Transition to skilled birth attendance integration of TBAs into rural health programmes. By 1952, the United Nations Children’s Fund (UNICEF) began to supply trained TBAs with delivery-kits. The goal of these early programmes was to improve perina- tal healthcare (8). Nearly 20 years later, interest in pri- mary healthcare and in traditional medicine in relation to primary healthcare had grown to the extent that the UNICEF and WHO sponsored a technical consultation on TBA training. By the time of the 1978 Alma Ata Declaration, the WHO was fully in support of training TBAs to extend the reach of primary healthcare serv- ices. At that time, the WHO recommended that trained TBAs work side-by-side in ‘articulation’ with the mod- ern health system, so that the informal traditional and formal modern health systems could presumably co- exist without conflict. The success of the WHO’s en- couragement can be measured by the rapid increase in the number of countries undertaking TBA training. For example, in 1972, only 20 countries had TBA training programmes. It is now estimated that 85% of deve- loping countries have some form of TBA training (8). With the advent of the safe motherhood initiative and without evidence to show that the risk approach and trained TBAs can reduce maternal mortality, there has been a gradual waning of enthusiasm for TBAs. In 1992, the WHO emphasized that, if TBAs were going to contribute to safe motherhood, they must be ‘inte- grated’ into the modern health system through training, supervision, and technical support (4). However, by 1997, the WHO and many safe motherhood advocates turned from TBA training to promote skilled birth at- tendance for all (8), most recently calling for a ‘new’ and ‘expanded role’ for TBAs, where TBAs act as ‘link workers’ to skilled birth attendants rather than as pri- mary care providers (10,11). The broad goals of TBA training programmes are to reduce maternal and child mortality and morbidity and to improve the reproductive health of women. The objectives include: enhancing the linkages between the modern health system and community, increasing the number of TBA-attended births, and improving the skills and stature of TBAs (4). Training programmes vary, however, in addressing these objectives. For ex- ample, individuals, non-governmental organizations, and missions have trained TBAs through the private sector and also through local, state and national gov- ernment, and international agencies have trained them through the public sector. Training programmes may last from several days to several months and may in- clude clinical practice at a health facility, follow-up su- pervision, and continuing education (12). The content of curricula of TBA training also var- ies. Most TBAs have been trained to upgrade their skills so as to be able to perform safe deliveries. Con- 473 sistent with the emphasis on extending the reach of pri- mary healthcare, many TBAs have also been trained to take on the expanded functions of prevention, screen- ing, and referral (12,13). Very few programmes have included content on initial response and stabilization of maternal and newborn complications (e.g. resuscitation of newborns or detection and management of sepsis), and content that would be very useful to those who are confronted with emergencies and that might save lives (13). The answer to the question: is TBA training effec- tive? depends on the objectives and content of a particu- lar training programme and the outcomes measured. From 1997 to 2002, we conducted a meta-analysis of the available published and unpublished studies on the effectiveness of TBA training. We updated this review for selected topics in 2003 and 2004 (13-15). The goal of the meta-analysis was to provide information that would inform policy decisions about future TBA train- ing and about the needs of evaluation research. Specific objectives were (a) to describe the effect of training on TBA and maternal attributes, such as knowledge and behaviour, (b) to determine the impact on pregnancy outcomes, and (c) to describe the quality of the litera- ture on evaluation. MATERIALS AND METHODS Details of materials, methods, and statistical analy- ses have been described elsewhere (13-15). Briefly, a broad search yielded nearly 1,200 documents, of which 60 studies met the following eligibility criteria: the intervention was TBA training; intervention group data were derived from trained TBAs (reference to intervention), and mothers and neonates whose care was provided by trained TBAs or who were living in areas where more than 50% of births were attended by trained TBAs (a proxy for exposure); comparison group data were available; dependent measures were related to knowledge, attitudes, behaviour, or maternal and peri-neonatal health outcomes; documents were in English and published during January 1970–June 1999; research design was either experimental or qua- si-experimental; and data were sufficient to calculate an effect size. The sample of studies, representing three regions of the world—Asia, Africa, and Latin America/ Caribbean—contained 1,695 outcomes. TBA and ma- ternal attributes comprised 95% of the outcomes, and pregnancy outcomes comprised the remainder. The attribute outcomes were independently sorted into 24 maternal and child health content areas for sub-group analysis. In 2002, we repeated the search for studies having outcomes relating to antenatal care and refer- ral for obstetric complications. In 2004, we repeated the search for studies having outcomes relating to safe