High Maternal Mortality Ratio (MMR) is a challenge a head of the Ministry of Public Health of Afghanistan. The MMR is very high in Afghanistan, 1900/100,000 (UNICEF, 2004) live births and in Badakhshan of Afghanistan it is the highest ever recorded in the world, 5600/100,000 live births (UNICEF 2002). Yet the role of TBAs in reduction of MMR has become less important and training TBAs has been stopped by the World Health Organization, UNICEF, and the Ministry of Public Health. I strongly believe that TBAs can still play a vital role in the reduction of MMR by the provision of safe and clean delivery with extensive supervision and a marginal incentive, which is cost effective, identification of early danger signs of pregnancy and referral of mothers to Emergency Obstetric Care centers.
Globally speaking about Maternal Mortality Ratio around 585, 000 maternal deaths happening every year through out the world mainly in developing countries (Gijs et al 1999). The main causes of these deaths are five major complications of delivery such as: hemorrhage, infections, high blood pressure, obstructed labour and unsafe abortion, which can easily be prevented by provision of comprehensive maternal care system at the community and district level. Home deliveries are high in percentage in Afghanistan conducted either by a Untrained Traditional Birth Attendant or relatives without assistance of professional health worker. Safe and clean delivery is very important for each delivery and training those TBAs who is the only mean of assistance in terms of delivery for the majority of women in the country can be vital. Provision of marginal incentive for Trained TBAs is a good strategy for encouraging them to do a better job and it is much cost effective than provision of professional health worker with midwifery skills for each delivery all over the country. In a country of 25,000,000 people where 78% (www.prb.org)of the population live in rural areas without basics of life and health care. To provide health professional with midwifery skill to attend all deliveries, there is a need to train 8,000 midwives and they will not only need salary, but also housing, education for their children and job for their husbands, which can be too costly, while we need 16,666 TBAs if each covering a population of1500.
Five major causes of Maternal Mortality such as hemorrhage, infections, high blood pressure, obstructed labour and unsafe abortion, which could be prevented if the danger signs are early diagnosed by the TBAs who is the first and for most of the mothers in the country the only source of basic care. Therefore training and extensive supervision of the TBAs with the marginal incentive can assure best performance of the TBAs. "According to a recent study, more than 40 per cent of deaths among women of child-bearing age are caused by complications in pregnancy that are preventable" (www.unicef.org/afghanistan). On the other hand in the past TBAs haven't been successful and effective in reduction of MMR, because they have been volunteers and volunteerism in Afghanistan is challenging strategy to achieve the most from the people. Early diagnosis of danger signs and referring the mothers to higher level of Obstetric Care remain vital for the pregnant mothers.
Referral of mothers once the danger signs are diagnosed to the next level of care with more comprehensive obstetric care, rarely available, is another issue and it is difficult to achieve. The economical condition of the families is not at the level that they could transfer their patients to higher levels, which is mainly available only in the cities. In addition the terrain in the country prohibits most of the people to reach to the basic health care, especially during the winter. Furthermore transport is still an issue in the country. Taking the above issues into consideration if we stop training TBAs who is the first and the only contact for most of the women to help them diagnose the danger signs in advance and give them time to reach the next level of care at least few days earlier than delivery day would be a disaster for them.
In conclusion, TBAs can play a significant role in reduction of the Maternal Mortality Rate in Afhganistan if they are well trained and extensively supervised. Moreover the TBAs should be allocated a marginal incentive in order for them to be encouraged to do their job in a proper manner.
