I. T. Kamal  ( Secretary. National Committee on Maternal Health, Karachi. )

The report of the community based post intervention qualitative evaluation of a seven year long project published last month in this Journal¹, states that there is some evidence of positive change in the knowledge and skills of TBAs as a result of training. Since the nature of the evidence is not described and since no information has been documented as to the pre and post training practices of the TBAs, it is rather difficult to gauge the impact of training.
The findings of the survey are based on focus group discussions, which represent retention of theoretical learning. In TBA training the importance of their “unlearning” of harmful practices outweighs the retention of theoretical learning. By the degree of their unlearning one measures the positive change in their practices. Without direct or indirect evidence of this change it is not possible to deduce that there has been palpable impact of training. Hence some of the conclusions of the survey are debatable.
The project claims to have demonstrated facts, which have been long known e.g., “TBAs are a readily accessible health care resource.” In fact this information had formed the basis of a very aggressive and intensive national TBA training programme as an integral part of the Accelerated Health Programme launched by the government in the early 80s.
It is mentioned that because TBAs have knowledge of high risk factors they are referring pregnant women in time to the source of professional help. This needs to be substantiated by data about the number of and reasons for referrals and their outcome. Furthermore in the absence of specific information about the supportive mechanism to the TBA, it is difficult to determine the effectiveness of her referrals.
In a period of seven years of fairly high cost interventions in ten districts, it would be reasonable to expect some change in the maternal morbidity and mortality figures. It has not been documented whether deliveries by trained TBAs have made a difference. Neither does one find infomation about community’s reaction to the utilization of trained TBA versus untrained TBAs, i.e. is there a preference for the trained ones.
A reference to the World Bank Report of 1993 confirms the realization about the effectiveness of the role of nurses and midwives as primary health care providers². The report has also quoted a World Health Assembly Resolution of 1992, which called upon the member states to strengthen their nursing and midwifery services.
Following these two references the author suggests that, “Strengthening the TBA services through additional training will be a step in the right direction.” implying that training TBAs would mean, “Strengthening midwifery services.” It is ironical that midwifery should be so misunderstood in a country, which has one of the highest MMRs in the world. It appears that even in our senior medical professionals’ minds the terms TBA and midwife are synonymous.
In fact there are many other WHA Resolutions and reports related to nursing and midwifery e.g. WHA 30.48 (1977), WHA 36,11 (1983), WHO (1989) and WHO (1993)³. In WHA 1987 countries reported upon the degree of implementation of various resolutions. Unfortunately there has not been much progress made in Pakistan regarding the improvement in the quality of training being imparted to either nurses⁴, or midwives⁵.
It might be enlightening for a vast majority of the health professionals and the public alike to know: that a “midwife” is a specialist in normal obstetrics; that most countries of the world, developed or developing, which have succeeded in bringing their MMR down, have done so by training and utilizing their midwives. In most of Europe and Great Britain, in the public sector, all the normal births are handled by midwives and that even when an obstetrician becomes pregnant, she is cared for by a midwife because the doctors do not deal with normal pregnancy and normal child births. Countries which eliminated the midwife and tried to reduce their MMR by hospitalization and using doctors for every child birth took much longer and paid a much higher price to succeed (USA is an example of this strategy). Having realized the value of the midwife now the midwife is being brought back into the health care delivery system.
Training of TBAs has received a lot of attention and international support in the last century^6-9. Yet no country in the world has been able to make motherhood safer than before by only training TBAs. The rare success stories are of those countries, which trained, supervised and supported the TBAs with a fairly organized referral system. Pakistan however is not one of these countries.
It would be wise for a country with limited resources for health care, to move with extreme caution in designing and implementing TBA training programmes. At their best TBAs should be considered a very temporary approach to manage a permanent situation by any developing country⁷.
The authorities need to concentrate on a “Replacement Strategy” and start investing in an achievable goal of training midwives for promoting safer motherhood particularly through domiciliary m idwifery.

1.Islam A, Malik FA. Role of traditional birth attendants in improving reproductive health: lessons from the family project, Sindh. JPMA., 2001:51:218-22.
2.Kwast EB The Role and Training of Midwives for Safe Motherhood. Paper presented at the Symposium on Professional Training for Safe Motherhood, Singapore, XIII FIGO World Congress. 1991.
3.World Health Assembly Resolutions; WHA 30 48, 1977, WHA 36.11, 1989.
4.Kamal IT Evaluation of Implementation of the Revised Nursing Curriculum In Pakistan, EMRO/ WHO, 1999.
5.Kamal IT Situation Analysis of Midwifery Training in Sindh, NCMII/UNICEF, 2000,
6.Kamal IT Training and Utilization of The t radiuonal Birth Attendant in the Eastern MediterTanean Region of WHO. EMRO/ WHO, 1983.
7.Kainal I.T, “The Traditional Birth Attendant; A Reality and a Challenge’ Int. J. Gynecal. Obstet,,1998.63 (Suppl-l) 1 12-15.
8.Maternal Health and Safe Motherhood Programme. Report of the Scientific and Technical Advisory Group, Geneva, WHO, 1993.
9.Towards One Trained Birth Attendant Per Village Report of Regional Consultation, EMRO/W 10, 1989.