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Research

The Impact of TBA Training in Ghana

Background

Many national governments, international organizations and donor agencies spend large sums of money to train traditional birth attendants (TBAs). The justification for this expenditure is that a large proportion of births are attended by TBAs, especially in areas where access to healthcare providers with more training and/or resources is limited. But does training TBAs ultimately result in safer births? In collaboration with the Regional Health Administration in Brong-Ahafo Region, FHI evaluated TBA training conducted in central Ghana during the mid-1990s. The purpose of the study was to determine the impact of training on TBA practices and ultimately on maternal morbidity.

Study Design

All TBAs in selected study areas were identified and a qualitative assessment carried out to gain a better understanding of TBA roles. Four hundred five TBAs and 1,961 women who had a birth in the last three years and had contact with a TBA at some point before, during and after delivery were interviewed. TBAs were asked about their practices; trained and untrained TBAs were compared. Mothers were asked about any difficulties experienced. Outcomes of mothers attended by trained and untrained TBAs were compared.

Results

The typical TBA interviewed for this study, regardless of her training status, was in her fifties, had six living children of her own, had never attended school, and had learned her trade as an apprentice to another TBA. The mean number of deliveries attended per month was 2.3 for the trained TBAs and 1.5 for the untrained TBAs.

The TBA interviews showed that:

  • Most of the trained (70%) but less than 10% of the untrained kept specific items such as soap for hygienic purposes.
  • Trained TBAs knew more about family planning (96% knew at least one method) than untrained TBAs (57% knew of at least one method), and were also more likely to have recommended its use to clients (81% vs. 26%) and to have provided contraceptives.

The interviews with mothers found that:

  • Retained placenta was less common among mothers attended by trained TBAs.
  • There was no difference between clients of trained and untrained TBAs in referral patterns, excessive bleeding or postpartum use of family planning.
  • The level of foul discharge was similar for women attended by trained and untrained TBAs; however, the level of postpartum fever was lower for women attended by trained TBAs.
  • A larger proportion of women attended by trained TBAs were in labor for more than 18 hours, although it is possible that women called in trained TBAs after experiencing problems with their labors.

Conclusions

Although the training had an effect on process indicators such as record keeping, hygiene, and knowledge about family planning, there was little evidence to support the hypothesis that training TBAs results in better health outcomes for mothers. The training did not have an impact on referral or excessive bleeding and did not lead to greater use of family planning postpartum. The study was large enough to be able to detect meaningful differences between trained and untrained TBAs.

Improving access to contraception remains the best means of primary prevention of maternal morbidity, but TBAs may not be the best family planning promoters. Improving access to facilities that can provide good emergency obstetrics care and postpartum counseling on family planning may be a more promising secondary prevention strategy.

May 1998