An Intervention Involving Traditional Birth Attendants in Pakistan
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The findings reported by Jokhio et al. (May 19 issue)1 are encouraging in that the intervention involving traditional birth attendants significantly reduced perinatal mortality. Disappointingly, however, it had no significant effect on maternal mortality. Some data suggest that traditional birth attendants may be counterproductive in reducing maternal mortality.2 In the developing world, 440 of 100,000 births result in maternal death, as compared with 12 of 100,000 in the developed world.3 To achieve any significant reduction in maternal mortality in the developing world, it may be necessary to phase out the involvement of traditional birth attendants and move toward developing a base of professional midwives and good antenatal care.4 The study by Jokhio et al. shows that partly trained traditional birth attendants are an important stopgap in making delivery safer, but we must all strive toward the goal of helping the developing nations build their professional maternity services in order to reach the Millennium Development Goals of reduced child mortality and improved maternal health by 2015.
James B. Davis, M.B., Ch.B.
Birmingham Women's Hospital
Birmingham B15 2TG, United Kingdom
baffoe1@yahoo.com
References
Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352:2091-2099.
Liljestrand J, Pathmanathan I. Reducing maternal mortality: can we derive policy guidance from developing country experiences? J Public Health Policy 2004;25:299-314.
UNICEF. Maternal mortality statistics. (Accessed September 8, 2005, at http://www.childinfo.org/eddb/mat_mortal/.)
Manandhar DS, Osrin D, Shrestha BP, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-979.
The authors reply: We agree with Dr. Davis in his support for making professional maternity services available to all, but we do not underestimate the task of achieving this goal in developing countries that have large rural communities and minimal midwifery services.1
Dr. Davis's opinion that training traditional birth attendants has little effect on reducing maternal mortality is widely held but is not supported by good-quality evidence.2 In addition, neither ongoing support nor integration with existing health services formed part of previous widely applied training initiatives.
Our study showed that training and integrating traditional birth attendants within an improved system of delivering maternal health care reduced perinatal deaths by about 30 percent. Despite its large size, our trial was not powered to detect a reduction in maternal mortality of a similar size. The Nepal trial referred to by Dr. Davis supports the hypothesis that community-level intervention resulting in clean delivery and better links with existing services can improve neonatal and maternal outcomes.3
In striving toward the Millennium Development Goals, we believe that our findings show that large gains can be made while we work to achieve professional maternity services for all.
Abdul Hakeem Jokhio, M.B., B.S., Ph.D.
Liaquat University of Medical and Health Sciences
Jamshoro, Pakistan
jokhiohl@super.net.pk
Heather R. Winter, M.D.
Kar Keung Cheng, M.B., B.S., Ph.D.
University of Birmingham
Birmingham B15 2TT, United Kingdom
References
International commitments to safe motherhood. (Accessed September 8, 2005, at http://www.safemotherhood.org/commitments/.)
Sibley L, Ann Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20:51-60.
Manandhar DS, Osrin D, Shrestha B, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-979.
James B. Davis, M.B., Ch.B.
Birmingham Women's Hospital
Birmingham B15 2TG, United Kingdom
baffoe1@yahoo.com
References
Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352:2091-2099.
Liljestrand J, Pathmanathan I. Reducing maternal mortality: can we derive policy guidance from developing country experiences? J Public Health Policy 2004;25:299-314.
UNICEF. Maternal mortality statistics. (Accessed September 8, 2005, at http://www.childinfo.org/eddb/mat_mortal/.)
Manandhar DS, Osrin D, Shrestha BP, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-979.
The authors reply: We agree with Dr. Davis in his support for making professional maternity services available to all, but we do not underestimate the task of achieving this goal in developing countries that have large rural communities and minimal midwifery services.1
Dr. Davis's opinion that training traditional birth attendants has little effect on reducing maternal mortality is widely held but is not supported by good-quality evidence.2 In addition, neither ongoing support nor integration with existing health services formed part of previous widely applied training initiatives.
Our study showed that training and integrating traditional birth attendants within an improved system of delivering maternal health care reduced perinatal deaths by about 30 percent. Despite its large size, our trial was not powered to detect a reduction in maternal mortality of a similar size. The Nepal trial referred to by Dr. Davis supports the hypothesis that community-level intervention resulting in clean delivery and better links with existing services can improve neonatal and maternal outcomes.3
In striving toward the Millennium Development Goals, we believe that our findings show that large gains can be made while we work to achieve professional maternity services for all.
Abdul Hakeem Jokhio, M.B., B.S., Ph.D.
Liaquat University of Medical and Health Sciences
Jamshoro, Pakistan
jokhiohl@super.net.pk
Heather R. Winter, M.D.
Kar Keung Cheng, M.B., B.S., Ph.D.
University of Birmingham
Birmingham B15 2TT, United Kingdom
References
International commitments to safe motherhood. (Accessed September 8, 2005, at http://www.safemotherhood.org/commitments/.)
Sibley L, Ann Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20:51-60.
Manandhar DS, Osrin D, Shrestha B, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-979.