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Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and challenges: A case study of incorporated TBA in Timor-Leste

Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and... Background: One current strategy to overcome the issue of shortage of qualified health workers has focused on the use of community health workers in the developing countries to deliver health care services specifically to the most vulnerable communities in the rural areas. Timor-Leste is the one of the world’s newest developing countries that has incorporated the traditional birth attendance in its health system through a family health promoter initiative in response to reproductive and child health, hence to improve primary health care delivery and increase number of healthcare workforce. Methods: The study utilized a non-systematic review of the literature using key words such as community health workers, traditional birth attendants, reproductive health, child health and health outcomes. A case study from Timor-Leste was also used. Results: Traditional birth attendants have performed wide variety of tasks including outreach and case finding, health and patient education, referrals, home visits and care management. Evidence indicated that there were, to varying degrees, positive associations between traditional birth attendance training and maternity care. Traditional birth attendance training was found to be associated with significant increases in attributes such as knowledge, attitude, behavior, advice for antenatal care, and pregnancy outcomes. However, some challenges faced by traditional birth attendants’ role in encouraging women to go to health center for preventive services would be the compliance and refusal of the referral. The implementation case study from Timor-Leste shows that integrating traditional birth attendance into a national healthcare system through Family Health Promoter program has been programmatic effective. It is recommended that the implementation should consider regular communication between health staff and community leaders in recruiting members of family health promoters, and the use of supportive supervision tools to identify weaknesses in the management of this initiative. Conclusion: In Timor-Leste, incorporating traditional birth attendance through family health promoter program has played crucial roles in delivering and increasing access to reproductive health services by women in rural communities of the nation. Whilst it requires a long-term commitment and good partnership, the current reduction in maternal mortality ratio in Timor-Leste is encouraging and serves to illustrate how this initiative aims to improve primary health care delivery and increase number of healthcare workforce. Keywords: Traditional birth attendants, Community health workers, Reproductive health, Family health promoters in Timor-Leste Correspondence: lapazsarmento@gmail.com School of Public Health, Georgia State University, Atlanta 30303, Georgia © 2014 Ribeiro Sarmento; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 2 of 9 http://www.apfmj.com/content/13/1/12 Background and due to limitation of published literatures on commu- Human resources are the key ingredients to a successful nity health workers in Timor-Leste, the search terms were health system functioning [1]. Nonetheless, a large num- not limited to other sub-regional groups obtained from ber of countries are still facing an overall shortage of different developing countries. To try and capture reports qualified health workers to perform and deliver the pri- in the grey literature, Google and key development agency mary health care services [2]. According to the World websites were also searched. Articles were included if they Health Organization (WHO), most developing countries provided some level of systematic review of evidence still experience varying degrees of shortages in qualified such as meta-analysis and observational studies relating to health workers in which current estimates suggest there community health workers in rural settings of low and is a shortage of 4.2 million health workers worldwide middle-income countries. [3]. A greater number of strategies have then been estab- A specific case study from Timor-Leste was utilized lished to overcome this issue. Those strategies include for the discussion of incorporating TBAs in a health care improving salaries and working conditions for qualified system. This case study does not include any experimen- health professionals, providing financial and compensa- tal research nor any research carried out on humans and tion incentives, and increasing capacity building for for- animals and as such did not require an ethical approval. mal health workers [4]. The WHO report also states that latter strategy to respond to the widespread problem of Results human resources for health has focused on the use of Basic roles of CHWs community health workers (CHWs) in the developing CHWs have been defined as the members of community countries where formal health workers are too few to who are selected by the communities to provide care for deliver health care services specifically to the poorest a broad range of health issues including reproductive and most vulnerable communities in the rural and re- and child health to the poorest and most vulnerable mote areas. communities [8]. Before describing the overall perform- The initial concept of CHWs has been used for several ance of CHWs, it is necessary to identify the different decades to render certain basic health care services to terms used for CHWs in different countries across the underserved populations [5]. CHWs have been defined globe (Table 1). as the lay members of community who work exclusively The establishment of CHWs has apparently been asso- to serve people who have lacked access to adequate care, ciated with the growing shortages of human resources and establish vital links between health care consumers within a health system, and the functions of CHWs are and providers to promote health in community settings mainly to help addressing this widespread issue. Despite [6,7]. It seems likely that the concept of CHWs and of being known by different titles, some literatures reveal activities they perform mainly depend upon the local that the tasks performed by CHWs are essentially the context and situation. In specific response to the repro- same. A review study conducted in the year of 1998 ductive and child health, these community-based workers demonstrates that CHWs have performed wide variety sometimes referred to as the traditional birth attendants of tasks including outreach and case finding, health and (TBAs) in some situations, have played important role in patient education, referrals, home visits and care man- providing maternity care based on the local community agement [9]. CHWs help connect health care services needs. It is imperative to further the focus on the TBAs with local communities for the provision of counseling, and the activities that these cadres of health workers health education, treatment and advocates experienced deliver in relation to reproductive and child health. There- in local needs [10]. For example, in the rural settings of fore, this paper summarizes the evidence-based informa- Gambia, Ghana, South Africa and Tanzania, CHWs with tion for the inclusion of TBAs in a health care system in minimal additional training have played vital roles in de- response to reproductive and child health services and livering counseling, treatment and health education for provides a case example from Timor-Leste of how it has such important diseases as malaria, HIV and tubercu- been implemented. losis for the local communities [10]. Indeed, in the South Asia countries like Bangladesh, Bhutan, Nepal and Sri- Methods Lanka, CHWs can help health care systems overcome The case study utilized a non-systematic review of the lit- both personnel and financial shortages by providing high erature using key words such as community health quality and cost-effective services to people in their workers, traditional birth attendants, reproductive health, homes [11]. Therefore, the most probable view on this child health and health outcome. A structured search of would be that by delivering basic health care services to PubMed, MeSH, PMC and Medline was also performed communities, CHWs have improved adherence to treat- for studies published from 1990 up to March 2014. The ment and reduced the burden of time and financial on search terms were limited to English-language publication, both health care consumers and providers. Nevertheless, Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 3 of 9 http://www.apfmj.com/content/13/1/12 Table 1 Alternative title for CHWs in various countries Benefits of CHWs in response to reproductive and child Title Country health services In many poor parts of the world where human resources Activista Mozambique are still in very short supply to provide basic health care, Agente comunitario de salud Peru CHWs have remained a significant workforce in deliver- Agente comunitário de saúde Brazil ing reproductive and child health services. In specific to Anganwadi India TBAs, they have been widely defined as the community Animatrice Haiti or family members (normally females of old age groups) Barangay health worker Philippines who are a product of tradition in assisting mothers dur- ing home delivery [13]. The competence and skills of Basic health worker India TBAs may vary widely across settings. Following the Brigadista Nicaragua years since the introduction of the Safe Motherhood Colaborador voluntario Guatemala Program, training of TBAs has been recognized as one Community drug distributor Uganda of the interventions intended to reduce maternal mortal- Community health agent Ethiopia ity and morbidity rates as well as to improve the repro- Community health promoter various countries ductive health of women [14]. A greater number of public health studies have been undertaken to review Community health representative various countries and identify the explanations for continued existence of Community health volunteer Malawi TBAs, hence their roles in delivering maternity care Community health worker various countries within the poorest communities. Community nutrition worker India One purpose from previous literatures is mainly focus Community resource person Uganda on the identification of the effectiveness of TBA training Female community health volunteer Nepal and its impact on reproductive health outcomes. A series of meta-analysis review identified that there were, Female multipurpose health worker Nepal to varying degrees, positive associations between TBA Health promoter various countries training and maternity care [14]. TBA training was Kader Indonesia found to be associated with significant increases in attri- Lady health worker Pakistan butes such as TBA knowledge, attitude, behavior and ad- Maternal and child health worker Nepal vice for antenatal care [14] and pregnancy outcomes Monitora Honduras [15]. Also, TBA training was significantly associated with referral behavior and maternal service use by women Mother coordinator Ethiopia with obstetric complications [16]. These associations Outreach educator various countries may lead to a significant reduction in maternal mortality Paramedical worker India and morbidity. However, although TBA training may Promotora Honduras have been associated with reduction of a substantial pro- Rural health motivator Swaziland portion of maternal mortality and morbidity, the infor- Shastho shebika Bangladesh mation and material about the training program should be improved and the effect of the training needs to be Shastho karmis (leaders of shastho shebika) Bangladesh evaluated in order to develop a strong evidence base. Sevika Nepal Using the same parameters such as knowledge, atti- Traditional birth attendant various countries tudes and practices, another systematic review also dem- Village drug-kit manager Mali onstrated that TBAs had incorporated the information Village health helper Kenya from the training program into their knowledge and Village health worker various countries practice for prevention, recognition and management of postpartum hemorrhage (PPH) in Gambia [17]. It was Adapted from Lehmann and Sanders [8]. revealed that despite of reducing PPH morbidity and mortality in home births in this setting, there is a need the tasks performed by CHWs may vary enormously by for Gambian TBAs to be trained to implement other settings and community needs. In many rural settings of practices relevant to prevention of this pregnancy com- the developing countries, CWHs sometimes referred to plication in the primary care setting. Similarly, assess- as TBAs, may have also been selected by communities ments in Brazil, Guatemala and Indonesia have shown to represent a major source where pregnant women can- that TBAs can identify early signs of complications dur- not access to maternal health services due to cultural, ing labor and delivery, and successfully refer mothers for socioeconomic or geographic barriers [12]. treatment in health centers by skilled health workers Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 4 of 9 http://www.apfmj.com/content/13/1/12 [18]. From this evidence, it seems likely that training of trained TBAs [21]. The most probable view on this TBAs may result in large improvements in reproductive would be that TBA training in hygienic practice does and child health, hence contribute to substantial reduc- not seem to give impact to the improvement of women tion of maternal morbidity and mortality. reproductive health; therefore, evaluation of the training In addition to performing home delivery and referral program is rigorously required with special attention to system for pregnancy complications, TBAs have also measure the specific outcomes such as maternal morbid- been engaged in some basic health care functions such ity due to postpartum infections. as health promotion and disease prevention. In Sub- Saharan Africa where home births remain a strong prefer- Practical challenges ence and might be often the only option, TBAs have been Involving trained TBAs in reproductive health care has involved in health promotion and disease prevention [19]. several advantages, including ease of access to reproduct- It is indicated that TBAs have played some critical roles in ive care and delivery of care to women in the community. health promotion by preventing mother to child Human However, challenges should be taken into consideration in Immunodeficiency Virus (HIV) transmission in the region order to measure limitations in delivering reproductive where HIV prevalence is remarkably high [19]. Those care. Some barriers of TBAs’ role in encouraging women tasks performed by TBAs have included disseminating in- to go to health center for preventive services would be the formation about perinatal HIV transmission, identifying compliance and refusal of the referral. The reasons might pregnant women in their communities and facilitating the lie within the financial limitation, lack of transportation use of available antenatal care and maternity care, ensur- and patients’ fear of painful treatment from formal health ing routine HIV counseling for women and their partners, workers [22]. Indeed, it seems likely that appropriate train- supervising treatment of mother and infant with nevira- ing and supervision should be provided for TBAs [15]. pine and offering advice to women on reducing the risk of The appropriate training simply means that it has to be HIV transmission [19]. practical-based training. When appropriate training, such In contrast to those findings above, it is argued that as clean practice of cutting umbilical cord (clean labor trained TBAs without the support of skilled back-up ser- practice), is available, these cadres of community health vices may not significantly reduce maternal mortality ra- workers can serve as effective as readily available human tio [17]. A recent cluster-randomized controlled trial resources in mobilizing communities, and delivering re- study in Pakistan demonstrated that involving trained productive care to women in the poorest settings. This TBAs in reproductive care did not reduce maternal mor- would ultimately be applicable to poorest settings where tality, but instead it led to a reduction in perinatal mor- TBA training has not yet been considered as part of an in- tality [19]. The findings showed that a cluster-adjusted novative strategy to combat shortages of human resources odds ratio for perinatal death was 0.70 for intervention in health systems. It is recommended that supervision and sub-districts as compared to control, which suggested direct observation of TBAs at work are critical for clarifi- a significant reduction in perinatal mortality of about cation of the most appropriate role of TBAs in reducing 30% in the intervention group [20]. Therefore, it is maternal mortality and morbidity in the poorest and most likely clear to assume that integrating TBA training vulnerable settings. Therefore, the roles of TBAs should into the health care system could be an effective strat- be functioned by good referral system and sufficient health egy to reduce perinatal mortality, but not maternal infrastructures, equipped with clean-birth kits after train- mortality ratio. ing sessions and supported from professionally trained Similarly, training of TBAs in hygienic practice during health workers during regular supervision [21]. delivery does not prevent postpartum infections [21]. The findings from a study that took place in a rural area Incorporating TBAs in practice: a case study from of Bangladesh illustrated that although trained TBAs Timor-Leste were likely to practice hygienic delivery, there was no Demographic significant difference in levels of postpartum infections Timor-Leste is located in Southeast Asia and Pacific, when delivering births by trained TBAs and untrained northwest of Australia and the east end of the Indonesian TBAs [21]. It seems likely that the inclusion of clean archipelago. The country has a land area of 14,954 square practice in TBA training program is ineffective to pre- kilometers and a population of over one million. The vent postpartum infections. The implication related country’s boundaries include the eastern half of the island to postpartum infections might be due to possible deter- of Timor, the Oecusse enclave in West Timor and the minants such as nutritional factors of the women par- islands of Atauro and Jaco. Timor-Leste gained its ticularly micronutrients and vitamins deficiencies [21]. independence after 25 years of Indonesian occupation Therefore, postpartum infection would not be affected through a referendum made in September 1999. More directly by clean practices at delivery performed by than half of the Timorese are under 18 years of age. In Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 5 of 9 http://www.apfmj.com/content/13/1/12 Table 2 Distribution of national health workers in purely economic terms, Timor-Leste is a middle-income Timor-Leste economy and one of the most oil dependent economies Category Number in the world [23]. The high fertility rate, where on aver- age women give birth to 5.7 children throughout their Assistant Pharmacists 116 lifetime is a key contributing factor to the high annual Environmental Health Officers 27 population growth rate of 2.7 per cent [24]. While much Laboratory assistants 132 of the country remains agrarian, a phenomenon of rapid Medical Practitioners (General Practitioner) 75 urbanization has been reported where about 22 per cent Medical Practitioners (Medical Specialists) 9 of the population lives in the urban areas [25]. The health Medical technicians 48 status at the community level remains low and for many children and women life remains a day-to-day struggle Midwives 53 for survival. Nurses 1800 Nutrition Professionals 31 Maternal and child health situation in Timor-Leste Optometrists 13 Maternal height and pre-pregnancy weight has enor- Pharmacists 15 mous influence over birth outcomes. Shorter and lighter Physiotherapists 1 women are more likely to have babies with low birth Public Health Officers 13 weight. These women are also most likely to experience Public Health Professionals 64 difficulties in childbirth and could likely die. Maternal Sanitary inspectors 160 and under-five mortalities remain high: maternal mortal- ity is 557 per 100,000 live births and under-five mortality Traditional Birth Attendants (Community Health Volunteers) 1647 is 64 per 1,000 live births [24]. Statistics also show that 30 per cent of births are delivered by a skilled nurse or Incorporating TBAs through family health promoters midwife, nearly 18 per cent of deliveries are carried out initiative in Timor-Leste by TBAs and 49 per cent by a relative or some other In 2007 the Ministry of Health (MoH) of Timor-Leste people, which are relatively high [24]. Whilst much have rolled out a national cadre of volunteer Family Health been done to build the capacity of the health sector ser- Promoters or Promotor Saude Familia (PSF) with main vice delivery, it is clear that the quality of services needs objective to increase the number of health workers and to be further enhanced. strengthen its national health system in delivering ma- ternal and child health services including reproductive Healthcare resources in Timor-Leste health intervention program into the community level. Timor-Leste significantly faces some challenges in gener- This initiative has been extensively supported by devel- ating resources for health systems particularly human opment agencies, particularly the government of the and physical resources such as facilities and equipment. United States through its Agency for International Devel- Current workforces in Timor-Leste still suffer shortages opment (USAID). for the provision of health services nationwide [26]. PSFs are community health volunteers that are not Table 2 below illustrates the distribution of national MoH staff nor do not receive a monthly salary for their health workers in Timor-Leste in 2011. work, however, they are provided with incentives. Com- In terms of health structure, the organization for na- munity members are selected to be PSFs by village lead- tional health system consists of central services, and dis- ership and trained by MoH staff to provide basic trict health services (community health centers, health community health services with an emphasis on teach- posts and mobile clinics) (Figure 1) [27]. Relatively, ing and motivation of families they visited, including re- physical resources (facilities) in the district level are productive health. Especially in rural areas, some of the still inadequate and human resources have limited volunteers include TBAs who have played a key role in capacity to provide health care services to all people. assisting pregnant women before, during and after deliv- Assistance from external organizations and individuals ery. These volunteers are also expected to take an active are needed and welcomed. The Ministry of Health of role in conducting health promotion activities through Timor-Leste has collaborated with Cuban government an integrated community health services (also called by employing around 350 Cuban medical doctors to SISCa). SISCa program has been developed to address supplement clinical services in district and sub-district the shortfall of health care service delivery at the com- levels and sending around 680 East Timorese students munity level by improving uptake of preventive health- to study Medicine under the scholarship from Cuban care and access to basic medical services [27,29]. One government [28]. responsibility of PSFs is to conduct home visits and Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 6 of 9 http://www.apfmj.com/content/13/1/12 Figure 1 Overall structure of the Timor-Leste Health System. Adapted from Martins and Trevena [27]. assist health staff when they provide community out- from 660 per 100,000 live births in 2003 to 557 per reach services. In the year of 2009, the number of 100,000 live births in 2010. trained PSFs registered in the database of MoH was over It seems likely that the PSF is both programmatic and 1,500 [30]. The PSF program has been extended along cost effective. There are some strength related to the re- with the introduction of SISCa. cruitment, training, implementation and management of PSFs have been provided with training, materials and this program. They include MoH is able to recruit many supervision in their house-to-house visits with pregnant PSFs, MoH is able to train PSFs, PSFs actively participate mothers in a campaign called Mai Ita Koko (or Come in SISCa program, and SISCa provides solid structure to Let’s Try) [30]. The type of training included basic manage PSFs. Although being effectively programmatic, knowledge to encourage women to attend clinics for there are some specific challenges faced by PSFs during pre- and post-natal care and practice of handling labour implementation in Timor-Leste. A major challenge has with clean equipment. The training was provided by group been the compliance and refusal of the referral due to of skilled health care workers from district level in financial limitation and lack of transportation for pa- conjunction with support from some Non-Governmental tients who reside in rural areas. Another challenge has Organizations (NGOs) such as Care International and been the minimum incentives provided to PSFs, which World Vision. contributes to lack of motivation to provide outreach In the training, eight photo cards that depict relevant activity program. Timorese images and portray recommended maternal Even though many PSFs actively participate in monthly behaviours were developed (Figure 2). The images and implementation of SISCa, continuation to socialize, messages on the cards are simple, clear, culturally rele- supervise and promote the role of PSFs is required to vant, and action oriented. PSFs have been trained to use address the constraints from this initiative as mentioned the cards as an educational tool during home visits and above. Therefore, it is recommended that effective im- to encourage women and families to adopt one or more plementation should consider regular communication behaviours, such as having a skilled birth attendant or between health staff and community leaders in recruit- selecting a family planning method after delivery. The ing PSFs, and the use of supportive supervision tools to chosen behaviour(s) is checked off on a colourful poster identify weaknesses in the management of this initiative. A proper evaluation program should also be conducted that contains each of the photos and is left with the fam- ily to remind them of their choice. to further examine the effectiveness of the PSF initiative. The PSFs follow up with families throughout the mother’s pregnancy to monitor progress toward their Conclusion goals. The home visits have been well received by Despite of being the most important aspect of health mothers who appreciate the support provided by the care systems, human resources have been a neglected PSFs. Since the implementation of PSF program, a sig- component of a health system development. It is im- nificant improvement has been observed in the propor- perative that the engagement of CHWs in the health tion of women receiving antenatal care from a skilled system function should be considered to address the health staff as a result of PSF referral system – an in- growing shortage of formal health workers. This paper crease from 41 per cent in 2006 to 86 per cent in 2010 has identified that although the evidence of whether the [24]. The maternal mortality ratio has also improved roles of TBAs may reduce maternal mortality ratio varies Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 7 of 9 http://www.apfmj.com/content/13/1/12 Figure 2 Photo cards developed for PSFs to use during implementation. Adapted from Health Alliance International (HAI) [30]. by findings, training of TBAs is considered to be an ef- It is evident that TBA training has shown significant re- fective complimentary strategy to attend home births sults in reduction of maternal mortality and morbidity in that still remain high in the poorest countries and in the some developing countries where home delivery is high poorest rural populations within countries. Indeed, this and still the main preference. Findings from some litera- paper has described how Timor-Leste has integrated tures illustrate that substantial improvement in health TBA through PSF program into its basic health service outcomes has been achieved and sustained through the package delivery to reduce reproductive and child health TBA training. It shows that trained TBAs have provided issues of the country. basic level of maternity care, for example, their role in Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 8 of 9 http://www.apfmj.com/content/13/1/12 prevention and management of postpartum haemorrhage. Author’s information DRS holds a Bachelor degree in Medical Science from Latrobe University and Also, the greatest contribution from trained TBAs to re- a Master’s degree in Public Health from the University of Queensland in duce maternal mortality and morbidity can be observed in Australia. DRS is currently enrolled at the School of Public Health of Georgia the area of health promotion, for example, their role in State University in Atlanta under a Fulbright-SERN Scholarship Program. disseminating information to women on perinatal trans- mission of HIV. In delivering reproductive care to women Acknowledgments The author would like to thank Timor-Leste’s government, Fulbright Program, in the community, TBAs may face various challenges such Georgia State University and the Asia Pacific Family Medicine for giving op- as referral compliances that should be considered. In spe- portunity to further enhance technical knowledge as part of education and cific to Timor-Leste, incorporating TBAs through PSF ini- learning aspects. Through this, DRS has a chance to publish this work. tiative has played crucial roles in delivering and increasing Received: 20 March 2014 Accepted: 29 October 2014 access to reproductive health services by women in rural communities of the nation. 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Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and challenges: A case study of incorporated TBA in Timor-Leste

Asia Pacific Family Medicine , Volume 13 (1) – Nov 26, 2014

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Springer Journals
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Copyright © 2014 by Ribeiro Sarmento; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-014-0012-1
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25469105
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Abstract

Background: One current strategy to overcome the issue of shortage of qualified health workers has focused on the use of community health workers in the developing countries to deliver health care services specifically to the most vulnerable communities in the rural areas. Timor-Leste is the one of the world’s newest developing countries that has incorporated the traditional birth attendance in its health system through a family health promoter initiative in response to reproductive and child health, hence to improve primary health care delivery and increase number of healthcare workforce. Methods: The study utilized a non-systematic review of the literature using key words such as community health workers, traditional birth attendants, reproductive health, child health and health outcomes. A case study from Timor-Leste was also used. Results: Traditional birth attendants have performed wide variety of tasks including outreach and case finding, health and patient education, referrals, home visits and care management. Evidence indicated that there were, to varying degrees, positive associations between traditional birth attendance training and maternity care. Traditional birth attendance training was found to be associated with significant increases in attributes such as knowledge, attitude, behavior, advice for antenatal care, and pregnancy outcomes. However, some challenges faced by traditional birth attendants’ role in encouraging women to go to health center for preventive services would be the compliance and refusal of the referral. The implementation case study from Timor-Leste shows that integrating traditional birth attendance into a national healthcare system through Family Health Promoter program has been programmatic effective. It is recommended that the implementation should consider regular communication between health staff and community leaders in recruiting members of family health promoters, and the use of supportive supervision tools to identify weaknesses in the management of this initiative. Conclusion: In Timor-Leste, incorporating traditional birth attendance through family health promoter program has played crucial roles in delivering and increasing access to reproductive health services by women in rural communities of the nation. Whilst it requires a long-term commitment and good partnership, the current reduction in maternal mortality ratio in Timor-Leste is encouraging and serves to illustrate how this initiative aims to improve primary health care delivery and increase number of healthcare workforce. Keywords: Traditional birth attendants, Community health workers, Reproductive health, Family health promoters in Timor-Leste Correspondence: lapazsarmento@gmail.com School of Public Health, Georgia State University, Atlanta 30303, Georgia © 2014 Ribeiro Sarmento; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 2 of 9 http://www.apfmj.com/content/13/1/12 Background and due to limitation of published literatures on commu- Human resources are the key ingredients to a successful nity health workers in Timor-Leste, the search terms were health system functioning [1]. Nonetheless, a large num- not limited to other sub-regional groups obtained from ber of countries are still facing an overall shortage of different developing countries. To try and capture reports qualified health workers to perform and deliver the pri- in the grey literature, Google and key development agency mary health care services [2]. According to the World websites were also searched. Articles were included if they Health Organization (WHO), most developing countries provided some level of systematic review of evidence still experience varying degrees of shortages in qualified such as meta-analysis and observational studies relating to health workers in which current estimates suggest there community health workers in rural settings of low and is a shortage of 4.2 million health workers worldwide middle-income countries. [3]. A greater number of strategies have then been estab- A specific case study from Timor-Leste was utilized lished to overcome this issue. Those strategies include for the discussion of incorporating TBAs in a health care improving salaries and working conditions for qualified system. This case study does not include any experimen- health professionals, providing financial and compensa- tal research nor any research carried out on humans and tion incentives, and increasing capacity building for for- animals and as such did not require an ethical approval. mal health workers [4]. The WHO report also states that latter strategy to respond to the widespread problem of Results human resources for health has focused on the use of Basic roles of CHWs community health workers (CHWs) in the developing CHWs have been defined as the members of community countries where formal health workers are too few to who are selected by the communities to provide care for deliver health care services specifically to the poorest a broad range of health issues including reproductive and most vulnerable communities in the rural and re- and child health to the poorest and most vulnerable mote areas. communities [8]. Before describing the overall perform- The initial concept of CHWs has been used for several ance of CHWs, it is necessary to identify the different decades to render certain basic health care services to terms used for CHWs in different countries across the underserved populations [5]. CHWs have been defined globe (Table 1). as the lay members of community who work exclusively The establishment of CHWs has apparently been asso- to serve people who have lacked access to adequate care, ciated with the growing shortages of human resources and establish vital links between health care consumers within a health system, and the functions of CHWs are and providers to promote health in community settings mainly to help addressing this widespread issue. Despite [6,7]. It seems likely that the concept of CHWs and of being known by different titles, some literatures reveal activities they perform mainly depend upon the local that the tasks performed by CHWs are essentially the context and situation. In specific response to the repro- same. A review study conducted in the year of 1998 ductive and child health, these community-based workers demonstrates that CHWs have performed wide variety sometimes referred to as the traditional birth attendants of tasks including outreach and case finding, health and (TBAs) in some situations, have played important role in patient education, referrals, home visits and care man- providing maternity care based on the local community agement [9]. CHWs help connect health care services needs. It is imperative to further the focus on the TBAs with local communities for the provision of counseling, and the activities that these cadres of health workers health education, treatment and advocates experienced deliver in relation to reproductive and child health. There- in local needs [10]. For example, in the rural settings of fore, this paper summarizes the evidence-based informa- Gambia, Ghana, South Africa and Tanzania, CHWs with tion for the inclusion of TBAs in a health care system in minimal additional training have played vital roles in de- response to reproductive and child health services and livering counseling, treatment and health education for provides a case example from Timor-Leste of how it has such important diseases as malaria, HIV and tubercu- been implemented. losis for the local communities [10]. Indeed, in the South Asia countries like Bangladesh, Bhutan, Nepal and Sri- Methods Lanka, CHWs can help health care systems overcome The case study utilized a non-systematic review of the lit- both personnel and financial shortages by providing high erature using key words such as community health quality and cost-effective services to people in their workers, traditional birth attendants, reproductive health, homes [11]. Therefore, the most probable view on this child health and health outcome. A structured search of would be that by delivering basic health care services to PubMed, MeSH, PMC and Medline was also performed communities, CHWs have improved adherence to treat- for studies published from 1990 up to March 2014. The ment and reduced the burden of time and financial on search terms were limited to English-language publication, both health care consumers and providers. Nevertheless, Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 3 of 9 http://www.apfmj.com/content/13/1/12 Table 1 Alternative title for CHWs in various countries Benefits of CHWs in response to reproductive and child Title Country health services In many poor parts of the world where human resources Activista Mozambique are still in very short supply to provide basic health care, Agente comunitario de salud Peru CHWs have remained a significant workforce in deliver- Agente comunitário de saúde Brazil ing reproductive and child health services. In specific to Anganwadi India TBAs, they have been widely defined as the community Animatrice Haiti or family members (normally females of old age groups) Barangay health worker Philippines who are a product of tradition in assisting mothers dur- ing home delivery [13]. The competence and skills of Basic health worker India TBAs may vary widely across settings. Following the Brigadista Nicaragua years since the introduction of the Safe Motherhood Colaborador voluntario Guatemala Program, training of TBAs has been recognized as one Community drug distributor Uganda of the interventions intended to reduce maternal mortal- Community health agent Ethiopia ity and morbidity rates as well as to improve the repro- Community health promoter various countries ductive health of women [14]. A greater number of public health studies have been undertaken to review Community health representative various countries and identify the explanations for continued existence of Community health volunteer Malawi TBAs, hence their roles in delivering maternity care Community health worker various countries within the poorest communities. Community nutrition worker India One purpose from previous literatures is mainly focus Community resource person Uganda on the identification of the effectiveness of TBA training Female community health volunteer Nepal and its impact on reproductive health outcomes. A series of meta-analysis review identified that there were, Female multipurpose health worker Nepal to varying degrees, positive associations between TBA Health promoter various countries training and maternity care [14]. TBA training was Kader Indonesia found to be associated with significant increases in attri- Lady health worker Pakistan butes such as TBA knowledge, attitude, behavior and ad- Maternal and child health worker Nepal vice for antenatal care [14] and pregnancy outcomes Monitora Honduras [15]. Also, TBA training was significantly associated with referral behavior and maternal service use by women Mother coordinator Ethiopia with obstetric complications [16]. These associations Outreach educator various countries may lead to a significant reduction in maternal mortality Paramedical worker India and morbidity. However, although TBA training may Promotora Honduras have been associated with reduction of a substantial pro- Rural health motivator Swaziland portion of maternal mortality and morbidity, the infor- Shastho shebika Bangladesh mation and material about the training program should be improved and the effect of the training needs to be Shastho karmis (leaders of shastho shebika) Bangladesh evaluated in order to develop a strong evidence base. Sevika Nepal Using the same parameters such as knowledge, atti- Traditional birth attendant various countries tudes and practices, another systematic review also dem- Village drug-kit manager Mali onstrated that TBAs had incorporated the information Village health helper Kenya from the training program into their knowledge and Village health worker various countries practice for prevention, recognition and management of postpartum hemorrhage (PPH) in Gambia [17]. It was Adapted from Lehmann and Sanders [8]. revealed that despite of reducing PPH morbidity and mortality in home births in this setting, there is a need the tasks performed by CHWs may vary enormously by for Gambian TBAs to be trained to implement other settings and community needs. In many rural settings of practices relevant to prevention of this pregnancy com- the developing countries, CWHs sometimes referred to plication in the primary care setting. Similarly, assess- as TBAs, may have also been selected by communities ments in Brazil, Guatemala and Indonesia have shown to represent a major source where pregnant women can- that TBAs can identify early signs of complications dur- not access to maternal health services due to cultural, ing labor and delivery, and successfully refer mothers for socioeconomic or geographic barriers [12]. treatment in health centers by skilled health workers Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 4 of 9 http://www.apfmj.com/content/13/1/12 [18]. From this evidence, it seems likely that training of trained TBAs [21]. The most probable view on this TBAs may result in large improvements in reproductive would be that TBA training in hygienic practice does and child health, hence contribute to substantial reduc- not seem to give impact to the improvement of women tion of maternal morbidity and mortality. reproductive health; therefore, evaluation of the training In addition to performing home delivery and referral program is rigorously required with special attention to system for pregnancy complications, TBAs have also measure the specific outcomes such as maternal morbid- been engaged in some basic health care functions such ity due to postpartum infections. as health promotion and disease prevention. In Sub- Saharan Africa where home births remain a strong prefer- Practical challenges ence and might be often the only option, TBAs have been Involving trained TBAs in reproductive health care has involved in health promotion and disease prevention [19]. several advantages, including ease of access to reproduct- It is indicated that TBAs have played some critical roles in ive care and delivery of care to women in the community. health promotion by preventing mother to child Human However, challenges should be taken into consideration in Immunodeficiency Virus (HIV) transmission in the region order to measure limitations in delivering reproductive where HIV prevalence is remarkably high [19]. Those care. Some barriers of TBAs’ role in encouraging women tasks performed by TBAs have included disseminating in- to go to health center for preventive services would be the formation about perinatal HIV transmission, identifying compliance and refusal of the referral. The reasons might pregnant women in their communities and facilitating the lie within the financial limitation, lack of transportation use of available antenatal care and maternity care, ensur- and patients’ fear of painful treatment from formal health ing routine HIV counseling for women and their partners, workers [22]. Indeed, it seems likely that appropriate train- supervising treatment of mother and infant with nevira- ing and supervision should be provided for TBAs [15]. pine and offering advice to women on reducing the risk of The appropriate training simply means that it has to be HIV transmission [19]. practical-based training. When appropriate training, such In contrast to those findings above, it is argued that as clean practice of cutting umbilical cord (clean labor trained TBAs without the support of skilled back-up ser- practice), is available, these cadres of community health vices may not significantly reduce maternal mortality ra- workers can serve as effective as readily available human tio [17]. A recent cluster-randomized controlled trial resources in mobilizing communities, and delivering re- study in Pakistan demonstrated that involving trained productive care to women in the poorest settings. This TBAs in reproductive care did not reduce maternal mor- would ultimately be applicable to poorest settings where tality, but instead it led to a reduction in perinatal mor- TBA training has not yet been considered as part of an in- tality [19]. The findings showed that a cluster-adjusted novative strategy to combat shortages of human resources odds ratio for perinatal death was 0.70 for intervention in health systems. It is recommended that supervision and sub-districts as compared to control, which suggested direct observation of TBAs at work are critical for clarifi- a significant reduction in perinatal mortality of about cation of the most appropriate role of TBAs in reducing 30% in the intervention group [20]. Therefore, it is maternal mortality and morbidity in the poorest and most likely clear to assume that integrating TBA training vulnerable settings. Therefore, the roles of TBAs should into the health care system could be an effective strat- be functioned by good referral system and sufficient health egy to reduce perinatal mortality, but not maternal infrastructures, equipped with clean-birth kits after train- mortality ratio. ing sessions and supported from professionally trained Similarly, training of TBAs in hygienic practice during health workers during regular supervision [21]. delivery does not prevent postpartum infections [21]. The findings from a study that took place in a rural area Incorporating TBAs in practice: a case study from of Bangladesh illustrated that although trained TBAs Timor-Leste were likely to practice hygienic delivery, there was no Demographic significant difference in levels of postpartum infections Timor-Leste is located in Southeast Asia and Pacific, when delivering births by trained TBAs and untrained northwest of Australia and the east end of the Indonesian TBAs [21]. It seems likely that the inclusion of clean archipelago. The country has a land area of 14,954 square practice in TBA training program is ineffective to pre- kilometers and a population of over one million. The vent postpartum infections. The implication related country’s boundaries include the eastern half of the island to postpartum infections might be due to possible deter- of Timor, the Oecusse enclave in West Timor and the minants such as nutritional factors of the women par- islands of Atauro and Jaco. Timor-Leste gained its ticularly micronutrients and vitamins deficiencies [21]. independence after 25 years of Indonesian occupation Therefore, postpartum infection would not be affected through a referendum made in September 1999. More directly by clean practices at delivery performed by than half of the Timorese are under 18 years of age. In Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 5 of 9 http://www.apfmj.com/content/13/1/12 Table 2 Distribution of national health workers in purely economic terms, Timor-Leste is a middle-income Timor-Leste economy and one of the most oil dependent economies Category Number in the world [23]. The high fertility rate, where on aver- age women give birth to 5.7 children throughout their Assistant Pharmacists 116 lifetime is a key contributing factor to the high annual Environmental Health Officers 27 population growth rate of 2.7 per cent [24]. While much Laboratory assistants 132 of the country remains agrarian, a phenomenon of rapid Medical Practitioners (General Practitioner) 75 urbanization has been reported where about 22 per cent Medical Practitioners (Medical Specialists) 9 of the population lives in the urban areas [25]. The health Medical technicians 48 status at the community level remains low and for many children and women life remains a day-to-day struggle Midwives 53 for survival. Nurses 1800 Nutrition Professionals 31 Maternal and child health situation in Timor-Leste Optometrists 13 Maternal height and pre-pregnancy weight has enor- Pharmacists 15 mous influence over birth outcomes. Shorter and lighter Physiotherapists 1 women are more likely to have babies with low birth Public Health Officers 13 weight. These women are also most likely to experience Public Health Professionals 64 difficulties in childbirth and could likely die. Maternal Sanitary inspectors 160 and under-five mortalities remain high: maternal mortal- ity is 557 per 100,000 live births and under-five mortality Traditional Birth Attendants (Community Health Volunteers) 1647 is 64 per 1,000 live births [24]. Statistics also show that 30 per cent of births are delivered by a skilled nurse or Incorporating TBAs through family health promoters midwife, nearly 18 per cent of deliveries are carried out initiative in Timor-Leste by TBAs and 49 per cent by a relative or some other In 2007 the Ministry of Health (MoH) of Timor-Leste people, which are relatively high [24]. Whilst much have rolled out a national cadre of volunteer Family Health been done to build the capacity of the health sector ser- Promoters or Promotor Saude Familia (PSF) with main vice delivery, it is clear that the quality of services needs objective to increase the number of health workers and to be further enhanced. strengthen its national health system in delivering ma- ternal and child health services including reproductive Healthcare resources in Timor-Leste health intervention program into the community level. Timor-Leste significantly faces some challenges in gener- This initiative has been extensively supported by devel- ating resources for health systems particularly human opment agencies, particularly the government of the and physical resources such as facilities and equipment. United States through its Agency for International Devel- Current workforces in Timor-Leste still suffer shortages opment (USAID). for the provision of health services nationwide [26]. PSFs are community health volunteers that are not Table 2 below illustrates the distribution of national MoH staff nor do not receive a monthly salary for their health workers in Timor-Leste in 2011. work, however, they are provided with incentives. Com- In terms of health structure, the organization for na- munity members are selected to be PSFs by village lead- tional health system consists of central services, and dis- ership and trained by MoH staff to provide basic trict health services (community health centers, health community health services with an emphasis on teach- posts and mobile clinics) (Figure 1) [27]. Relatively, ing and motivation of families they visited, including re- physical resources (facilities) in the district level are productive health. Especially in rural areas, some of the still inadequate and human resources have limited volunteers include TBAs who have played a key role in capacity to provide health care services to all people. assisting pregnant women before, during and after deliv- Assistance from external organizations and individuals ery. These volunteers are also expected to take an active are needed and welcomed. The Ministry of Health of role in conducting health promotion activities through Timor-Leste has collaborated with Cuban government an integrated community health services (also called by employing around 350 Cuban medical doctors to SISCa). SISCa program has been developed to address supplement clinical services in district and sub-district the shortfall of health care service delivery at the com- levels and sending around 680 East Timorese students munity level by improving uptake of preventive health- to study Medicine under the scholarship from Cuban care and access to basic medical services [27,29]. One government [28]. responsibility of PSFs is to conduct home visits and Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 6 of 9 http://www.apfmj.com/content/13/1/12 Figure 1 Overall structure of the Timor-Leste Health System. Adapted from Martins and Trevena [27]. assist health staff when they provide community out- from 660 per 100,000 live births in 2003 to 557 per reach services. In the year of 2009, the number of 100,000 live births in 2010. trained PSFs registered in the database of MoH was over It seems likely that the PSF is both programmatic and 1,500 [30]. The PSF program has been extended along cost effective. There are some strength related to the re- with the introduction of SISCa. cruitment, training, implementation and management of PSFs have been provided with training, materials and this program. They include MoH is able to recruit many supervision in their house-to-house visits with pregnant PSFs, MoH is able to train PSFs, PSFs actively participate mothers in a campaign called Mai Ita Koko (or Come in SISCa program, and SISCa provides solid structure to Let’s Try) [30]. The type of training included basic manage PSFs. Although being effectively programmatic, knowledge to encourage women to attend clinics for there are some specific challenges faced by PSFs during pre- and post-natal care and practice of handling labour implementation in Timor-Leste. A major challenge has with clean equipment. The training was provided by group been the compliance and refusal of the referral due to of skilled health care workers from district level in financial limitation and lack of transportation for pa- conjunction with support from some Non-Governmental tients who reside in rural areas. Another challenge has Organizations (NGOs) such as Care International and been the minimum incentives provided to PSFs, which World Vision. contributes to lack of motivation to provide outreach In the training, eight photo cards that depict relevant activity program. Timorese images and portray recommended maternal Even though many PSFs actively participate in monthly behaviours were developed (Figure 2). The images and implementation of SISCa, continuation to socialize, messages on the cards are simple, clear, culturally rele- supervise and promote the role of PSFs is required to vant, and action oriented. PSFs have been trained to use address the constraints from this initiative as mentioned the cards as an educational tool during home visits and above. Therefore, it is recommended that effective im- to encourage women and families to adopt one or more plementation should consider regular communication behaviours, such as having a skilled birth attendant or between health staff and community leaders in recruit- selecting a family planning method after delivery. The ing PSFs, and the use of supportive supervision tools to chosen behaviour(s) is checked off on a colourful poster identify weaknesses in the management of this initiative. A proper evaluation program should also be conducted that contains each of the photos and is left with the fam- ily to remind them of their choice. to further examine the effectiveness of the PSF initiative. The PSFs follow up with families throughout the mother’s pregnancy to monitor progress toward their Conclusion goals. The home visits have been well received by Despite of being the most important aspect of health mothers who appreciate the support provided by the care systems, human resources have been a neglected PSFs. Since the implementation of PSF program, a sig- component of a health system development. It is im- nificant improvement has been observed in the propor- perative that the engagement of CHWs in the health tion of women receiving antenatal care from a skilled system function should be considered to address the health staff as a result of PSF referral system – an in- growing shortage of formal health workers. This paper crease from 41 per cent in 2006 to 86 per cent in 2010 has identified that although the evidence of whether the [24]. The maternal mortality ratio has also improved roles of TBAs may reduce maternal mortality ratio varies Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 7 of 9 http://www.apfmj.com/content/13/1/12 Figure 2 Photo cards developed for PSFs to use during implementation. Adapted from Health Alliance International (HAI) [30]. by findings, training of TBAs is considered to be an ef- It is evident that TBA training has shown significant re- fective complimentary strategy to attend home births sults in reduction of maternal mortality and morbidity in that still remain high in the poorest countries and in the some developing countries where home delivery is high poorest rural populations within countries. Indeed, this and still the main preference. Findings from some litera- paper has described how Timor-Leste has integrated tures illustrate that substantial improvement in health TBA through PSF program into its basic health service outcomes has been achieved and sustained through the package delivery to reduce reproductive and child health TBA training. It shows that trained TBAs have provided issues of the country. basic level of maternity care, for example, their role in Ribeiro Sarmento Asia Pacific Family Medicine 2014, 13:12 Page 8 of 9 http://www.apfmj.com/content/13/1/12 prevention and management of postpartum haemorrhage. Author’s information DRS holds a Bachelor degree in Medical Science from Latrobe University and Also, the greatest contribution from trained TBAs to re- a Master’s degree in Public Health from the University of Queensland in duce maternal mortality and morbidity can be observed in Australia. DRS is currently enrolled at the School of Public Health of Georgia the area of health promotion, for example, their role in State University in Atlanta under a Fulbright-SERN Scholarship Program. disseminating information to women on perinatal trans- mission of HIV. In delivering reproductive care to women Acknowledgments The author would like to thank Timor-Leste’s government, Fulbright Program, in the community, TBAs may face various challenges such Georgia State University and the Asia Pacific Family Medicine for giving op- as referral compliances that should be considered. In spe- portunity to further enhance technical knowledge as part of education and cific to Timor-Leste, incorporating TBAs through PSF ini- learning aspects. Through this, DRS has a chance to publish this work. tiative has played crucial roles in delivering and increasing Received: 20 March 2014 Accepted: 29 October 2014 access to reproductive health services by women in rural communities of the nation. 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Anderson T: Cuban health cooperation in Timor-Leste and the South West Pacific. In South-South Cooperation: a Challenge to the Aid System, Anderson T. Quezon City, Philippines; 2010. 29. Ministry of Health of Timor-Leste: Integrated Community Health Services: SISCa Guidelines. Dili, Timor-Leste; 2007. 30. Health Alliance International (HAI): Community Health Services in Timor-Leste. USA: United States Agency for International Development (USAID); 2007. doi:10.1186/s12930-014-0012-1 Cite this article as: Ribeiro Sarmento: Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and challenges: A case study of incorporated TBA in Timor-Leste. Asia Pacific Family Medicine 2014 13:12. 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Asia Pacific Family MedicineSpringer Journals

Published: Nov 26, 2014

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