J HEALTH POPUL NUTR 2006 Dec;24(4):472-478 ISSN 1606-0997 $ 5.00+0.20 © 2006 International Centre for Diarrhoeal Disease Research, Bangladesh Transition to Skilled Birth Attendance: Is There a Future Role for Trained Traditional Birth Attendants? Lynn M. Sibley1 and Theresa Ann Sipe2 1Center for Research on Maternal and Newborn Survival, Emory University, 1520 Clifton Road, Suite 436, Atlanta, GA 30322, USA and 2Rollins School of Public Health, Behavioral Science and Health Education, Emory University, 1518 Clifton Road, Atlanta, GA 30322 ABSTRACT A brief history of training of traditional birth attendants (TBAs), summary of evidence for effectiveness of TBA training, and consideration of the future role of trained TBAs in an environment that empha- sizes transition to skilled birth attendance are provided. Evidence of the effectiveness of TBA training, based on 60 studies and standard meta-analytic procedures, includes moderate-to-large improvements in behaviours of TBAs relating to selected intrapartum and postnatal care practices, small significant increases in women’s use of antenatal care and emergency obstetric care, and small significant decreas- es in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia. Such findings are consistent with the historical focus of TBA training on extending the reach of primary healthcare and a few programmes that have included home-based management of complications of births and the new- borns, such as birth asphyxia and pneumonia. Evidence suggests that, in settings characterized by high mortality and weak health systems, trained TBAs can contribute to the Millennium Development Goal 4—a two-thirds reduction in the rate of mortality of children aged less than 14 years by 2015—through participation in key evidence-based interventions. Key words: Traditional birth attendants; Skilled birth attendants; Meta-analysis; Maternal mortality; Perinatal mortality; Training INTRODUCTION Every year, an estimated four million babies die in the first four weeks of life, and a similar number of babies are stillborn. Moreover, half a million women die from pregnancy-related causes. Most of these deaths occur at home during the first postnatal or postpartum week, especially within the first 24 hours of birth. Most oc- cur in developing countries with weak or failing health systems, with South Asia and sub-Saharan Africa being especially hard-hit (1-3). For more than three decades, Correspondence and reprint requests should be addressed to: Dr. Lynn M. Sibley Associate Professor Center for Research on Maternal and Newborn Survival Emory University 1520 Clifton Road, Suite 436 Atlanta, Georgia 30322 USA Email: lsibley@emory.edu Fax: 404-727-9676 the World Health Organization (WHO) and other agen- cies of the United Nations promoted training of tradi- tional birth attendants (TBAs) as a global public-health strategy to reduce this tragic loss of life (4). Lack of evidence to demonstrate that trained TBAs can reduce maternal mortality led to controversy over their train- ing in relation to safe motherhood and a policy shift to skilled birth attendance (5-7). In this paper, we provid- ed a brief history of TBA training, reviewed evidence of the effectiveness of TBA training, and considered the future role of trained TBAs in an environment that emphasizes the transition to skilled birth attendance. Although TBAs have been trained since the late 1800s, important milestones over the last century illus- trate the shifting policies on TBA training as a global public-health strategy. Credit for the first formal train- ing programme is usually given to a British missionary midwife, Miss M.E. Wolfe, working in Sudan in 1921 (8,9). The Inter-Governmental Conference of Far-East- ern countries, held in Bangkok in 1937, called for the