote breastfeeding behavior changes.

"Everything in India Happens by Jugaad": Dai-mas in Institutions in Rural Rajasthan.

Since the introduction of a scheme promoting institutional deliveries in India, dai-mas (traditional midwives) have not become obsolete, but remain integral to institutional caregiving in rural areas in ways that are not always recognized. Based on ethnographic fieldwork in rural Rajasthan, I discuss two institutional contexts in which dai-mas were encountered - traditional midwife training event and hospital births. By examining how dai-mas' authoritative knowledge is reconfigured within institutions, I suggest that the polysemic Hindi term jugaad - a phrase describing the kinds of improvisation required in resource-poor settings - captures different aspects of dai-mas' relationships with and within institutions and the state of maternal caregiving in rural India.

Reasons for the utilization of the services of traditional birth attendants during childbirth: A qualitative study in Northern Ghana.

BACKGROUND: Skilled delivery reduces maternal and neonatal mortality. Ghana has put in place measures to reduce geographical and financial access to skilled delivery. Despite this, about 30% of deliveries still occur either at home or are conducted by traditional birth attendants. We, therefore, conducted this study to explore the reasons for the utilization of the services of traditional birth attendants despite the availability of health facilities. METHOD: Using a phenomenology study design, we selected 31 women who delivered at facilities of four traditional birth attendants in the Northern region of Ghana. Purposive sampling was used to recruit only women who were resident at a place with a health facility for an in-depth interview. The interviews were recorded and transcribed into Microsoft word document. The transcripts were imported into NVivo 12 for thematic analyses. RESULTS: The study found that quality of care was the main driver for traditional birth attendant delivery services. Poor attitude of midwives, maltreatment, and fear of caesarean section were barriers to skilled delivery. Community norms dictate that womanhood is linked to vaginal delivery and women who deliver through caesarean section do not receive the same level of respect. Traditional birth attendants were believed to be more experienced and understand the psychosocial needs of women during childbirth, unlike younger midwives. Furthermore, the inability of women to procure all items required for delivery at biomedical facilities emerged as push factors for traditional birth attendant delivery services. Preference for squatting position during childbirth and social support provided to mothers by traditional birth attendants are also an essential consideration for the use of their services. CONCLUSION: The study concludes that health managers should go beyond reducing financial and geographical access to improving quality of care and the birth experience of women. These are necessary to complement the efforts at increasing the availability of health facilities and free delivery services.

Empowering traditional birth attendants as agents of maternal and neonatal immunization uptake in Nigeria: a repeated measures design.

BACKGROUND: Adequate immunization coverage in rural communities remain a challenge in Nigeria. Traditional birth attendants (TBAs) form an integral part of the social, cultural and religious fabric in most rural communities in Nigeria. Despite their limitations in handling the complications of childbirth, TBAs are widely accepted and patronized, especially in rural areas. The objectives of the project were to empower TBAs and assess the use of a culturally adapted audio-visual workshop intervention to change their knowledge, attitude and willingness to promote immunization uptake. METHODS: A repeated-measures design that used a convenience sampling technique to select 90 TBAs from the three geopolitical zones of Imo State, Nigeria. The TBAs were engaged through a culturally adapted audio-visual workshop. Data were collected before and immediately after intervention using a pretested questionnaire. Chi square test was done to determine any significant association with the zone of practice and paired sample t-test analysis to determine any significant pre and post intervention change. Level of significance was set at p ≤ ·05. RESULTS: More than half of the TBAs had at most, a secondary level of education (54·4%). The average length of time they practiced as TBAs was 16 years with an average of ten birth deliveries per month. After the intervention, all the respondents (100%) reported a willingness to always promote immunization uptake and also, there was a statistically significant increase in Knowledge (p < ·000). Similarly, the level of knowledge in the post intervention period appeared to be significantly associated with the zone of practice (p = ·027). CONCLUSION: The workshop intervention empowered the TBAs irrespective of their zones of residence by successfully improving their knowledge, though at varying levels; and consequently, their willingness to always promote immunization uptake.