Traditional Birth Attendants in Developing Countries Cannot Be Expected to Carry Out HIV/AIDS Prevention and Treatment Activities

Abstract

Pregnancy and birth, fertility and fertility regulation are all greatly affected by the exigencies of HIV and AIDS, and vice versa. Women and infants can only benefit if the respective policymakers, researchers and service providers in sexual and reproductive health and HIV/AIDS, particularly those involved in prevention of mother-to-child transmission of HIV, gain greater knowledge of each others' expertise and seek to integrate the best of both into the care they each offer. The growth in access to antiretroviral treatment for mothers as well as infants, including during pregnancy and the breastfeeding period, makes such efforts even more timely and crucial. Yet there are worrying signs that specialists in both camps are making inappropriate policy and service delivery recommendations based on too little knowledge of each others' patches. As an example of this problem, this article discusses and rejects a recommendation in a recent BMJ article that traditional birth attendants could be trained to carry out HIV prevention and possibly provide HIV tests and drugs for prevention of HIV transmission during home deliveries in developing countries.

Résumé

Les spécialistes du VIH/SIDA, particulièrement en prévention de la transmission du VIH de la mère à l'enfant, et les spécialistes en santé génésique se rendent compte que leurs domaines respectifs se chevauchent, une évolution prometteuse et cruellement nécessaire. La grossesse et l'accouchement, la fécondité et la régulation de la fécondité sont autant de domaines profondément touchés par le VIH et le SIDA, et vice versa. Si les décideurs, les chercheurs et les prestataires de services à tous les niveaux se familiarisent davantage avec les compétences de leurs homologues et s'efforcent d'intégrer le meilleur des deux domaines dans les soins qu'ils assurent, cela ne pourra être que bénéfique pour les femmes et les nourrissons. L'accès élargi des mères et des nouveau-nés au traitement antirétroviral, notamment pendant la grossesse et l'allaitement, rend ces efforts encore plus essentiels. Pourtant, il semble que des spécialistes des deux camps fassent des recommandations erronées sur les politiques et la prestation des services, dues à une connaissance insuffisante des secteurs de chacun et à un manque de consultations, au lieu de mieux intégrer les services et de collaborer plus étroitement. A titre d'exemple, l'article étudie la recommandation d'un récent article du BMJ estimant que les accoucheuses traditionnelles pourraient être formées à la prévention du VIH, et fournir des tests du VIH et des médicaments pour prévenir la transmission du VIH pendant les accouchements à domicile dans les pays en développement.

Resumen

La creciente conciencia de parte de los especialistas en VIH/SIDA— especialmente aquellos que trabajan en la prevención de la transmisión de VIH de madre a bebé—y los especialistas en salud sexual y reproductiva de los nexos importantes entre sus respectivas áreas de trabajo es un acontecimiento necesario y esperanzador a nivel global. El embarazo y el parto, la fertilidad y la regulación de la fertilidad están todos muy afectados por las exigencias del VIH y el SIDA, y viceversa. Las mujeres y los bebés sólo pueden beneficiarse si quienes elaboran polı́ticas, los investigadores y los proveedores de servicios a todos los niveles de la atención en salud comparten sus respectivos conocimientos y buscan integrar lo mejor de cada área en la atención que ofrecen. Al aumentar el acceso al tratamiento antirretroviral para madres y bebés durante el embarazo y el perı́odo de lactancia, estos esfuerzos se hacen aún más cruciales y oportunos. Por lo tanto, es preocupante que especialistas en ambos campos hagan recomendaciones inapropiadas—tanto de polı́tica como de provisión de servicios—sin suficiente conocimiento de la otra área y sin consultar con sus contrapartes, en lugar de buscar una mayor integración de los servicios y estrechar su trabajo en común. Un ejemplo es la recomendación publicada en un artı́culo reciente del BMJ de capacitar a las parteras tradicionales en la prevención del VIH y posiblemente la provisión de exámenes de VIH y drogas para la prevención de la transmisión de VIH durante los partos en el hogar en los paı́ses en desarrollo.

Key Words:

• HIV/AIDS
• maternity services
• integration of services
• prevention of mother-to-child transmission of HIV
• traditional birth attendants

The failure to provide birthing women with proper delivery and post-partum care in developing countries, most pronounced in rural areas of the poorest countries, has been spotlighted by global initiatives in maternal mortality and for safe motherhood since the 1980s. Until quite recently, many health professionals and policymakers in the Safe Motherhood movement have supported the training of traditional birth attendants (TBAs) as an alternative to the more expensive route of fully trained midwives for normal births and emergency obstetric services to handle complicated cases. It has long been recognised,¹ however, and is now widely accepted, that training of TBAs is not a solution to preventing maternal mortality. This is because TBAs simply do not have the resources or skills to do more than assist at uncomplicated births in very basic ways. Furthermore, they are not health workers but women giving childbirth assistance mainly in their local village to women who do not wish to seek or cannot access assistance from formal health service providers.² As such, they mostly do not work with the formal health system or attend very many births each year. Managing pregnancies and deliveries, particularly in HIV-positive women, as well as carrying out HIV testing and counselling for pregnant women involve a level of technical complexity that TBAs simply do not have.

According to a 1998 World Health Organization report, most TBAs have had one month or less of training related to delivery care alone, and studies in Africa and Asia have found that training TBAs in the absence of skilled back-up support did not decrease women's risk of dying in childbirth.² Where the resources for and access to a more skilled level of care are available, women are seeking that care, and TBAs are slowly but surely being consigned to history—which is where they belong.

I was therefore taken aback to read an article in the BMJ special issue on “Global voices on the AIDS catastrophe” in January 2002³ that suggested involving TBAs in information dissemination on HIV, promotion of HIV prevention, and even HIV testing and counselling and provision of nevirapine at home deliveries to prevent perinatal HIV transmission. The article points out that an estimated one million HIV-positive pregnant women worldwide give birth each year without professional help. The goal, it says, would be to “extend the benefits of recent advances in perinatal HIV research” to women in the poorest rural communities of developing countries—in addition to their role in assisting women giving birth at home and in post-partum care.⁴

This is a valiant goal but not for TBAs to carry out, as those with experience of TBAs will know.⁵ The fact is that a total of 60 million women in developing countries deliver at home without trained assistance each year. Nor are all these births always attended by TBAs, but often by relatives or no one at all,⁶ as shown in the most recent Demographic and Health Survey data.(Table 1)

Table 1 Attendant at delivery by region (%)⁷

Region	Doctor	Other skilled attendant	TBA	Relative	No one	Don't know
Sub-Saharan Africa	5.8	39.1	22.2	26.8	5.9	0.4
Middle East/North Africa	45.2	21.2	16.2	15.6	1.6	0.3
Asia	16.6	24.6	40.8	16.4	1.6	0.3
Latin America/Caribbean	47.8	16.4	24.4	9.7	1.4	0.4

* Compiled from the most recent available Demographic and Health Survey data using stat compiler.

⁷

Finding TBAs, let alone training them, has proved problematic for the Safe Motherhood movement (see Allotey⁸, for example). And even if they could be trained, neither their outreach nor their scope of practice is likely to make any significant inroads into the HIV epidemic. It has been less than ten years since the expectations on TBAs have finally been reduced to a more realistic level among most Safe Motherhood proponents. The last thing we need is for HIV experts to repeat the same mistake from a new angle.

This mistake is unfortunately part of a worrying trend rather than an isolated example. Although those with expertise in HIV/AIDS on the one hand, and those with expertise in sexual and reproductive health on the other, have become increasingly aware of the important intersections between their respective areas of work, they are sometimes proposing inappropriate policies and making unrealistic recommendations for service delivery based on too little knowledge and too little joint consultation and work with colleagues in each others' fields.

UNAIDS guidelines have long recognised the intersections between HIV/AIDS prevention and treatment and women's reproductive and sexual health needs. Thus, the guidelines for prevention of mother-to-child transmission of HIV (PMTCT)⁹ in the context of pregnancy include:

•	prevention of HIV infection in women who are pregnant and all women of childbearing age, which includes promotion of safe sexual behaviour, condom promotion and STI treatment;
•	prevention of unwanted pregnancies, which includes family planning and abortion; and
•	prevention of HIV transmission to the infant by the HIV-infected mother, which includes STD screening and treatment, prophylactic treatment with antiretrovirals, avoidance of unnecessary invasive obstetric procedures, and alternatives to prolonged breastfeeding.

Several regimens for delivery of short-course antiretroviral treatment for PMTCT have been fully field tested in developing countries and approved, and could be delivered through scaled-up national programmes. Of course as long as there is no one to administer HIV tests or deliver these drugs to women giving birth at home, the public health impact of such programmes will be greatly reduced. Even so, TBAs simply cannot be expected to assume this burden of care.

The UNAIDS guidelines advocate access for women to adequate antenatal, delivery and post-partum care,⁹ and call for:

•	early access to antenatal care (ANC) before 34–36 weeks of pregnancy;
•	voluntary HIV counselling and testing;
•	a minimum package for ANC including screening and treatment of anaemia and STIs, and vitamin supplementation;
•	delivery care by a skilled attendant; and
•	counselling on infant feeding and caring, and support for the mother's infant feeding choice.

Existing antenatal and delivery services are often not comprehensive and not always of the best quality, but more women are starting to use them in all developing country regions (Carla AbouZahr, World Health Organization, personal communication, recent data analysis, 2003). Simply making more of these services available and training more skilled attendants would go a long way towards achieving these goals. Issues of quality and access certainly need to be addressed, but the point is that women will use formal services once they are available, and it is crucial to build on that, rather than look backwards.

AIDS has become an important underlying factor in direct maternal deaths, an indirect cause of maternal deaths in itself and a contributor to other indirect causes of maternal deaths.¹⁰ In addition to PMTCT, antiretroviral treatment is finally being made available to keep pregnant and breastfeeding women with HIV infection healthy as well as prevent infection in their infants,¹¹ not only in the developed world but also for a small but growing number of women in developing countries. An integrated approach is thus called for in developing countries,¹² in which women receive skilled antenatal, delivery and post-partum care and benefit from antiretroviral treatment for HIV infection for themselves, while preventing perinatal and breastfeeding transmission of HIV to their infants.

To reach those giving birth at home, antenatal, delivery and post-partum services must be available for all 60 million women in need of them; that is the best way to reach the one million pregnant women globally with HIV. Given that both a reduction in HIV/AIDS infection, improvements in maternal health and reductions in maternal mortality and morbidity are part of the Millennium Development Goals,¹³ it would seem reasonable to call for priority attention by governments to these tasks without further delay.

Acknowledgements

An earlier, shorter version of this commentary was posted on the BMJ website in October 2002. Thanks to Carla AbouZahr for providing data.