Transition to skilled birth attendance The authors of “Newborn health: a key to child survi- val” in a 2005 special issue of The Lancet—eloquently argued that women, newborns, and children all have rights, and all would greatly benefit from a health sys- tem that delivers proven interventions through a con- tinuum-of-care approach, i.e. from pregnancy through labour, birth, and the postpartum and postnatal periods, and into early childhood; and including home, periph- eral health facility, and hospital (1,18). They contended that, with sufficient coverage, affordable low-tech ap- proaches could reduce the number of newborn deaths by up to one-third and prevent over half of child deaths. Thus, they urge a balanced, phased approach to poli- cy and programming such that service modalities of family-community care and outreach save lives now, especially among the poor, while the health system is simultaneously strengthened, and facility-based clini- cal care is made available and equitable, in time. To achieve even greater reductions in newborn, and early child mortality and to reduce maternal mortality, they emphasized that facility-based clinical care, including skilled birth attendance and an intact referral system, i.e. a functioning health system, is required. Given an environment of scarce resources, there is an understandable concern among safe motherhood advocates that investment in family-community care approaches will set-back advances made with respect to increasing skilled birth attendance and emergency obstetric care. We agree with the Millennium Task Force on Child Health and Maternal Health that, “A strategy designed to address maternal mortality as its true aim—and not just some welcome, but coincidental by product of a health intervention designed primarily for another purpose (averting newborn death, for ex- ample)—must include interventions that prevent and treat complications that kill women” (2). We believe that a balanced, phased approach encompasses such interventions and that, realistically, there is no ethical alternative. To improve pregnancy outcomes, there is a critical need, not only to upgrade health facilities and train, strategically deploy, and retain professional care providers, but also to evaluate, refine, and disseminate promising community-based approaches to care during birth and the immediate postpartum and postnatal peri- ods. ACKNOWLEDGEMENTS The meta-analysis of effectiveness of TBA training was made possible through funding support from the World Bank (Small Grants Program for Safe Mother- hood), USAID (Intra Health/PRIME I Project, Acade- my for Educational Development/SARA Project), US- AID, DFID and the Bill and Melinda Gates Foundation 477 (University of Aberdeen/IMMPACT Project), and the Bill and Melinda Gates Foundation (Save the Children/ Saving Newborn Lives Project). The views presented here represent those of the authors. REFERENCES 1. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L (Lancet Neonatal Survival Steering Team). Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365:977-88. 2. Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AMR, Rosenfield A. Who’s got the power? Transforming health systems for wom- en and children. London: Earthscan Publications, 2005. 185 p. 3. World Health Organization. The world health re- port 2005: make every mother and child count. Ge- neva: World Health Organization, 2005. 243 p. 4. World Health Organization. Traditional birth attendants: a joint WHO/UNICEF/UNFPA state- ment. Geneva: World Health Organization, 1992. 18 p. 5. Maine D. Safe motherhood programs: options and issues. New York, NY: Center for Population and Family Health, Faculty of Medicine, School of Public Health, Prevention of Maternal Mortality, Columbia University, 1993. 36 p. 6. Starrs A. The safe motherhood action agenda: priorities for the next decade. Report on the Safe Motherhood Technical Consultation, 18-23 October 1997, Colombo, Sri Lanka. New York, NY: Family Care International, 1998. 30 p. 7. Bergstrom S, Goodburn E. The role of traditional birth attendants in the reduction of maternal mor- tality. In: De Brouwere V, Lerberghe VW, editors. Safe motherhood strategies: a review of the evi- dence. Antwerp: ITG Press, 2001:451. (Studies in health services organization and policy, no. 17). 8. Fleming JR. What in the world is being done about TBAs? An overview of international and national attitudes to traditional birth attendants. Midwifery 1994;10:142-7. 9. Genesis, developing access to women’s history sources in the British Isles. Durham University Li- brary. (www.genesis.ac.uk/archive, accessed on 16 December 2005).