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Traditional birth attendants lack basic information on HIV and safe delivery practices in rural Mysore, India

  • Purnima Madhivanan1Email author,
  • Bhavana N Kumar1,
  • Paul Adamson2 and
  • Karl Krupp1
BMC Public Health201010:570

DOI: 10.1186/1471-2458-10-570

Received: 22 March 2010

Accepted: 22 September 2010

Published: 22 September 2010

Abstract

Background

There is little research on HIV awareness and practices of traditional birth attendants (TBA) in India. This study investigated knowledge and attitudes among rural TBA in Karnataka as part of a project examining how traditional birth attendants could be integrated into prevention-of-mother-to-child transmission of HIV (PMTCT) programs in India.

Methods

A cross-sectional survey was conducted between March 2008 and January 2009 among TBA in 144 villages in Mysore Taluk, Karnataka. Following informed consent, TBA underwent an interviewer-administered questionnaire in the local language of Kannada on practices and knowledge around birthing and HIV/PMTCT.

Results

Of the 417 TBA surveyed, the median age was 52 years and 96% were Hindus. A majority (324, 77.7%) had no formal schooling, 88 (21.1%) had up to 7 years and 5 (1%) had more than 7 yrs of education. Only 51 of the 417 TBA (12%) reported hearing about HIV/AIDS. Of those who had heard about HIV/AIDS, only 36 (72%) correctly reported that the virus could be spread from mother to child; 37 (74%) identified unprotected sex as a mode of transmission; and 26 (51%) correctly said healthy looking people could spread HIV. Just 22 (44%) knew that infected mothers could lower the risk of transmitting the virus to their infants. An overwhelming majority of TBA (401, 96.2%) did not provide antenatal care to their clients. Over half (254, 61%) said they would refer the woman to a hospital if she bled before delivery, and only 53 (13%) felt referral was necessary if excessive bleeding occurred after birth.

Conclusions

Traditional birth attendants will continue to play an important role in maternal child health in India for the foreseeable future. This study demonstrates that a majority of TBA lack basic information about HIV/AIDS and safe delivery practices. Given the ongoing shortage of skilled birth attendance in rural areas, more studies are needed to examine whether TBA should be trained and integrated into PMTCT and maternal child health programs in India.

Background

Worldwide, it is estimated that there are more than 60 million non-institutional births each year with the vast majority being attended by traditional birth attendants (TBA) [1]. In most developing countries in South Asia, less than half of pregnant women receive trained medical assistance during their delivery[2, 3]. While shockingly high, this figure still masks an even greater underlying inequality between urban and rural areas where most of the population resides. In developing countries, rural mothers are 40% less likely to be attended by skilled health personnel compared with their urban counterparts[2].

With almost 60% of births occurring at home[4], India faces a variety of challenges in providing high quality maternal child healthcare. Currently, the estimated maternal mortality ratio (MMR) at 450 per 100,000 live births, casts doubt upon the country's ability to reach its Millennium Development Goal of 109 maternal deaths per 100,000 live births by 2015[1]. The country has also made only slow progress in expanding access to antiretrovirals for prevention of mother-to-child transmission of HIV (PMTCT). Each year only about 20% of the estimated 50,000 HIV positive pregnant women receive prophylaxis to prevent transmission of HIV to their infant [5].

There is growing evidence from Africa and other parts of the world showing that TBA may be able to play an important role in improving maternal child outcomes and preventing HIV. Greenwood et al, in their randomized control trial on TBA training in Gambia, demonstrated a 62% reduction in maternal mortality. Their study also showed a significant increase in maternal tetanus immunization rates, and maternal antenatal attendance among mothers delivering with trained TBA[6]. Jokhio and colleagues, in their large cluster randomized intervention study on prevention of perinatal mortality in Pakistan, reported a 20% reduction in perinatal death when TBA were trained and provided with disposable delivery kits[7]. Perez et al, in a large feasibility study of TBA willingness to participate in HIV prevention programs in Zimbabwe, found 75% acceptability among TBA to participate in HIV prevention activities such as accompanying new-borns to closest health centre to receive medication (15%) and assisting health centers in documenting ANC-PMTCT services [8]. Another study in Tanzania showed that women receiving HIV advice from a trained and motivated TBA were three times more likely to accept an HIV test and also had a three-fold increased chance of receiving Nevirapine for prevention of mother-to-child transmission of HIV[9].

There are few recent studies on the birthing practices of TBA in India, and none investigating knowledge and attitudes about HIV. Stella Mulder and Karen Trollope-Kumar in studies from different parts of India reported a number of customary practices among TBA. Mulder observed that many attendants were replacing traditional practices for treating the cord stump with ash or dung[10] with more modern remedies such as antiseptic powder. Similarly, Trollope-Kumar observed that many TBA she studied also administered both allopathic and herbal medicines[11]. Other common TBA practices described in these studies included: providing advice on diet and activity[10, 11], disposing of the placenta through burial[10, 11], delivering women in a supine or crouching position, sprinkling water on the child immediately after birth, and wiping the baby with coconut or castor oil followed by a warm soap bath[10]. Mulder also noted that TBA appeared to have low knowledge regarding many life-threatening complications including excessive bleeding, prolonged labor, and vaginal tears[10].

This study investigated practices and knowledge about birthing and HIV/PMTCT among active TBA attending births in rural areas of Mysore Taluk in the south Indian state of Karnataka.

Methods

Study Site

Karnataka state with an MMR of 221 per 100,000 live births has the highest rate of maternal death among South Indian States[12]. It has also been identified as one of the 6 high HIV prevalence states in the country. Rates of infection vary substantially across the state's 27 districts with an average of just under 1% of antenatal clinic attendees being infected with HIV[13]. Mysore District is located in the southern part of the state bounded by Mandya district to the northeast, Chamrajanagar district to the southeast, Kerala state to the south, Kodagu district to the west, and Hassan district to the north. The district has an area of 6,854 km2 and a population of 2,641,027, of which about half (49%) are females[14]. Approximately 62.8% of the population live in rural areas. Overall, the literacy rate is 63.5%. Hindus constitute 87.4% of the population, Muslims 8.9%, and Christians, Buddhists and other religious groups about 3.7%. Kannada and Urdu are the dominant languages in this area.

Data collection

Between August and November 2009, 511 TBA were screened and 417 enrolled in a descriptive cross-sectional survey. To be eligible, a potential participant had to be able to speak Kannada or Urdu; understand and give informed consent; and have delivered a minimum of 10 babies in the previous year. The survey was conducted in 144 villages located ten kilometers or more outside of Mysore City since active TBA in Mysore District are typically found in rural areas with poor access to medical care. TBA were identified through key-informant interviews with village elders, community health workers, and recently delivered mothers registered with government health workers. In addition, participating TBA were asked to refer any other birth attendants they knew of in their local area. Three Masters degree-level graduates in Social Work or Psychology were selected as interviewers. All interviewers were trained for four weeks in issues around relationship building, privacy and confidentiality, and methods for administering questionnaires in a standardized, non-judgmental fashion. After undergoing an informed consent process, eligible TBA answered a structured face-to-face interview in Kannada in a private setting at their home or place of work. The study was approved by the Vikram Hospital Independent Ethics Committee.

Statistical analysis

Data were analyzed using Stata 10.1 (Stata Corporation, College Station, TX). Descriptive statistical methods were used to provide a general profile of the study population. Analyses were conducted using Pearson chi-squared or Fisher-exact tests for categorical variables and t-tests for comparison of continuous variables.

Results

Demographics

Of the 511 TBA screened, 428 (83.7%) were found eligible for the study. Reasons for non-eligibility included having delivered less than 10 babies in the previous year or being unable to give informed consent. Of the 428 eligible women, 417 (97.4%) agreed to be interviewed. The median age of study participants was 52 years (range: 26-80 years) with 77 (18%) aged 40 years or less, 138 (33%) between 41-54 years, and 202 (48%) over 55 years of age. A large majority (324, 77.7%) had no formal education, 88 (21%) had between one and seven years and five (1.2%) had more than seven years of education. Among these participants, 415 (99.5%) were Hindus and two (0.48%) were Muslim. None of the participants reported full time employment as a TBA.

Knowledge, Attitudes and Beliefs about HIV/AIDS

Only 51 of the 417 (12.3%) TBA reported hearing about HIV/AIDS. Among those, 25 (49%) wrongly believed that only 'sick looking' people could spread infection, and 21 (42%) thought HIV could be transmitted through touching or hugging. Additionally, 32 (64%) reported that HIV could be spread by mosquitoes and 11 (21.6%) were not aware that the virus could be transmitted through blood or blood products. When asked about vertical transmission of HIV, 14 (28%) did not know that HIV could be spread from mother to child and 28 (56%) were unaware that infected mothers could deliver healthy infants. When TBA were asked what precautions they took to protect themselves against HIV, 39 (76%) said they avoided attending births for women they suspected were HIV-infected, 3 (6%) reported wearing rubber gloves during deliveries, 2 (4%) said they rubbed oil on their hands prior to carrying out procedures, 3 (6%) reported taking herbal remedies before deliveries, 2 (4%) cleaned all surfaces after each procedure, and 1 (2%) reported using sterilized blades and instruments.

TBA Birthing Practices

Antepartum Practices

A large majority (401, 96.2%) of TBA reported not providing antenatal care for the woman prior to the onset of labor contractions. About 372 TBA (89%) advised women to use special postures when seated, 354 (85%) advised special postures for sleep, 282 (68%) prescribed special foods and diets, 255 (61%) told women to massage their abdomen with special oils, and 182 (43%) suggested exercise. When participants were asked how abortions were carried out in their village, 88 (21%) reported consumption of raw papaya, 61 (14.6%) reported consumption of heat producing foods, and 318 (76%) reported they didn't know.

Intrapartum Practices

Almost all TBA (404, 96.9%) reported telling their clients to contact them only at the onset of fast painful contractions. Among the remainder, 23 (6%) advised waiting until the water breaks, and 10 (2.4%) told their clients to notify them once the child's head crowned. The supine position was the most commonly reported delivery posture (228, 54.7%), followed by squatting (140, 33.6%), sitting (105, 25.2%) and kneeling (43, 10.3%). When asked what tools were used during deliveries, almost all (98%) reported using a blade, 25 (6%) a scissors, 2 (0.5%) forceps, and 2 (0.5%) a suction bulb. Just over half (183, 51.9%) reported sterilizing their equipment prior to a delivery. When TBA were asked whether they would ever refer women to a medical center, 70% said they would if the baby was stuck, if a mother had excessive bleeding before delivery (60.9%) and if the baby came out the wrong way (56.8%). Other reasons reported for hospital referrals were: if the umbilical cord came out before the baby (37.9%), if there was excessive bleeding following birth (12.7%), if the placenta was stuck (11.2%), and if the umbilical cord was wrapped around the baby's head (4.6%) (Table 1).
Table 1

Birthing practices of traditional birth attendants in Mysore Taluk, India (N = 417)

Characteristic

Total

 

N

(%)

Would you consider this a high-risk pregnancy

  

   Age <17 & >35 yrs

210

50.4

   First pregnancy or >5 times pregnant

163

39.1

   Past h/o spontaneous abortion

208

49.9

   Past h/o blood pressure

245

58.8

   Past h/o caesarian section

267

64.0

   Past h/o postpartum hemorrhage

178

42.7

   Stillbirth during last delivery

228

54.7

   Abnormal presentation of fetus

288

69.1

   Mother's height <1.45 m

171

41.0

   Fetus stops moving or unable to hear the baby

288

69.1

   Twins

228

54.7

Do you advise any of the following treatments

  

   Special food and diet

282

67.6

   Enema

13

3.1

   Exercise

182

43.6

   Massage with oil on stomach

255

61.2

   Special posture to sit

372

89.2

   Special posture to sleep

354

84.9

   Medicines

78

18.7

   Pushing out the abdomen during the pain

191

45.8

When do you advise your clients to get you when they are ready to deliver

  

   Breaking of bag of waters

23

5.5

   Fast painful contractions

404

96.9

   Head is coming out

10

2.4

What is the most common posture for delivering a woman in labor

  

   Seated

105

25.2

   Squatting

140

33.6

   Laying down

228

54.7

   Kneeling

43

10.3

What would you do if there is excessive bleeding before delivery

  

   Refer to medical center

254

60.9

   Do nothing, will have normal delivery

6

1.44

   Don't know

19

4.56

What would you do if there is excessive bleeding after delivery

  

   Wait until 'bad blood' has passed

414

99.3

   Refer to medical center

53

12.7

What would you do: After the baby is delivered, the placenta becomes stuck inside the woman or it does not come out right away

  

   Massage the uterus

134

32.1

   Manually clear the placenta by hand

50

11.9

   Induce vomiting by stuffing hair into mouth in order to expel placenta

65

15.6

   Induce vomiting by sticking hand into mouth in order to expel placenta

18

4.3

   Drink castor oil

1

0.2

   Refer to medical center

47

11.2

   Don't know

11

2.6

What would you do if:

  

Umbilical cord comes out of the woman before the baby

  

   Deliver baby normally

15

3.6

   Manually push the cord back inside the woman

54

12.9

   Rotate the baby's position inside the mother

11

2.6

   Refer to medical center

158

37.9

   Don't know

156

37.4

   Refuse to answer

15

3.6

Umbilical cord is wrapped around the baby's head

  

   Leave the cord until the baby is delivered

104

24.9

   Loosen the cord around the baby's neck

239

57.3

   Tie and cut the cord after the shoulders come through the pelvis

15

3.6

   Refer to medical center

19

4.6

   Don't know

15

3.6

   Refuse to answer

3

0.72

Baby is stuck inside the mother

  

   Change the position of the mother

13

3.1

   Refer to the medical center

292

70.0

   Don't know

12

2.88

   Refused to answer

5

1.2

Baby comes out the wrong way

  

   Deliver the baby normally

123

29.5

   Refer to medical center

237

56.8

   Don't know

39

9.35

   Refuse to answer

3

0.72

Mother gets a fever, feels dizzy or becomes pale

  

   Give mother water to drink

92

22.1

   Refer to medical center

194

46.5

   Don't know

38

9.1

   Refuse to answer

1

0.24

There are cuts and tears in the woman's vaginal wall after birth

  

   Wash with soap and water

93

22.3

   Apply turmeric with oil

11

2.6

   Don't know

133

31.9

   Refused to answer

9

2.2

A newborn does not cry

  

   Blow in the baby's ear

115

27.6

   Splash baby with cold water

126

32.2

   Massage baby's back, feet or hands

108

25.9

   Hold baby with legs upward

65

15.6

   Flick the baby's hands or feet

82

19.7

   Refer to medical center

22

5.3

Postpartum Practices

If the baby did not cry immediately after delivery, 126 (32.6%) TBA reported splashing the baby with cold water; 115 (27.6%) blew in the baby's ear; 108 (25.9%) massaged the baby's back, hands and feet; 82 (19.7%) flicked the baby's feet, 65 (15.6%) held the baby upside down and 22 (5.3%) would refer the mother and infant to a medical center. Less than a third of participants (113, 27.1%) said they advised clients to breastfeed immediately after delivery. About half, 186 (44.6%) told women that they could breastfeed after several hours, while 99 (23.7%) advised waiting for 24 hours and 19 (4.6%) specified other periods. Most (77.7%) reported telling clients that colostrum was good for the baby, but 91 (21.8%) advised against it.

Discussion

This study shows that knowledge about HIV/AIDS is extremely low among TBA living in rural areas of Mysore Taluk. An overwhelming majority (88%) of surveyed birth attendants had not even heard of HIV/AIDS, a surprising finding given that the epidemic in India is more than two decades old. This is in stark contrast to high levels of knowledge found by the government of India among the general population in HIV sentinel surveillance surveys. The 2006 National Behavioral Surveillance Survey showed 75 percent of people living in rural areas were aware of HIV/AIDS[15]. Even the small number of TBA in our study, who had knowledge about HIV demonstrated poor understanding about how the virus was transmitted. Additionally, less than half of those were aware of the potential for preventing vertical transmission of HIV. Finally, 39 of the 51 TBA (76%) who had said they had heard of HIV/AIDS, expressed unwillingness to attend the births of HIV-infected mothers.

The level of knowledge about safe birthing practices was also low among TBA. Considering that obstetrical hemorrhage and sepsis are still the leading cause of maternal death in India[16], it is not surprising that the study found only 13% of TBA referred mothers experiencing excessive bleeding following birth to a medical center, and that only about half (51.9%) sterilized equipment prior to deliveries. Other 'unsafe' procedures still practiced among TBA included sucking secretions out of a baby's mouth and nose with their mouth, applying cow dung, ghee (clarified butter) and other preparations on the umbilical cord, and inducing vomiting by stuffing hair in a woman's throat to stimulate contractions of the uterus to clear the placenta. Even more concerning, TBA appeared to have low levels of awareness about when clients should be referred to a hospital. A small number of TBA (4.6%) said they would refer a mother to a medical center if the umbilical cord was wrapped around the baby's head, and just over half (56.8%) would refer the mother if the baby was coming out the wrong way. Most TBA but not all (70%) would refer the woman if the baby was stuck inside the birth canal.

While knowledge deficits on both HIV and birthing practices among TBA appear large, they underline a continuing dilemma for countries like India where more than 60% of the population lives in rural areas[17]. While the Government of India has made substantial investments in increasing rural healthcare through its National Rural Health Mission, access to skilled birth attendance is still an unrealized goal for much of the population. Integrating TBA in the rural health system may be a viable short-term solution for lowering maternal and infant mortality in rural areas with limited access to medical care. Additionally, as some studies in Africa have shown[8, 18], TBA could contribute to HIV prevention efforts, particularly those focused on mother-to-child transmission of HIV. Studies in India have already demonstrated that training TBA can improve newborn care[19], increase uptake of maternal health services[20], and reduce neonatal mortality[21]. The difficulties of training TBA should not be underestimated however. Many have low levels of literacy and some may not be interested in further training. Attention must be given to making instruction relevant to the local cultural milieu in which TBA practice and germane to the realities of rural birth attendance. Furthermore, any effort to integrate TBA must be harmonized with national health policies and the existing priorities of the National Rural Health Mission. Given all these challenges, training TBA may still be India's best hope for reaching Millennium Development Goal 5 by 2015.

This study has several limitations. First, it was carried out among rural TBA living in Mysore Taluk and may not be representative of TBA in other areas of India. In addition, it was impossible to verify how large a practice each TBA had since this was self reported and might have been subject to recall and information bias. Second, respondents' accounts of events around pregnancy and childbirth may be subject to recall and information bias. It is likely that the TBA may have underreported some practices leading to a conservative estimate of our findings because of social desirability bias. Finally, it is likely that some of the questions were not answered by the respondents, as they may have not understood the vocabulary or terminology in spite of the fact that the questions were from formative research conducted prior to this study among TBA in the region.

Conclusion

Traditional birth attendants will continue to play an important role in maternal child health in India for the foreseeable future. This study demonstrates that a majority of TBA lack basic information about HIV/AIDS and safe delivery practices. Given the ongoing shortage of skilled birth attendance in rural areas, more studies are needed to examine whether TBA should be trained and integrated into PMTCT and maternal child health programs in India.

List of Abbreviations

AIDS: 

Acquired Immuno Deficiency Syndrome

HIV: 

Human Immunodeficiency Virus

MMR: 

Maternal Mortality Ratio

PMTCT: 

Prevention of Mother to Child Transmission of HIV

TBA: 

Traditional Birth Attendants

UNICEF: 

United Nations Children's Fund

WHO: 

World Health Organization.

Declarations

Acknowledgements

For their generous assistance on this project, the authors would like to thank the Project Kisalaya team for all their efforts in data collection and all TBA in the study for their participation. We would like to express our appreciation to Zonta, Wyoming for their generous donations of birthing kits. In addition, the authors would like to express their gratitude to Dr Arthur Amman, president of Global Strategies for HIV Prevention for advising on this project and critically reviewing the manuscript for content and language.

Funding/Support: This work was supported by an Elizabeth Glaser Pediatric AIDS Foundation International Leadership Award to Purnima Madhivanan.

Role of the Sponsor: Elizabeth Glaser Pediatric AIDS Foundation had no role in the study design, conduct, collection, management, analysis, or interpretation of the data, or preparation, review, or approval of the manuscript.

Authors’ Affiliations

(1)
Public Health Research Institute of India
(2)
San Francisco Department of Public Health

References

  1. UNICEF: State of the World's Children 2009: Maternal and Newborn Health. New York. 2009, --- Either ISSN or Journal title must be supplied..Google Scholar
  2. Childinfo: Monitoring the situation of women and children. --- Either ISSN or Journal title must be supplied.. [http://www.childinfo.org/delivery_care.html]
  3. McClure EM, Wright LL, Goldenberg RL, Goudar SS, Parida SN, Jehan I, Tshefu A, Chomba E, Althabe F, Garces A, et al: The global network: a prospective study of stillbirths in developing countries. Am J Obstet Gynecol. 2007, 197 (3): 247-10.1016/j.ajog.2007.07.004. e241-245View ArticlePubMedPubMed CentralGoogle Scholar
  4. Mavalankar D, Vora K, Prakasamma M: Achieving Millennium Development Goal 5: is India serious?. Bulletin of the World Health Organization. 2008, 86 (4): 243-243A. 10.2471/BLT.07.048454.View ArticlePubMedPubMed CentralGoogle Scholar
  5. WHO: PMTCT strategic vision 2010-2015: preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. 2010, Geneva: World Health OrganizationGoogle Scholar
  6. Greenwood AM, Bradley AK, Byass P, Greenwood BM, Snow RW, Bennett S, Hatib-N'Jie AB: Evaluation of a primary health care programme in The Gambia. I. The impact of trained traditional birth attendants on the outcome of pregnancy. The Journal of tropical medicine and hygiene. 1990, 93 (1): 58-66.PubMedGoogle Scholar
  7. Jokhio AH, Winter HR, Cheng KK: An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. The New England journal of medicine. 2005, 352 (20): 2091-2099. 10.1056/NEJMsa042830.View ArticlePubMedGoogle Scholar
  8. Perez F, Aung KD, Ndoro T, Engelsmann B, Dabis F: Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study. BMC public health. 2008, 8: 401-10.1186/1471-2458-8-401.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Msaky H, Kironde S, Shuma J, Nzima M, Mlay V, Reeler A: Scaling the frontier: traditional birth attendant involvement in PMTCT service delivery in Hai and Kilombero districts of Tanzania. abstract no.: ThPeE8084. International Conference on AIDS 2004; Bangkok, Thailand. 2004Google Scholar
  10. Mulder S: Midwifery in rural India: a study of traditional birth attendants in Tamil Nadu, India. Aust Coll Midwives Inc J. 1995, 8 (1): 24-30. 10.1016/S1031-170X(05)80009-1.View ArticlePubMedGoogle Scholar
  11. Trollope-Kumar K: The Traditional Birth Attendant in Garhwal, India: Towards a Culturally Relevant Training Program. Canadian Journal of Midwifery Research and Practice. 2002Google Scholar
  12. Special Bulletin on Maternal Mortality in India 2004-06. --- Either ISSN or Journal title must be supplied.. [http://censusindia.gov.in/Vital_Statistics/SRS_Bulletins/MMR-Bulletin-April-2009.pdf]
  13. Karnataka State Profile. --- Either ISSN or Journal title must be supplied.. [http://newdelhi.usembassy.gov/pepfars/pepfarstateskar.pdf]
  14. Mysore District. --- Either ISSN or Journal title must be supplied.. [http://www.mysore.nic.in/index.htm]
  15. National AIDS Control Organisation: National Behavioural Surveillance Survey (BSS) 2006. 2006, --- Either ISSN or Journal title must be supplied.. [http://www.nacoonline.org/upload/NACO%20PDF/General_Population.pdf]Google Scholar
  16. Kausar R: Maternal Mortality in India - Magnitude, Causes and Concerns. Indian Journal for the Practising Doctor. 2005, 2 (2):
  17. India: Urban Poverty Report 2009: Factsheet. --- Either ISSN or Journal title must be supplied.. [http://data.undp.org.in/poverty_reduction/Factsheet_IUPR_09a.pdf]
  18. Wanyu B, Diom E, Mitchell P, Tih PM, Meyer DJ: Birth attendants trained in "Prevention of Mother-To-Child HIV Transmission" provide care in rural Cameroon, Africa. Journal of midwifery & women's health. 2007, 52 (4): 334-341.View ArticleGoogle Scholar
  19. Satishchandra DM, Naik VA, Wantamutte AS, Mallapur MD: Impact of training of traditional birth attendants on the newborn care. Indian J Pediatr. 2009, 76 (1): 33-36. 10.1007/s12098-008-0229-9.View ArticlePubMedGoogle Scholar
  20. Mathur HN, Sharma PN, Jain TP: The impact of training traditional birth attendants on the utilisation of maternal health services. J Epidemiol Community Health. 1979, 33 (2): 142-144. 10.1136/jech.33.2.142.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD: Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet. 1999, 354 (9194): 1955-1961. 10.1016/S0140-6736(99)03046-9.View ArticlePubMedGoogle Scholar
  22. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/570/prepub

Copyright

© Madhivanan et al; licensee BioMed Central Ltd. 2010

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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