474 J Health Popul Nutr Dec 2006 delivery and newborn-care practices. Altogether, these update searches yielded two new studies plus three documents that were more recent versions of studies already included in the original sample. Most outcomes measured were reported as percent- ages. The percent difference associated with each out- come was converted to a common scale using the effect size index Cohen’s h, representing the standardized difference between the trained and the untrained TBA group on the outcome of interest. The variance-weight- ed mean effect size for each sub-group of outcomes was then calculated, and homogeneity tests were per- formed on the distributions of the weighted mean effect sizes. With a few exceptions, homogeneity of variance was rejected (α=<0.05), and the weighted mean effect size and 95% confidence interval were calculated us- ing formulae based on a random effects model. Sen- sitivity analysis was conducted to detect the presence of publication bias. In addition, stratified analyses, by study design and sampling procedure, were performed to examine the influence of these potential moderating variables on the weighted mean effect sizes. Lastly, sub-group analyses conducted to date include antenatal care, referral for emergency obstetric care, birthing and newborn-care practices, perinatal and newborn health outcomes. RESULTS The findings of the meta-analysis were positive for the sub-groups of outcomes measured (Table 1). Strati- fying each sub-group analysis by the study design and sampling procedure did not change the overall conclu- sions. The medium-to-large effect size values for be- haviour of TBAs relating to intrapartum, including safe delivery, clean delivery, and cord-care practices, represented significant increases of 44%, 103%, and 53% respectively for the trained TBA group over the untrained TBA group at baseline. Likewise, the me- dium-to-large effect size values for behaviour of TBAs relating to counselling on maternal nutrition, early exclusive breastfeeding, and immunization (primarily TT) represented significant increases (15%). The mod- erate-to-large effect sizes for knowledge and behaviour of TBAs relating to antenatal care—positive medium- to-large values—were also significant and represented 177% and 47% increases respectively for the trained TBA group over the untrained TBA group at baseline, as was the small effect size for maternal behaviour relating to use of antenatal care services—a 38% in- crease for women cared for by trained TBAs (14). The small effect sizes for both behaviour of TBAs and ma- ternal behaviour relating to referral of obstetric compli- cations were significant and represented 36% and 22% increases respectively for the trained TBA group over the untrained TBA group at baseline (15). However, the Sibley LM and Sipe TA large standard errors and wide confidence intervals revealed the variability in these TBA and maternal attribute data. Lastly, the effect size value for perina- tal mortality represented a significant 8% decrease in mortality associated with TBA training (13). Although the number of studies included in the latter sub-analy- sis was small, the effect size values for birth asphyxia and mortality due to pneumonia represented 11% and 8% decreases respectively in cause-specific newborn mortality (13). Small standard errors and narrow con- fidence intervals highlighted the homogeneity of these outcome data. DISCUSSION TBA training is associated with moderate-to-large improvements in behaviours relating to selected in- trapartum and postnatal care practices, and small but significant decreases in perinatal mortality and neona- tal mortality due to birth asphyxia and pneumonia. The findings are consistent with the historical focus of TBA training on extending the reach of primary healthcare and a few TBA training programmes that have includ- ed management of birth asphyxia and pneumonia care. TBA training is also associated with small but signifi- cant increases in women’s use of antenatal care and emergency obstetric care, suggesting that referral is a multi-faceted process, and influence of TBAs on care- seeking behaviour may be limited. Unfortunately, incomplete reporting by authors re- sulted in loss of studies and datasets and limited our ability to examine which intervention characteristics were associated with better outcomes, cost-effective- ness, and the association between training and maternal mortality—the rationale for the policy shift away from TBA training. Moreover, due to the variable quality of studies included in our sample, we could not address causality and only the magnitude and direction of the association between training and the outcomes could be measured. More rigorous studies are now being con- ducted. In a recent cluster-randomized controlled trial from Pakistan, Jokhio and colleagues showed that TBA training, linked to outreach and facility-based care, re- sulted in a statistically significant reduction of 30% in perinatal mortality (16). The estimated percent reduc- tion was similar for maternal mortality, but it was not significant. Millennium Development Goal (MDG) 4 aims to reduce mortality of children, aged less than five years, by two-thirds between 1990 and 2015. MDG 5 aims to reduce maternal mortality by three quarters during this timeframe. Policy regarding the best strategies to meet these goals, however, swings between com- munity-based care and facility-based care, while safe motherhood and child-survival advocates compete for limited resources (2-3). The findings of the meta-ana-