Editor

LETTERS TO THE EDITOR

EDITOR: The entire July/August 2001 issue of the Journal of Midwifery & Women’s Health, devoted to international health, is of particular interest to me as I have been a consultant for the American College of Nurse-Midwives’ Global Outreach department for 4 years, most recently involved in Life Saving Skills Training of Trainers in Cambodia. Of special interest is the article by Gloyd et al, “Impact of Traditional Birth Attendant Training in Mozambique: A Controlled Study” (pages 210 – 6). The study design is commendable, especially the sample size; it was a prodigious research accomplishment. My comments stem from the discussion and analysis. The authors state, “the study failed to demonstrate a reduction in mortality (perinatal?) associated with TBA training.” Yet, a reduction in mortality can only truly be demonstrated by a longitudinal study design and not a “comparative synchronous” study as this was. Again, the hypotheses of the study, evidenced only through inference in the discussion, purported to show impact of training; but, impact is indeed difficult to “tease out” without the longitudinal power of that design. How was a training program that included only infection control and knowledge of danger signs for referral expected to significantly impact mortality by comparing three groups in a population that all received comparable rates (93–98%) of prenatal care? This statistic infers that all three groups had comparable access to, and utilization of, governmental health posts or clinics. Also, the “trained TBAs had no medicine” or other means to deal with complications. One of the most interesting points of discussion was the issue of constraints on the relationship of the mbuya to her neighbors. Having lived for many years among chiManyika speaking people in eastern Zimbabwe, I see this as a very important point to raise. However, other issues were glossed over, such as the “cost” to the family in leaving home to go to a health facility for delivery. Normally, pregnant women go to the health facility days or usually weeks in advance to await birth, leaving young children and household affairs under the often dubious supervision of young people. In evaluating the significance of TBA training, it concerns me that mostly negative connotations were brought out. If the basic assumption is that better-trained attendants should equal better outcomes, then it is somewhat amazing the group that had the least percentage of

births at a health facility (Group 1– 43%, as compared to 58% and 77%) had outcomes at least as good as the others. It was noted that increased use of trained TBAs seemed to reduce the numbers who went to health facilities. If outcomes were the same, what would be the advantage for many women in leaving home? To me, the study shows that all three groups are impacted by the same socio-economic factors: lack of supplies, difficult transport to the provincial hospital, etc. Women who used the trained TBAs preferred having a TBA at the birth. That is a high commendation indeed. It was significant that, after training, the numbers of births attended by these TBAs increased. That is a valid impact result. Another impact reported was that the trained TBAS in group 1 were able to mobilize a significant number of people for Family Planning. I agree with the final analysis of the study, which recognizes the ideal of combining well-prepared TBAs with a system that permits feasible access to the support of professional midwives and other health services. Winifred W. Thomas, CNM, MSN Dayton, Ohio AUTHOR’S RESPONSE: Ms. Thomas is correct that our study design could not demonstrate a “reduction” in mortality. The uncontrolled longitudinal studies we cited have shown temporal mortality reductions associated with TBAs that are not very convincing given the external factors that contribute to mortality change. We believe a controlled longitudinal study with a comparable sample should be done; it would certainly have more power than our study. Our design did, however, have considerable power and did not detect a significant difference in mortality between sites with trained TBAs compared to comparable sites without trained TBAs. I hope we did not imply that the TBA training was limited to hygienic delivery and referral. The courses were well supervised, participative in nature, and followed training norms of UNICEF and WHO. The initial TBA training was in groups of 10 and lasted 3 weeks. Thereafter, each group received an annual refresher course of 1 week. Although TBAs were not given oxytocin or other medicines, they were provided rather expensive UNICEF TBA kits. Moreover, each TBA was supervised and furnished bleach, soap, and kerosene every 3 months. This was a model program for Mozam-

Journal of Midwifery & Women’s Health • Vol. 47 No. 1, January/February 2002 © 2002 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.

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bique; their training, supervision, and work was certainly comparable to any in the country and superior to many TBA programs I have seen worldwide. Access to government health facilities was poor in both of the rural zones: group 1 with and group 2 without TBA training. The high proportion of women reporting at least one prenatal care visit in both groups is likely because of the long history of sustained community education and mobilization in these rural communities. The same explanation is probably related to the unexpectedly high proportion of women in these rural communities (including those living close to trained TBAs) who reported having managed to obtain health facility births. The issue of the cost to the family of a pregnant woman leaving her dependents for several weeks to be near a health facility for birth is troubling for us as well; such a cost may exceed the potential benefit of a health facility birth. However, the consistent preferences for and obtainment of health facility births reported by the women in this study has made us reconsider what had previously been a reluctance to building waiting houses at health facilities for pregnant women near term. Nevertheless, it is arguable that given the conditions of inadequate staffing, supervision, equipment, morale, and transport at these facilities, their preference for health facility birthplace may not be in their best interests. Structural adjustment programs linked with debt repayment have slashed public health spending and made the public health sector dependent on donor policies, which have often shifted resources from health care infrastructure development to community-based initiatives. By the time of the study, training of elementary midwives had completely ceased in Mozambique and national maternal health programs was focused primarily on TBA training and support. Ironically, investment in the TBA program has, at least in Mozambique, contributed to the inadequate conditions at health facilities to which the TBAs should be able to refer their clients. Although births at health facilities with inadequate staffing and conditions should also not be assumed to be safer than home births attended by TBAs, the literature suggests that good and accessible maternity facilities will reduce mortality in resource deprived countries. We do not believe that our conclusions focused on negative connotations of TBAs. We were pleased with the increased family planning reported in TBA zones. Our findings simply did not support what have been widespread and sometimes romantic assumptions of the efficacy of TBA training in mortality reduction in a large sample of outcomes. Our conclusion is consistent with that of Ms. Thomas; we believe TBA training programs should be maintained or even expanded as long as they do not divert resources from investing in a health care infrastructure with trained midwives and doctors who

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can provide essential birth care. Moreover, client preferences for health facility birth should be considered when making decisions on how resources are allocated. Stephen Gloyd, MD, MPH Health Alliance International and University of Washington Seattle, WA EDITOR: I am writing to express my concern over the advertisement in the July/August 2001 issue of the Journal of Midwifery & Women’s Health entitled, “Early Options: Educating Physicians and Women About Medical Abortion.” I feel this advertisement crosses the line of product or program advertisement into the whole controversial field of abortion. I don’t think it belongs in the journal. In reading the entire page, there is no question about its support for abortion. The continuing education program includes topics on “medical abortion regimens, patient management, patient counseling, the role of ultrasound and early surgical abortion in medical abortion care etc.” The use of the word “options” in this advertisement certainly does not indicate that “other options” to medical abortion are intended or supported. Also, the disclaimer under “General Information” in the journal, after the masthead page, states that “the publication of controversial viewpoints expressed within manuscripts, Letters to the Editor, Exchange Columns, and Issues and Opinions does not imply endorsement by the journal etc...” On the same page, the disclaimer for advertising material is for products. The advertisement I am protesting about is neither a manuscript etc. as mentioned above, nor a product, but is advertised as, “an ongoing program of continuing medical education exclusively in abortion practice.” It includes a medical product which is a part of a much larger program about abortion practice. Personally, in my past practice as a midwife, I have cared for many women who have planned for or have undergone abortions as I would care for any woman without laying my feelings on them. However, in a broader context of my own spiritual and moral construction, I feel very strongly about the destruction of life in the abortion process and do not wish to support any organization that encourages or supports it without at the same time offering other valid options. This advertisement in the journal by the National Abortion Federation Hotline does not indicate that it offers other valid options. I don’t feel the indicated journal disclaimers disassociates the publisher or the ACNM from support of the advertisement. Sr. Teresita Hinnegan, CNM, MSW Pennsylvania

Journal of Midwifery & Women’s Health • Vol. 47, No. 1, January/February 2002