Editorial: Integrating continuous support of the traditional birth attendant into obstetric care by skilled midwives and doctors: a cost‐effective strategy to reduce perinatal mortality and unnecessary obstetric interventions

In the beginning of 2003, one of the authors (JvR) was privileged to attend a home birth in The Gambia guided by a traditional birth attendant (TBA). The woman was a gravida 2 para 1 and had started labour in the morning. Everybody in the whole compound was anxiously waiting for the child to be born. Nobody (the TBA included) would know whether the baby would be born alive, because there was no foetal monitoring whatsoever. The TBA gave continuous emotional support to the woman, an evidence-based strategy to improve the outcome of labour (Hodnett et al. 2004). She would have been rather empty-handed had serious complications suddenly occurred. Only in the case of postpartum haemorrhage (PPH) she would be able to administer misoprostol to the woman (Walraven et al. 2004). In fact the TBA was participating in a randomized trial of misoprostol for the prevention of PPH and although she was illiterate, she was able to follow the necessary procedures for the trial (Walraven 2003). In case of obstructed labour, antepartum haemorrhage, transverse lie and eclampsia, the TBA would have had no tools to deal with these serious complications. Hence, TBAs will not have any impact to reduce the appallingly high maternal mortality ratios in the less privileged parts of our global village. TBA practice was therefore considered to be of less value and the international safe motherhood movement started from 1997 onwards to concentrate on skilled attendance during labour and emergency obstetric care when complications would occur (Kruske & Barclay 2004). In the early afternoon, the woman gave birth to a full term normal weight baby with an Apgar score of 9/10 and there was great relief and joy all over the place. How different, however, is the situation in many of the delivery rooms of health facilities in sub-Saharan Africa and Asia. Pregnant women in labour are generally not allowed to bring a relative with them into the labour ward to give continuous support. One of the authors (JvR) happened to be a guest-worker early this year in the big university hospital in Dar es Salaam with a case load of 30–60 births a day. Women in labour lay in bed in complete isolation in pain without a continuous support giver. They are assessed by medical students, intern, resident and specialist doctors and midwives infrequently, in view of the overwhelming numbers. Those workers are trained in life-saving skills, but they seem to have forgotten (or may never have been taught) the importance of continuous emotional support. This aspect of care seems not to be emphasized, and assumed to be impossible or neglected in the prevailing circumstances. Lack of emotional support for women in labour has been described as ‘violence against women in health-care institutions’ (d'Oliveira et al. 2002). Furthermore, when women have caesarean sections, the newborns are admitted to the neonatology ward, because the woman cannot care for the baby herself without the help of a caregiver. This practice does contribute to an already high perinatal mortality rate (of over 120 per 1000), while at the same time the caesarean section rate (of over 30%) is extremely high (Kidanto et al. 2004). Continuous support for women during childbirth, especially when the caregiver is not a member of the hospital staff, when it begins in early labour and in settings where epidural analgesia is not available, has been shown in a Cochrane Review to be effective in reducing operative vaginal birth and caesarean section (Hodnett et al. 2004). It also reduces the need for intrapartum analgesia and women report less dissatisfaction with their childbirth experiences. In addition to the midwifery and emergency obstetric care skills provided by midwives and doctors, women in childbirth thus need continous emotional support, nowadays often only provided by TBAs. ‘Being supported’ is one of the major factors which determine women's positive perceptions of their birthing experience (Fenwick et al. 2003). International safe motherhood programmes have forgotten to pay attention to this important part of obstetric care. It is now time to recognize that we need both in our labour rooms and that we should allow women to bring a continuous support giver with them into the labour ward. For reasons of privacy this can only be other women in the large labour wards in low resource countries. We have to resist the objections which will be made by the professional caregivers as they may not be willing to accept people, not in pain, who watch their performance. The introduction of the continuous supportive caregiver will lead to better perinatal outcome and less unnecessary intervention. It is a strategy that can be implemented immediately without any cost. Now is the time to introduce this in all those places where women up till now suffer from anxiety and loneliness during childbirth. Perinatal care should be re-humanized (Chalmers 2002).