Re-examining authoritative knowledge in the design and content of a TBA training in India
Introduction
Traditional birth attendants (TBA) and/or family members assist 47 per cent of births in the developing world (WHO, 1997a). TBA training has been an important component of public health interventions since the 1970s to improve maternal and child health in developing countries (WHO, 1978). In India, many women of comparatively lower educational and lower economic background1 especially living in rural areas with lesser resources continue to depend more on TBAs for assistance during childbirth (IIPS, 2007). According to the National Family Health Survey (NFHS-3) data, 61 per cent of births take place at home and 37 per cent are assisted by TBAs (IIPS, 2007). As public health resources in developing countries are limited, decisions on TBA training need to be corroborated with knowledge about TBA training outcomes including content and design (Hitesh, 1996, Piper, 1997, Lettenmaier et al., 1988, Foster et al., 2004).
WHO advocated for ‘three cleans’ (hand washing with soap, clean cord care and clean surface), promoted awareness on the importance of breast feeding and weighing babies, and addressed some of the potentially unhygienic and harmful practices in communities through TBA training (WHO, 1993). Over a period of time TBA training content changed and included various other aspects of reproductive health including family planning, HIV/AIDS, oral rehydration, identification of risk and referral. However, since the 1990s, the TBA training strategy has been increasingly seen as irrelevant, ineffective or, on the whole, a failure due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Donor agencies providing funding for TBA training in developing countries subsequently withdrew their funds and reallocated it to providing a skilled attendant during delivery (Walraven and Weeks, 1999, Kruske and Barclay, 2004). TBAs have been blamed for causing maternal and infant deaths with their unhygienic and harmful practices (Guha, 1998, WHO, 1998a, WHO, 1998b, GOI, 2000). They have also been blamed for not having the capacity in terms of knowledge, training skills and literacy to take advantage of the TBA training (WHO, 1999, GOI, 2000, Bulterys et al., 2002, UNICEF, 2004) and for deterring and delaying referrals (WHO, 2005):
In many countries, TBAs have received training in order to promote safer birth practices, including clean delivery and avoidance of harmful practices. However, to fulfill all the requirements for management of normal pregnancies and births and for identification and management or referral of complications, the education, training, and skills of TBAs are insufficient. Their background may also mean that their practices are conditioned by strong cultural and traditional norms, which may also impede the effectiveness of their training (WHO, 1999: 31).
There are several studies that have demonstrated post-training positive health outcomes among mothers and infants such as; reduction in perinatal mortality (Bang et al., 2005, Jokhio et al., 2005, Sibley and Ann Sipe, 2006) reduction in common perinatal conditions (Gill et al., 2011) improvement in newborn care (Satishchandra et al., 2009), protection against postpartum fever and retained placenta (Smith et al., 2002) and positive change during the postpartum period, especially in cases of haemorrhage or infection (Bailey et al., 2002). This suggests that TBAs have the capacity to grasp information conveyed in training programmes and to apply newly acquired practices in their work in their communities.
However apart the ability of the TBAs, the other significant component, generally overlooked is the design and content of the training programme. Researchers have noted serious deficiencies in information on TBA training content and design and its linkage with birthing practices. A meta-analysis of studies on TBA training effectiveness in developing countries noted that, except for reporting on the curriculum content, most studies on TBA training failed to describe the content and design of TBA training programmes (Sibley et al., 2004):
The WHO encouraged health planners in 1990 to promote the provision of trained birth attendants for all women. Unfortunately, there was, at least in some countries, little quality control in the design or content of these programs. (Kruske and Barclay, 2004: 307)
Kruske and Barclay (2004) observe that the training courses in developing countries were in most cases simplified versions of the ‘professional midwives’ training or direct translation of WHO guidelines, ignoring their local appropriateness. TBA training strategy and content has not appreciated the immense cultural gap between biomedical methods of care and community birthing practices (WHO, 2005). Smith (2006) observed that government training programmes in India do not present the TBAs with any modern practical ways of birthing that are meshed with tradition. Furthermore, it has been observed that certain useful traditional practices have changed with training; the squatting and sitting positions encouraged by TBAs during labour also now well accepted in the medical community worldwide as advantageous to positive birth outcomes (Bhardwaj et al., 1995, Bajpai, 1996a, Odent, 2001, Mathews et al., 2005) but, with training, TBAs are changing to use of the supine position. Mathews et al. (2005) argue this is because the trainers in the TBA training programmes are generally medically trained professionals and advocate the use of the supine position.
This paper aimed to assess the approach used in disseminating birthing knowledge to local TBAs drawing evidence from the content and design of a TBA training programme conducted in the Ahmednagar District in India. The assumption tested is whether medical knowledge is construed as ‘authoritative knowledge’ that is privileged over local women's ‘traditional’ wisdom and practices. We draw on Jordan's concept of authoritative knowledge to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India. This paper is a segment of a larger PhD project assessing post-training TBA practices of a training conducted in Ahmednagar district, the findings of which are published earlier (Saravanan et al., 2011). As the training programme had been conducted before the study, the content and design of the local training programme was assessed by documents and data collected during the field visit.
The Indian TBA training programme strategy has been reviewed in more detail in this paper as international policy paradigm has been reviewed in detail earlier (Kruske and Barclay, 2004). Information was drawn from significant policy documents published by the Government of India(GoI), Ministry of Health and Family Welfare (GoI, 2000a, GoI, 2000b, GoI, 2002, GoI, 2007) as well as Millennium Development Goals Report (GoI, 2005). Search strategy within these documents and thematic analysis was completed by firstly reading and rereading to gain an understanding of the fabric of the content. These were then clustered into themes. (Green and Thorogood, 2004, Fraser et al., 2007). A search strategy was conducted of electronic databases for TBA training design and content and internationally acclaimed safe motherhood practices. Information was sourced from CINAHL, Cochrane Database of Systematic Reviews, Medline, PubMed, JSTOR EBCOhost, Science Direct and several other Nursing and Public Health databases. Keywords included, traditional birth attendant, skilled attendants, maternal mortality, safe motherhood, TBA training, hypothermia, colostrum, postpartum bleeding, safe delivery kit and birth weight. The literature reviewed included health reports, policy documents and international research articles. The research builds on and extends the concept of authoritative knowledge in the context of TBA training programmes in India by arguing for recognition of the social, cultural and public health importance of trained and untrained birth attendants.
Section snippets
Rationale and objectives of the TBA training programme in India
The Reproductive and Child Health programme (RCH2 ) document
Authoritative knowledge
Jordan (1993) states that authoritative knowledge results when one kind of knowledge gains ascendance and legitimacy, and consequently other kinds of knowledge are devalued or dismissed. The concept of authoritative knowledge has been further developed by Davis-Floyd and Carolyn (1997) who devised an analytical framework to describe the different motivations that guide decisions associated with birth. Davis-Floyd states that the consequence of legitimating one kind of knowing as authoritative
Traditional birth attendants training design in developing countries
Every element of the programme design has an impact on the outcome and effectiveness of the training. The importance of needs assessment is to understand the diversity of the existing problem and to incorporate the local context into the training, and the importance of a baseline study is to assess knowledge, attitudes and existing practices (Rööst et al., 2004). It also helps in understanding the knowledge of TBAs, the local needs and available resources before developing the training
Study findings: training design of a TBA training programme conducted in India
The implementation of the Government of India (GoI) TBA training programme is undertaken through Non-Governmental Organisations (NGOs). In this case, the training was conducted on behalf of the GoI by Pravara Medical Trust (PMT), a medical institute in collaboration with a local NGO, the Community Rural Health Project (CRHP). The training was conducted in Ahmednagar district in the year 2002 and most of the implementation work was assigned to CRHP. The trainers were mainly from a medical or
Content of traditional birth attendants training programmes in developing countries
TBAs are generally taught biomedical ways to conduct a clean delivery such as use of the disposable delivery kit; timely referral of women for emergency obstetrical care, and care of the newborn (Jokhio et al., 2005). TBAs are taught methods of conducting hygienic delivery comprising the ‘three cleans’ that is; hand washing with soap, clean cord care and clean surface (Chongsuvivatwong et al., 1991, Goodburn et al., 2002, PATH, 2002, Fatmi et al., 2005, Sibley and Ann Sipe, 2006) and to manage
Birthing practices used by traditional birth attendants in developing countries with emphasis on South Asia
A study of perinatal mortality in developing countries observes that the causes of adverse maternal and infant outcomes are inadequately treated maternal complications, inadequate neonatal care, and harmful home care practices, such as the discarding of colostrum, the application of unclean substances to the umbilical-cord stump, and the failure to keep babies warm (Zupan, 2005). South Asia and India in particular, is an example of the complex and unique ways in which modernity is shaping local
Study findings: content covered in the TBA training programme in Ahmedanagar district
The content of a TBA training programme conducted CRHP and PMT in Ahmendnagar district of Maharashtra state has been critically reviewed. The available documental evidence on the content covered in the TBA training programme included; the training manual prepared by PMT and distributed to TBAs after the training, the video shown to TBAs during the training programme, and the training project report submitted by PMT to the GOI.
Discussion
Previous systematic reviews have identified that are inadequacies in the reporting of training design and content quality of TBA training programmes in developing countries (Sibley et al., 2004). Among the studies that have assessed TBA training designs many note that ‘most programmes did not undertake any needs assessment to derive an information base for developing an appropriate curriculum for TBAs' (UNFPA, 1996: 4). Similarly, findings from this study in Ahmednagar reveals certain
Re-examining authoritative knowledge
The programmes' rationale and objectives were based on the assumption that the institutionalisation of birth and the provision of skilled attendants during delivery are the solution to improve maternal and infant health in developing countries, thus emphasising a biomedical approach to maternal and infant health problems. Indeed, the implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local
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