Traditional birth attendants lack basic information on HIV and safe delivery practices in rural Mysore, India

Worldwide, it is estimated that there are more than 60 million non-institutional births each year with the vast majority being attended by traditional birth attendants (TBA) [1]. In most developing countries in South Asia, less than half of pregnant women receive trained medical assistance during their delivery[2, 3]. While shockingly high, this figure still masks an even greater underlying inequality between urban and rural areas where most of the population resides. In developing countries, rural mothers are 40% less likely to be attended by skilled health personnel compared with their urban counterparts[2].

With almost 60% of births occurring at home[4], India faces a variety of challenges in providing high quality maternal child healthcare. Currently, the estimated maternal mortality ratio (MMR) at 450 per 100,000 live births, casts doubt upon the country's ability to reach its Millennium Development Goal of 109 maternal deaths per 100,000 live births by 2015[1]. The country has also made only slow progress in expanding access to antiretrovirals for prevention of mother-to-child transmission of HIV (PMTCT). Each year only about 20% of the estimated 50,000 HIV positive pregnant women receive prophylaxis to prevent transmission of HIV to their infant [5].

There is growing evidence from Africa and other parts of the world showing that TBA may be able to play an important role in improving maternal child outcomes and preventing HIV. Greenwood et al, in their randomized control trial on TBA training in Gambia, demonstrated a 62% reduction in maternal mortality. Their study also showed a significant increase in maternal tetanus immunization rates, and maternal antenatal attendance among mothers delivering with trained TBA[6]. Jokhio and colleagues, in their large cluster randomized intervention study on prevention of perinatal mortality in Pakistan, reported a 20% reduction in perinatal death when TBA were trained and provided with disposable delivery kits[7]. Perez et al, in a large feasibility study of TBA willingness to participate in HIV prevention programs in Zimbabwe, found 75% acceptability among TBA to participate in HIV prevention activities such as accompanying new-borns to closest health centre to receive medication (15%) and assisting health centers in documenting ANC-PMTCT services [8]. Another study in Tanzania showed that women receiving HIV advice from a trained and motivated TBA were three times more likely to accept an HIV test and also had a three-fold increased chance of receiving Nevirapine for prevention of mother-to-child transmission of HIV[9].

There are few recent studies on the birthing practices of TBA in India, and none investigating knowledge and attitudes about HIV. Stella Mulder and Karen Trollope-Kumar in studies from different parts of India reported a number of customary practices among TBA. Mulder observed that many attendants were replacing traditional practices for treating the cord stump with ash or dung[10] with more modern remedies such as antiseptic powder. Similarly, Trollope-Kumar observed that many TBA she studied also administered both allopathic and herbal medicines[11]. Other common TBA practices described in these studies included: providing advice on diet and activity[10, 11], disposing of the placenta through burial[10, 11], delivering women in a supine or crouching position, sprinkling water on the child immediately after birth, and wiping the baby with coconut or castor oil followed by a warm soap bath[10]. Mulder also noted that TBA appeared to have low knowledge regarding many life-threatening complications including excessive bleeding, prolonged labor, and vaginal tears[10].

This study shows that knowledge about HIV/AIDS is extremely low among TBA living in rural areas of Mysore Taluk. An overwhelming majority (88%) of surveyed birth attendants had not even heard of HIV/AIDS, a surprising finding given that the epidemic in India is more than two decades old. This is in stark contrast to high levels of knowledge found by the government of India among the general population in HIV sentinel surveillance surveys. The 2006 National Behavioral Surveillance Survey showed 75 percent of people living in rural areas were aware of HIV/AIDS[15]. Even the small number of TBA in our study, who had knowledge about HIV demonstrated poor understanding about how the virus was transmitted. Additionally, less than half of those were aware of the potential for preventing vertical transmission of HIV. Finally, 39 of the 51 TBA (76%) who had said they had heard of HIV/AIDS, expressed unwillingness to attend the births of HIV-infected mothers.

The level of knowledge about safe birthing practices was also low among TBA. Considering that obstetrical hemorrhage and sepsis are still the leading cause of maternal death in India[16], it is not surprising that the study found only 13% of TBA referred mothers experiencing excessive bleeding following birth to a medical center, and that only about half (51.9%) sterilized equipment prior to deliveries. Other 'unsafe' procedures still practiced among TBA included sucking secretions out of a baby's mouth and nose with their mouth, applying cow dung, ghee (clarified butter) and other preparations on the umbilical cord, and inducing vomiting by stuffing hair in a woman's throat to stimulate contractions of the uterus to clear the placenta. Even more concerning, TBA appeared to have low levels of awareness about when clients should be referred to a hospital. A small number of TBA (4.6%) said they would refer a mother to a medical center if the umbilical cord was wrapped around the baby's head, and just over half (56.8%) would refer the mother if the baby was coming out the wrong way. Most TBA but not all (70%) would refer the woman if the baby was stuck inside the birth canal.

While knowledge deficits on both HIV and birthing practices among TBA appear large, they underline a continuing dilemma for countries like India where more than 60% of the population lives in rural areas[17]. While the Government of India has made substantial investments in increasing rural healthcare through its National Rural Health Mission, access to skilled birth attendance is still an unrealized goal for much of the population. Integrating TBA in the rural health system may be a viable short-term solution for lowering maternal and infant mortality in rural areas with limited access to medical care. Additionally, as some studies in Africa have shown[8, 18], TBA could contribute to HIV prevention efforts, particularly those focused on mother-to-child transmission of HIV. Studies in India have already demonstrated that training TBA can improve newborn care[19], increase uptake of maternal health services[20], and reduce neonatal mortality[21]. The difficulties of training TBA should not be underestimated however. Many have low levels of literacy and some may not be interested in further training. Attention must be given to making instruction relevant to the local cultural milieu in which TBA practice and germane to the realities of rural birth attendance. Furthermore, any effort to integrate TBA must be harmonized with national health policies and the existing priorities of the National Rural Health Mission. Given all these challenges, training TBA may still be India's best hope for reaching Millennium Development Goal 5 by 2015.

Traditional birth attendants will continue to play an important role in maternal child health in India for the foreseeable future. This study demonstrates that a majority of TBA lack basic information about HIV/AIDS and safe delivery practices. Given the ongoing shortage of skilled birth attendance in rural areas, more studies are needed to examine whether TBA should be trained and integrated into PMTCT and maternal child health programs in India.