Traditional Birth Attendants: A valuable asset or a drain on resources?
“No woman should die in pregnancy or childbirth” is a phrase that is stamped all over official WHO maternal health documentation. Sustainable Development Goal 3, Good Health and Wellbeing, aims to reduce the global mortality ratios to less than 70 per 100,000 live births by 2030, down from 216 per 100,000 in 2015.  Despite maternal mortality rates nearly halving since 1990, over 800 women die from pregnancy or childbirth related complications each day, with 99% of these in developing countries.  For many mothers in rural and low income areas, visits from a traditional birth attendant (TBA) – someone who has no formal training and whose skills have been acquired from assisting other TBAs - will be the only form of pre- and post-natal healthcare that they receive.
As well as attending deliveries, TBAs offer advice on breastfeeding, reproductive health and provide vital social support to women. They are highly respected and trusted in communities given their understanding of local traditions, religions, cultures and languages. They are accessible at all times of the day and night, offer flexible payment plans to those they assist and are often preferred over skilled midwives, not just by the expectant mother, but also by family members and the wider village community. A severe lack of human resources in healthcare means that it is unrealistic to expect all births to take place in formal healthcare settings, thus the training of TBAs, who are ubiquitous, is a way of relieving the deficit of skilled healthcare workers. With maternal death rates as high as 2,000 per 100,000 live births in parts of Africa, some argue that it would be unethical not to utilise TBAs. 
However, the training and integration of TBAs into more formal healthcare settings remains controversial. As well as being unskilled, many are illiterate and keep no record of their activities, making monitoring impossible. The main causes of maternal death are haemorrhage, hypertension and sepsis, none of which are conditions TBAs will ever be able to treat, despite training.  When faced with limited resources, should policy makers be ploughing money into the training of unskilled attendants or focussing on a functioning healthcare service - one with increased access to and quality of healthcare facilities staffed with professional workers?
This question has been sought to be answered by an enormous body of literature examining what impact TBA training has on maternal health outcomes. The range of interventions that have been tested varies significantly, from providing TBAs with sterile delivery kits and explaining best hygiene practices, to training on resuscitation and drug administration. With many interventions happening in rural settings, studies are often too small for results to prove conclusive and many also lack clear definitions and descriptions on what formal training or integration has taken place. While some evidence is inadequate for drawing conclusions, parts do suggest that improving the skills of TBAs and integrating them into community-led healthcare groups and facilities leads to a reduction in maternal morbidity and still births. 
Current WHO guidelines recommend the use of TBAs to promote skilled care for childbirth and provide continuous support for women during labour, but only in the presence of a skilled attendant.  This is a big step away from their original stance in the 1960s which emphasised the training of TBAs and integration into the health system. Despite this reversal and push towards skilled attendants, TBAs undeniably play an important role in child birth in developing countries and in many places an effort is still being made to offer them training with a view to improve maternal health.
Much of the literature thus far has focused on the outcomes of integrating unskilled health workers into formal healthcare settings. Now however, there needs to be a greater emphasis on gaining a better understanding of the policies and mechanisms of successful intervention. What are the facilitators and barriers to engagement? What works and why? Our group at Polygeia are hoping to aid in answering these crucial questions.
 United Nations. (2015). In focus: Women and the Sustainable Development Goals (SDGs): SDG 3: Good health and well-being | UN Women – Headquarters. Retrieved April 29, 2017, from http://www.unwomen.org/en/news/in-focus/women-and-the-sdgs/sdg-3-good-health-well-being
 WHO. (2016). WHO | Saving mothers’ lives. WHO. Retrieved from http://www.who.int/reproductivehealth/publications/monitoring/infographic/en/
 Ana, J., & Harrison, K. (2011). Are traditional birth attendants good for improving maternal and perinatal health? BMJ, 342.
 Lassi, Z. S., Haider, B. A., & Bhutta, Z. A. (2010). Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. In Z. A. Bhutta (Ed.), Cochrane Database of Systematic Reviews (p. CD007754). Chichester, UK: John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD007754.pub2
 WHO. (2014). WHO | Optimizing health worker roles for maternal and newborn health.