INTRODUCTION AND BACKGROUND
Maternal and neonatal mortality are important public health issues in low and middle income countries (Patton et al, 2009). Reducing maternal and neonatal mortality rates was part of the Millenium Development Goals (MDGs)(Table 1) with unequal results in different countries, and it remains as an objective of the Sustainable Development Goals (SDGs)(Table 2).
Mexico’s maternal deaths rate is not as high as it is in some African or South Asian countries, but despite the efforts from the health authorities to reduce it, Mexico did not meet with the Millenium Development Goal of reducing the maternal mortality rate by three quarters by 2000 (OMS, 2015).
The maternal mortality in Mexico in 2018 was 30.2 deaths per 100,000 births (Direccion General de Epidemiologia, 2019), below the target stablished by the SDGs, the problem is the inequality, whilst that is the average maternal deaths rate for the whole country there is a big difference between regions. The risk of death related to pregnancy, delivery or puerperio in some states is 7 times higher than the risk in the states with the lowest rates of maternal mortality. These states have two things in common, they are also the poorest states in Mexico and they have a predominantly indigenous population (Direccion General de Epidemiologia, 2019). The risk of maternity related death is three times higher in indigenous women than in non-indigenous. (Enciso, 2014)
Another important characteristic of these regions is that a high percentage of the deliveries are attended by Traditional Birth Attendants (TBAs). () And there is also a relation between the origin of the woman and where they give birth. In two predominantly indigenous municipalities in Southern Mexico, 71% of the indigenous women gave birth at home versus the 18% of non-indigenous. (De Jesus-Garcia et al, 2018).
WHO (1992, pag.4) defines traditional birth attendant (TBA) as “a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship to other TBA.”
It has been demonstrated that investing in competent, motivated and supported midwifery personnel is a cost-effective strategy to improve the quality of care and maternal and neonatal outcomes (UNFPA, ICM, and WHO, 2014) and the incorporation of TBAs to the institutional programs of health is paramount to reduce the number of deaths related to pregnancy and birth. (Laureano et al, 2014).
The aim of this essay is to describe the work of the TBAs in rural areas of Mexico and explore how involve them to reduce the birth related death in these areas. With this aim a narrative bibliographic review has been done to reflects the findings of the most relevant studies.
The fact that most of the birth related deaths occur in areas with a predominantly indigenous population and where a high proportion of the births are attended by TBAs have made that numerous physicians blame TBAs of this health problem. This affirmation comes from an etnocentrist point of view and it does not take of other circunstances that surround the work done by the TBAs.
Just two studies have been found comparing the complications related to vaginal delivery in hospital and traditional care systems.
Mendez-Gonzalez and Cervera-Montejano (2002) observed that the total number of complications was similar among the two systems. Although there was a difference in who suffered these complications, being the maternal complications significantly higher when the birth was attended in the hospital and the number of neonatal complications higher in births attended in traditional delivery care.
Most of the complication occurs in women attended in hospital were related to clinical interventions, sometimes performed as a routine in despite of the current guidelines that recommend to perform these interventions where they are really needed (WHO, 1997; Jiang, 2017). More of the complications in women attended in hospital were related to the episiotomy and cannulation (Mendez-Gonzalez and Cervera-Montejano, 2002).
These results are coherent with what De Jesus-Garcia et al (2018) observed when they compared the incidence of perineal trauma in births attended in hospital by physicians and at home or other rural health facilities by TBAs. Being attended by a traditional midwife is protective (OR 0.41, 95% IC: 0.32-0.54). Protective factors for a perineal trauma are home delivery, indigenous ethnicity and upright posture in labour (De Jesus-Garcia et al, 2018).
This is in line with the evidence that suggests several benefits of giving birth upright (Gupta et al, 2017), and the fact that while TBAs in Mexico tend to attend deliveries in this posture, this is not the case in hospital, where very often the woman is not offered the option to choose how she wants to give birth and they are forced to do it in lithotomy posture.
Regarding the higher risk of neonatal complications after births attended by TBAs, some of them are are related to the resources that they have access to. The incidence of neonatal conjunctivitis was a 6.7% when the delivery was attended by TBAs versus a 0% when was attended in hospital. However, a deeper analysis of the data shows that just 56.7% of the TBAs could apply an antibiotic ointment in the eyes of the neonates versus a 100% in the hospital (Mendez-Gonzalez and Cervera-Montejano, 2002), which indicates more a supply problem than a bad praxis.
Mendez-Gonzalez and Cervera-Montejano (2002) observed also that only 68.3% of the TBAs had a delivery box available, however they know how to disinfect the instrumental and they used a disinfected instrument to cut the umbilical cord in 97.1% of the births attended.
Most of the deliveries attended by traditional midwives take place in rural areas at the woman’s house (Arguello-avendano and Mateo Gonzalez, 2014; De Jesus-Garcia et al, 2018). ). This means that usually TBA are not able to do their jobs in the nbest hygienic condition and some complications may be related to the place where they work and to how they work.
Laureano-Eugenio et al (2014) met with 84 TBAs form 51 different municipalities of the state of Jalisco. During this meeting the TBAs complained about the abandonment and discrediting of their practice by some health professionals from the national health system, but they showed openness to receive training and work in teams with them when this is planned from the respect and recognition to their beliefs and practices.
Most of the maternal deaths are preventable. The three main causes of maternal death worldwide are severe post-partum haemorrhage, hypertensive disorders and sepsis (Say et al, 2014). In Mexico, 23.2% of the maternal deaths were caused by a severe haemorrhage, 21.7% by hypertensive disorders and third casuse differs from the worldwide data, being in Mexico abortion, that caused 8.7% of the maternal deaths (Direccion General de Epidemiologia, 2019).
Regarding the first cause. TBAs in Mexico have shown some knowledge to detect when a delivery may be complicate and need to be attended in a hospital, and they recommend the women to go to the hospital for further investigations and to give birth (Pelcastre et al, 2005; Anderson et al, 2004). However, not all of them follow this advice, and they finally search the help of the TBA when they about to give birth. This could be an explanations for the higher rates of maternal mortality in births attended by TBAs despite of their advises.
There are two main barriers that indigenous women face and that prevent them to attend a hospital to give birth when they have been advised to do so. One is geographical, indigenous in Mexico live often in rural and isolated communities with very bad roads if any that very often became flooded or obstructed, this means a several hours travel to get the hospital (Pelcastre, 2004). In addition, they sometimes do not have a mean of transport and often they can not afford to pay for the travel, or they cannot leave their home because they have other children to take care of, since the husband usually spend the day outside.
This lack of health facilities is more acute in indigenous areas, In Xochistlahuaca, a rural predominantly indigenous area of Mexico, just 2 of the 116 communities have a health center, in Tlacoachistlahuaca, an area with 21,000 residents, just 7 of 53 communities have medical facilities. (De Jesus-Garcia et al, 2018).
The other barrier is cultural. Even women who have access to a hospital prefer to be attended by a TBA (Anderson, 2004). In a region of the southern state of Chiapas, only 8% of the deliveries took place in the health unit closest to the woman’s home. The reasons stated were the perception of poor attention and lack of trust in these centers (Sanchez, 1998). Some women in these areas do not want to attend institutional health facilities because they fear of bad treatment and being cut (episiotomia), as well as that 64% of this women does not speak Spanish and the staff in the hospital does not speak their language (De Jesus-Garcia et al, 2018). This can made them to not attend a hospital even when potential complications are detected by the TBA during the pregnancy.
In regards of the second cause, hypertensive disorders. They may be detected during pregnancy and when controlled and treated in time the risk of fatal complications may be reduced. A relatively cheap intervention that could save women lives would be a training program for TBAs about the symptoms of these disorders and the potential consequences, as well as provide them the tools to measure blood pressure and proteinuria, and teach them how to use them and when refers the woman to a hospital. However, not any evidence of this kind of interventions has been found.
Regarding the third cause of maternal mortality in Mexico, it is necessary to mention that abortion is not legal in all the Mexican states, but one, the Mexico City Federal District. While the women with economic resources can travel to Mexico City for an abortion in health facilities, this is not the case of poor women, that usually requires the service of illegal, not registered, abortion facilitators that put in a high risk their health and life.
For these women, being the abortion illegal and don’t having the means to get a health clinic in Mexico City, the best way to prevent deaths related to abortion would be a good program of sexual health.
The TBAs have an important role in this. They have an important influence on the reproductive and sexual health of women in their community, as well as on the promotion of gender equality and the empowerment of women, especially with regard to their health (Herrera et al, 2006; Romero, 2012)
The work of TBAs is very useful for the dissemination of family planning within indigenous communities, as it promotes female self-control of their fertility, transforms gender cultural patterns and modifies power structures in the intra-family nucleus. The feminine capacity to freely decide their own sexuality and reproductive capacity allows them to avoid putting their health at risk and choosing a personal life project. (Romero, 2012)
Traditional midwives are an indispensable human health resource to reduce maternal mortality rates in isolated and marginalized communities, they provide a comprehensive care to women that they would not otherwise receive due to distance and geographical and economic obstacles to reach institutional centers or cultural barriers.
Understanding their traditions, culture, beliefs and actions associated with reproduction, pregnancy and childbirth are fundamental in the design of training programs that contribute to the elimination of the risks associated with motherhood in isolated rural communities.
It is equally necessary an intervention in the hospital of this areas. The staff must be trained in intercultural skills and their knowledge refresh with the most up to date evidence to avoid clinical interventions that are not recommended as a routine and must be assesed in a per case base. Availability of translators would be also helpful to break these barriers.
TBAs should be included in women’s health plans and programs, not only as health care providers but as members with active participation in the design of such plans and programs. They should toghether with the national public health experts to analysed how their interventions can be improved respecting their traditions and customs.
Moreover, their role in their communities may help with the achievement of the 5th goal: Gender Equality.
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This study showed that some interventions that used to be done routunely in hospitals, and that now have been demostranste not been always needed, and indeed increasing the risks for the health of the mothers and the newborns.(Mendez and Cervera, 2002).
This is the case of the lithotomy position, for greater comfort of the professional who attends the delivery, but that favors the appearance of perineal tears, in addition to having negative effects on the mother’s ventilation and blood pressure; shaving the pubic beauty can increase the risk of infection by producing small lacerations; the application of enema at the beginning of labor, although the expulsion of fecal matter during childbirth does not increase the rate of infections; administration of a parenteral glucosate solution by protocol, which can reduce pain tolerance; the induction and chemical conduction of birth; or the episiotomy performed routinely. (Mendez and Cervera, 2002)
Perineal tears and episiotomies increase the risk of complications from infection (Johnson et al, 2012) to anal incontinence (Abbott et al, 2010). This is one of the factors that can explain why there were more complications in women attended in hospital in the Mendez and Cervera (2002) study. But another lecture could be that there are more risk deliveries attended in the hospital even if not all the women advised to attend the hospital do this.