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TBAs, Technology, and the Maternal Referral System » Women's Courage

TBAs, Technology, and the Maternal Referral System

February 17th, 2011 by klstaves Leave a reply »

Last week, Jenna pointed out (here) some of the limitations of Traditional Birth Assistant Training programs. While some TBA training programs have shown benefits – for example by improving hygiene conditions at TBA attended births[i] – many have shown disappointing results. One of the major causes of disappointment in TBA training programs has been the realization that the referral link between TBAs and hospitals often functions poorly. The reasons for this are two-fold. First, some studies have indicated that training TBAs to identify obstetric emergencies does not necessarily increase referral rates.[ii] Secondly, as Jenna mentioned last week, there is often insufficient time to transport women with obstetric emergencies to tertiary care facilities.

The ability of traditional birth assistants to respond to obstetric emergencies is inevitably limited. Though training can allow them to cope with some complications, it will not remove the need for hospital-based interventions. Given the challenges associated with creating an effective referral link between TBAs and hospitals, some have suggested that TBA training programs are inadequate responses to high maternal mortality. If TBAs cannot or will not refer women to obstetric care facilities in time to save their lives, are we better off focusing our attention on increasing institutional births rather than promoting traditional birth assistants?

While the referral link between traditional birth assistants and hospitals has been historically weak, there are good reasons to believe that this could change. A wave of technological innovations in the field of maternal health has brought two groups of technologies that seem particularly applicable to the issue of strengthening the connection between TBAs and hospitals.

The first of these groups of technologies include innovations that may widen the time window during which life-saving referrals can be made. This group of technologies included anti-shock garments (see the LifeWrap and my earlier post) which respond to inevitable transportation delays by providing a means to stabilize a woman long enough to be transported to the hospital. Elsewhere in the medical technology world, new low-cost home tests for pre-eclampsia are emerging (see Jhpiego), offering the possibility of earlier detection of obstetric emergencies. Technologies such as these could play a vital role in improving the effectiveness of TBA training programs by increasing the number of cases in which referrals can be made in time to save the mother.

In addition to technologies that improve referral outcomes, other technologies respond to the need to increase the rates of timely referrals. A 2004 survey identified the development of clear referral guidelines as an important component of successful maternal referral programs.[iii] Historically, the principal tool for this purpose has been the partogram. Partograms, which track the progress of labor by plotting indicators such as cervical dilation, fetal heart rate, and duration of labor, assist doctors in identifying when pharmaceutical or surgical intervention is necessary. While highly cost-effective, partograms have proven inappropriate in many settings, particularly ones in which birth assistants are relatively less educated. The relative complexity of the partogram has prevented it from being widely used among traditional birth assistants. In response to this issue, a new version of the partogram has been developed which provides a simpler set of referral guidelines. Called “the paperless partogram,” this system requires birth assistants to perform two simple calculations in order to calculate an ALERT estimated delivery time and an ACTION estimated delivery time. Birth attendants are instructed to make arrangements for transportation to a facility with surgical capabilities at the ALERT time and to deliver the baby at the ACTION time. [iv] This system, combined with other tools such as mobile phones which play an increasingly important role helping TBAs to determine an appropriate course of action, may result in a more effective maternal referral program.

Technologies, however well designed, ultimately are only tools. Developing the link between traditional birth assistants and hospitals will require further education efforts and thoughtful adaptation of technologies to meet local needs. Still, the emergence of tools such as the LifeWrap and the paperless partogram should prompt us to reconsider premature eulogies on traditional birth assistant training programs. Many barriers to effective maternal referral systems continue to exist, but we have yet to exhaust the possibilities for making them work.


[i] Sogunro, Oluremi. “Traditional obstetrics; a Nigerian experience of a traditional birth attendant training program.” International Journal of Gynecology & Obstetrics. Volume 25, Issue 5, October 1987, Pages 375-379

[ii] Sibley et al. “Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention.” Journal of Health, Population and Nutrition. June 2009. pp 379-390 <<http://centre.icddrb.org/images/JHPN273-Cultural_Theories_of_Postpartum_Bleeding_in_Matlab,_Bangladesh.pdf>

[iii] “Tsu, V.D. and B Shane. “New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop.” International Journal of Gynecology & Obstetrics
Volume 85, Supplement 1, June 2004, Pages S83-S93. <<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7M-4CDRKC3-B&_user=145269&_coverDate=06/30/2004&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1645749489&_rerunOrigin=scholar.google&_acct=C000012078&_version=1&_urlVersion=0&_userid=145269&md5=0a29a3a723d862bb77421ef2c20fa6ef&searchtype=a#toc37>>

[iv] “The Paperless Partogram: A simplified tool to prevent prolonged labor.” Maternova. <<http://maternova.net/blog/paperless-partogram-simplified-tool-prevent-prolonged-labor>>

iv. The Life Wrap. <<http://www.lifewraps.org>>.

v. “Jhpiego among first recipients of innovation award from USAID.” 11 October 2010.  <<http://www.jhpiego.org/media/releases/nr20101012.htm>>.

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1 comment

  1. kheflin says:

    Dear Kelly,

    You state: “Though training can allow them to cope with some complications, it will not remove the need for hospital-based interventions.” While I agree with this in principle, it is important to remember the practicality of all women in labor having access to emergency care. In much of the world, regardless the technologies developed, geography, time, and financial barriers are far too great to make anything besides TBAs a reasonable choice. Therefore, the presence of TBAs is better than nothing, and realistically for many regions, it is as good as it gets (for now).

    Then you ask: “If TBAs cannot or will not refer women to obstetric care facilities in time to save their lives, are we better off focusing our attention on increasing institutional births rather than promoting traditional birth assistants?” With my previous statement in mind, I answer you question with a firm “No.” I think the sheer idea of TBAs is so much better than what exists in many regions, so hoping for perfection (that is, access to the best-case technologies of hospitals) is not only unrealistic but can in fact be harmful if these hopes get in the way of the reasonable and possible implementation of TBAs in all communities.

    I like the tools you suggest to link TBAs to emergency healthcare, however, I still find it important to remember that in many instances, emergency healthcare was never an option before and won’t be still for some time.

    Thanks for your post!
    –KJH

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