Birth Attendants Trained in “Prevention of Mother-to-Child HIV
Transmission” Provide Care in Rural Cameroon, Africa

Benjamin Wanyu, BA, Emmanuel Diom, Nurse Aide, Patricia Mitchell, RGN, RMN,Pius M. Tih, MPH, PhD and Dorothy J. Meyer, CNM, MPH Since 1984, Cameroon Baptist Convention Health Board’s Life Abundant Primary health care program has
established primary health centers in remote villages and trained literate women in these villages as birth
attendants to offer antenatal care, low-risk delivery, and triage of high-risk mothers to larger health facilities.
In 2002, the birth attendants were trained to provide Prevention of Maternal-to-Child HIV Transmission
(PMTCT) services, including counseling, voluntary testing, performing oral rapid HIV tests (OraQuick;
OraSure Technologies, Inc., Bethlehem, PA), posttest counseling, and administering single-dose nevirapine
to HIV-positive women, to be taken in labor, and to their newborns. Ongoing supervision is provided by
nurse supervisors. Between July 2002 and June 2005, 30 PMTCT-trained birth attendants in 20 villages
counseled 2331 pregnant women and tested 2310 (99.1%) for HIV. Eighty-two women had a positive
OraQuick HIV test (3.5%). Forty-two of these mothers were delivered by the trained birth attendants, with
88.1% of mothers and 85.7% of newborns receiving single-dose nevirapine prophylaxis. Nevirapine-treated
babies were tested after 15 months of age, and two of 13 HIV-exposed infants had a positive rapid HIV
antibody test (15.3% transmission rate with treatment). Program challenges include: maintaining adequate
supplies of HIV tests kits and medications, supervising and supporting the PMCT-trained birth attendants on
a regular basis, and achieving exclusive breastfeeding and early weaning. J Midwifery Womens Health 2007;
52:334 –341 2007 by the American College of Nurse-Midwives.
keywords: Cameroon, community health aids, health services (indigenous), HIV seroprevalance, maternal
health services, nevirapine, perinatal care, rural health services
We do not talk of second best when there is only one. We This article describes the effectiveness of trained birth attendants know what the best antenatal care and OB/GYN care should be, as the point of service in a Prevention of Maternal-to-Child HIV but where these services can not be provided for whatever Transmission Program (PMTCT). The following quote from one reason, what should we, working in those locations do to save of the authors of this article illustrates the importance of this life, using the limited resources in our hands? In August 2006, I visited a village and was told that I was the I am one of 13 born to our mother in the house and in a village first health authority to come there. These people are voiceless, where there was no health facility and no motorable road until powerless, and poor. Who will speak for them? 1980. My family, like many others, depended on women who were skilled in assisting women in labour. I later came to knowthat these women are called traditional birth attendants. Myfather was one of them because he assisted our mother to give “Each day, 1800 children worldwide become in- birth to some of us. In fact, our father told us that I was born fected with HIV, the vast majority of them newborns. when my mother was alone. I know of families in my village In 2005, 9% of pregnant women in low- and where women died at child birth, right at home, they died from middle-income countries were offered services to bleeding, from retained placenta, or breech births. All the male circumcisions including mine were done by parents or neigh-bours. I lived through all this and remember some of the bloody Mother-to-child transmission (MTCT) of HIV is al- sites from delivery with horror and depression. Many people, who most entirely preventable where health care services are only talk about this and never saw a difficult delivery in the 1960sand 1970s in a village, will not know what we are talking about.
available and accessible. The current standard of care is Villages without roads and without health centers still exist in to begin antiretroviral therapy when a HIV-infected 2006. A well trained traditional birth attendant will do a lot of woman becomes pregnant if she is not already receiving good to evaluate a high-risk pregnant woman and refer on time In the absence of treatment or prophylaxis, to the hospital. It takes days to move from one of these villages it is estimated that 13% to 42% of children born to (Tinta) to the nearest hospital (Akwaya). Please, I wish to inviteWHO and other advocates of the abolition of traditional birth HIV-positive women will become infected with attendants to live in one of these villages and have one baby The HIV/AIDS pandemic remains a major public health challenge in sub-Saharan Africa. In many of theseresource-limited countries, testing pregnant women forHIV infection remains elusive, and providing antiretro-viral treatment during the entire pregnancy is not feasi-ble. It is known that the transmission of HIV can bereduced by as much as 47% with the administration of asingle dose of nevirapine to HIV-infected mothers during Address correspondence to Dorothy J. Meyer, CNM, MPH, 3243 SouthGila Drive, Flagstaff, AZ 86001. E-mail: labor and to their babies within the first 3 days of Volume 52, No. 4, July/August 2007
2007 by the American College of Nurse-Midwives 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2006.12.018 Therefore, in these countries, Prevention of Maternal-to- and challenges of implementing a PMTCT program Child HIV Transmission (PMTCT) programs primarily using trained birth attendants. It was initially performed consist of providing this targeted “single dose” antiret- at the direction of the Director of the Cameroon Baptist roviral prophylaxis. Additionally, African PMTCT pro- Convention Health Board (CBCHB) to respond to per- grams have focused upon urban areas, leaving pregnant sistent controversies and challenges raised by visiting women living in rural areas without access to HIV testing international and governmental agencies regarding the ability of the CBCHB-trained birth attendants to provide Ideally, deliveries should be attended by qualified PMTCT care. In addition to the program described here, health workers (skilled birth Other recog- TBAs were trained to be involved in PMTCT activities in nized types of birth attendants include traditional birth and Uganda (Dr. Marc Bulterys, Global Aids attendants (TBAs) and trained TBAs. TBAs are defined Program, National Center for HIV and Tuberculosis as local women with no or minimal training. The birth Prevention, Centers of Disease Control and Prevention, care they provide varies widely, and their role is depen- Lusaka, Zambia, written communication, July 2006).
dent upon the community in which they reside. TBAs orother individuals selected by their community may com- BACKGROUND
plete a course of training to enhance their knowledge orabilities in a specific topic or skill. These individuals are Cameroon is a country in sub-Saharan Africa that is now referred to as “trained traditional birth attendants.” slightly larger than California. The climate varies with At times, they are also called “trained birth attendants,” the terrain, from tropical forests along the coasts to which is a non-standard, informal definition. In this article, semiarid and hot in the north. The population, estimated the term “trained birth attendant” is used to refer to the at more than 17 million, consists of many tribal groups, birth attendants trained by the Life Abundant Primary each with its own language and cultural uniqueness. In health care program to provide perinatal services. This rural Cameroon, it is estimated that 44.2% of women are has been the commonly used term for the trained TBAs delivered by skilled birth attendants, 18.6% by traditional since the inception of the Life Abundant Primary health birth attendants, 29.7% by family members or others, and care program more than 20 years ago.
7.3% of women deliver Therefore, if PMTCT In sub-Saharan Africa, the presence of skilled birth care is limited to being only clinic- or hospital-based, less attendants at all births is an unforeseeable goal. Skilled than half of pregnant women would have access to birth attendants conduct less than half of deliveries, with PMTCT care. Additionally, not all hospitals and clinics an estimated 22.2% of deliveries attended by traditional in Cameroon have elected to offer a PMTCT program.
birth attendants, 26.8% by family members, and 5.9% of In Cameroon, it is estimated that 505,000 individuals women delivering Although TBAs are a sig- are presently living with AIDS; 61% are In nificant workforce who have been shown to capably 2004, the seroprevalence of HIV in Cameroon was 5.5%, perform certain aspects of maternity their role with the highest prevalence of HIV infection among remains controversial. Their role in HIV/AIDS preven- women in the North-West province (11.9%). The HIV tion and control has been and their involve- prevalence rate is slightly higher among pregnant women ment in HIV/AIDS activities has been questioned and than the overall prevalence among women (7.4% vs 6.8%, respectively). Until 2000, there were minimal A literature search could not find reference to a health activities within Cameroon that addressed MTCT.
program that has incorporated PMTCT care into the care The CBCHB is a private, faith-based health care provided by TBAs, trained TBAs, or trained birth atten- system consisting of 3 hospitals, 22 integrated health dants. This report describes the introduction, successes, centers, and 42 primary health centers. In 2000, theCBCHB developed and initiated a PMTCT program witha grant from the Elizabeth Glaser Pediatric AIDS Foun-dation. By December 2004, this program was actively Benjamin Wanyu, BA, is the Program Manager of the Life AbundantPrimary health care (LAP) PMTCT Program, Cameroon Baptist Conven- functioning in 115 facilities in 6 of the 10 provinces in Cameroon (44 CBCHB health facilities, 38 government, Emmanuel Diom, Nurse Aide, is the Coordinator of the Life Abundant 9 private/occupational, and 24 other private hospitals and Primary health care (LAP) PMTCT Program, Cameroon Baptist Conven- The majority of these PMTCT programs were started and continue to function within hospitals and Patricia Mitchell, RGN, RMN, is the Director of the Life AbundantPrimary health care program (LAP), Cameroon Baptist Convention Health health centers in larger towns and cities.
In 2002, the CBCHB PMTCT program was expanded Pius M. Tih, MPH, PhD, is the Director of the Cameroon Baptist to their primary health centers in an effort to reach the more isolated rural populations. CBCHB rural health Dorothy J. Meyer, CNM, MPH, (Capt. USPHS, Ret.), provides volunteer care services are provided by the Life Abundant Primary services to the Cameroon Baptist Convention Health Board with emphasison maternal child health.
health care program through primary health Journal of Midwifery & Women’s Health
These community-sponsored and -maintained health fa- serial HIV testing with two rapid HIV Tests (Determine cilities provide basic outpatient care and perinatal ser- and Hemastrip [Perlei Medical, Inc., Melbourne, FL]) to vices in rural villages, many of which are very remote.
The primary health center is managed by a local village The CBCHB PMTCT Program uses an “opt out” health committee and is staffed by health promoter(s) approach when providing HIV testing. In the primary and trained birth attendants. Using standing orders, the health centers, women are referred to alternate facilities health promoter provides limited outpatient medical care for common antenatal blood tests, but many are unable to treating common illnesses. All maternity care is provided get to these facilities because of poverty and limited at the primary health center by the trained birth atten- transportation. HIV testing is the only laboratory test dants, including antenatal, labor and delivery, and post- performed at the primary health center. The basic pro- partum care. In villages with primary health centers, gram guidelines for the training of PMTCT almost all women give birth at the primary health center were minimally modified in both counseling and labora- and are attended by the trained birth attendants. These tory techniques for the trained birth attendant training.
village health care workers are selected by the commu- The protocol for nevirapine administration follows nity and reside within the community. To be accepted for birth attendant training, the individual must be literate, who have a positive HIV test (OraQuick) are given one well-respected in the community, of positive moralattitude, and have given birth or fathered babies. Though 200-mg nevirapine tablet to take during labor. Nevirap- most of these birth attendants are females, gender is not ine should be taken by the mother between 2 and 48 hours before birth to assure transplacental passage to the The CBCHB Life Abundant Primary health care pro- fetus. The dose should be repeated if taken earlier than 48 gram provides both initial and ongoing training plus hours before birth. The trained birth attendant gives the supervision and technical support to the village health newborn 2 mg/kg nevirapine syrup within 72 hours after committees and primary health center staff through nurse birth. If the primary health center has no baby scale, the supervisors, who visit each site on a regular basis. On trained birth attendant gives a standard dose of 0.6 mL of their periodic visits, nurse supervisors administer immu- nevirapine. If the maternal dose was not taken within the nizations and evaluate more complicated patients.
appropriate time frame, the trained birth attendant givesthe newborn 2 doses (one immediately after birth and asecond at 48 –72 hours). Beginning in 2006, infants and TRAINED BIRTH ATTENDANT PMTCT PROGRAM DESCRIPTION
mothers were no longer given second doses of nevirapine A PMTCT program is initiated in a primary health center because of the length of the half life of the drug.
through a defined process. First, the supervisory staff Mixed feeding is commonly practiced in rural Cam- meets with the village health committee and educates There are multiple physical barriers to bottle them about HIV and PMTCT. After the presentation and feeding, including the lack of available formula and discussion, the village health committee is offered the potable water. Additionally, there is strong cultural option of integrating PMTCT care into the existing pressure on women to mix feed their infants with breast maternity care. If the committee accepts, the trained birth attendant is sent to complete additional formal training in Although the trained birth attendants are taught to the PMTCT protocol. This protocol includes confidential educate the women about the transmission of the HIV HIV counseling (group pretest and individual posttest virus through breast milk, few women in these rural counseling techniques), performing an oral fluid rapid villages have the support and capability to provide HIV antibody test (OraQuick; OraSure Technologies, formula to their children. The issue of formula feeding Inc., Bethlehem, PA), and peripartum administration of being “acceptable, feasible, affordable, sustainable and nevirapine to the mother and baby. Specific training is safe” (AFASS criteria) has been addressed by the WHO provided on how to explain the negative and the positiveHIV test, which includes description of the small possi- in a Consensus Statement published in October 2006.
bility that the test is false-positive and will require Several recent studies in African countries identified an additional HIV testing. If the OraQuick test is positive, increase in infant morbidity and mortality when the the nurse supervisor performs a second rapid HIV test on infants of HIV-infected mothers were weaned at 4 to 6 venous blood (Determine; Abbott Diagnostic Division, months of age. Unless replacement feeding is “AFASS”, Hoofddorp, The Netherlands) during a regular visit to the it is now recommended that HIV-infected women con- primary health center. In the case of discordant test tinue to breastfeed after 6 months with supplementation results, the mother is sent to a hospital or health center of complementary foods. Each mother and infant should for a third “tiebreaker.” The Centers for Disease Control be assessed at frequent intervals, and all breastfeeding and Prevention (CDC) has evaluated the rapid HIV tests should be stopped once the infant can be provided a performed by the CBCHB PMTCT program and found nutritionally adequate and safe diet without breast milk.
Volume 52, No. 4, July/August 2007
because of twin gestations and two women for PMTCT Table 1. Follow-up Determine Testing of 82 Women With Positive
prophylaxis when no medication was available at the primary health center. The remaining four women gave Test Results
birth at home. Each of these women had been referred toan alternate facility by the TBA because no medication was available at the primary health center. These women Reason the Determine test was not done
and/or their families selected home birth rather than delivery elsewhere. Prophylaxis was not possible for 20 Family left village after positive oral test women because 10 had not yet delivered, one delivered at a previable gestation, one delivered a premature baby at home who died soon after birth, two delivered stillborninfants, and six women moved to unknown locations.
Two women delivered twins. Therefore, a total of 62 women delivered 64 live infants. Of the 42 newborns PROGRAM REVIEW
delivered by the trained birth attendants, 36 (85.7%) Common PMTCT program data were analyzed from the were treated after birth. The reasons why six newborns data collection forms maintained by trained birth atten- were not treated included: 1) nevirapine syrup was not dants at each program site, as well as data from a defined available at four deliveries; 2) one mother refused to have verbal interview of each trained birth attendant. These her baby treated; and 3) one delivery occurred when the data were collected in a 1-week period of time by the trained birth attendant was not present with no other authors and include all data from the initiation of available staff trained to provide prophylaxis. The trained PMTCT care in July 2002 through June 2005.
birth attendants were able to treat 35 mother and baby In June 2005, PMTCT care had been initiated in 21 pairs following the PMTCT protocol in which they were primary health centers. One site was inactive, because the trained birth attendant died. The following data were The CBCHB PMTCT program attempts to perform collected from the 30 trained birth attendants working in polymerase chain reaction (PCR) testing in infants born the 20 active PMTCT primary health center sites.
to mothers who are HIV positive during the first 6 weeks Between July 2002 and June 2005, the trained birth of life. Because of the difficulty of drawing infant blood attendants counseled 2331 women, with 2310 (99.1%) and shipping it for testing, PCR testing is not performed accepting initial OraQuick testing. Eighty-two of the at the primary health centers. Instead, a rapid antibody 2310 women (3.5%) were OraQuick-positive.
test is performed (OraQuick or Determine) when the Of the 82 women who tested positive via the initial child reaches 15 months of age. Of the 64 children whose OraQuick test, 52 (63.5%) had a second rapid blood HIV mothers had a positive OraQuick test, 29 (45.3%) were antibody test with the Determine HIV test. Forty-nine women 15 months of age or older in June 2005. Fourteen had a positive second rapid HIV test, and three tested negative.
(48.3%) of the 29 children were tested for HIV. Thirteen Of the three women who had a negative Determine test, of these 14 children had received nevirapine prophylaxis one had a negative tiebreaker test, one refused a third at birth. Eleven of these thirteen children had negative test, and one was referred to the hospital with the test HIV tests and two had positive tests (15.3%). One of the result unknown. presents the follow-up of the HIV-positive children was alive, and one had died at 23 months. One child, who had not received prophylaxis, The trained birth attendants were taught to presump- tested negative. The mother of this child refused to return tively give prophylaxis to all women who had a positiveOraQuick test and to their newborns at delivery. Of the62 women who gave birth to live babies, 42 were Table 2. Postpartum Health Condition of Mother and Child—July
delivered by trained birth attendants at the primary health centers. Of these 42 women, 37 (88.1%) received neva- Health Status
Mother n (%)
Baby n (%)
rapine prophylaxis, and 5 women did not receivingprophylaxis at delivery. The reasons medication was not given included: 1) nevirapine tablets were not available at two deliveries; 2) two mothers refused prophylaxis; and 3) one woman delivered when the trained birth attendant was not present and no other staff was trained to provide prophylaxis. Sixteen of the 62 women gave *Alive and well was defined as being without obvious signs of illness and able to birth in other facilities with 11 (68.8%) receiving pro- perform common activities of daily living.
phylaxis. Four of these 16 women were referred by the †Sick was defined as having signs/symptoms of any illness and unable to trained birth attendant, including two women transferred consistently perform common daily activities.
Journal of Midwifery & Women’s Health
to clinic following the positive OraQuick test and deliv- Determine test has a longer shelf life and is donated, ered at an alternate facility that did not have PMTCT which reduces program costs. Although there are gaps, care. Ten infants were not tested because either their the supply of HIV blood assay kits is more stable. In family refused further testing or their family did not response to findings of this review and the encourage- return to the primary health center for further care. Two ment of a visiting team from Zambia and the United children were managed at alternate facilities for their the program began training the trained birth health care with their HIV test result unknown. One child attendants to perform Determine HIV blood tests in was not tested because tests kits were not available.
2006. After helping the nurse supervisors perform the Finally, the reason why two children were not tested Determine test and seeing the simple procedure, the could not be identified. presents the health status trained birth attendants were receptive to using the blood of the 82 women who were HIV-positive via the Ora- test. All have now been trained to perform the initial Quick test at the time of birth, and their 64 live born screening with the Determine HIV test.
Only 63.5% of the women with a positive OraQuick test had a second Determine test. We identified multiplebarriers to providing further testing, including geo- DISCUSSION
graphic isolation, manpower limitations, and difficulty in The acceptance rate of HIV testing varies greatly among obtaining test kits. It was initially assumed that the nurse populations. In the CBCHB PMTCT program, 91.2% of supervisors could visit the primary health centers women accepted HIV testing following counseling in monthly to support the PMTCT program, which included In the primary health centers, the acceptance rate performing the second rapid test, giving the patient the (99.1%) was significantly higher (P Ͻ .0001). A number final test results, and counseling the patient and family.
of factors likely contribute to this acceptance rate. First, Unfortunately, most nurse supervisors were unable to there is a national policy in Cameroon encouraging HIV visit their assigned primary health centers monthly sec- testing, which has been widely publicized including in ondary to the geographic isolation and their multiple rural Second, the PMTCT training curriculum other duties. Transportation remains a major challenge, provides a comprehensive knowledge base, including especially during rainy season when roads and trails are understanding why the program is important to each often impassable. Additionally, program transportation is woman, family, and the general community. The trained limited and local transportation is sporadic and unreli- birth attendants are taught to provide positive and accu- able. Finally, Determine HIV test kits were not always rate information first in a group session followed by available, secondary to supply problems.
private, individual counseling. Training emphasis is We found it problematic that a low proportion of placed on why confidentiality is necessary and how to women were not receiving the second HIV test. Although maintain confidentiality. Presenting information in a both the oral and blood tests have a high sensitivity and positive, sensitive, and confidential manner has also been specificity, slightly more false-positive and false-nega- shown to influence the acceptability of voluntary HIV tive results occur with the oral fluid than the whole blood testing in other African Additionally, the (Dr. Marc Bulterys, Global Aids Program, National trained birth attendants are highly regarded and trusted Center for HIV and Tuberculosis Prevention, Centers of within these communities, which contributes to women Disease Control and Prevention, Lusaka, Zambia, written being more accepting of the counseling and testing.
Finally, cultural factors may influence this high accep- Ideally, the nurse supervisors should be present to tance rate. PMTCT programs are initiated with the assist with the HIV test and posttest counseling. A involvement and support of the village health committee positive HIV test is life changing for each woman and and village chief. In these community-based and -sup- often emotionally difficult for the trained birth attendant ported clinics, women may feel pressure from these to present to her neighbor, whom many times she has authorities to utilize the primary health center services, known and interacted with since childhood. Unfortu- nately, having the nurse supervisor present is not An oral rapid HIV antibody test was used for the initial always possible, and the program is currently evalu- screening test because it was the most user-friendly and ating the possibility of the trained birth attendant per- acceptable to the trained birth attendants who did not forming the second test and presenting the final test perform any type of blood testing during perinatal care.
results to the woman. If instituted, further training will be We found that a recurrent program barrier was maintain- required for each trained birth attendant with the under- ing an adequate supply of OraQuick test kits. Both the standing that not everyone may be able to perform the oral and blood HIV rapid tests have a sensitivity of more second test and counseling required. Despite these prob- than 97%, but the OraQuick oral fluid assay has a relatively lems, the percentage of HIV-positive mothers treated short shelf-life and is more expensive than the more with nevirapine by the trained birth attendants (88.1%) at commonly-used rapid blood HIV assays in Africa. The the primary health centers is greater than that of mothers Volume 52, No. 4, July/August 2007
receiving nevirapine in all 155 CBCHB PMTCT facili- finding that HIV transmission was prevented in 85.7% (n ϭ 11/13) of the infants who were given nevirapine A continued challenge for the CBCHB PMTCT pro- and whose test results were available reaffirms the benefit gram has been prophylaxis of the newborn of HIV- infected mothers. In 2005, 41.3% of newborns received nevirapine at birth in all facilities served by the CBCHB and this review confirms the risks of disclosure of HIV PMTCT program. A significantly higher proportion of serostatus. It is not uncommon for marital violence to the newborns (85.7%) of HIV-infected mothers were occur, for women to be forcibly driven from their treated by the trained birth attendants in the primary homes, or for women to be abandoned by their health centers (P Ͻ .0001), compared to the newborns of husbands and families with the disclosure of the mothers who were not infected with HIV.
We found that a primary reason women and/or their Support Groups General Coordinator, written commu- babies were not treated by the trained birth attendants nication, July 2006). In this group of women, 11 was the lack of medication. The geographic isolation of (13.4%) did not receive further testing because the the primary health centers contributes to the challenge of families left their community after the initial positive maintaining medication supplies. During the review period, OraQuick test. Denial is also evident, as some believe the CBCHB PMTCT protocol changed, allowing pro- nothing will happen to the mother, child, and family if gram staff to dispense a nevirapine tablet to each mother further testing is not done. This may partially explain at the time of the initial antenatal positive HIV screening why 34.4% of families declined testing of their child at test and to instruct her to take the tablet in active labor.
15 months. A challenge for a number of the trained This change in policy and the increased attention by birth attendants has been that other individuals or PMTCT program administration to maintaining adequate family members have been accused of causing the supplies of nevirapine tablets has improved the percent- mother’s positive HIV test through witchcraft. Al- age of mothers receiving prophylaxis since this analysis though the trained birth attendant does their best to explain that HIV/AIDS is a medical illness, witchcraft Maintaining an adequate supply of nevirapine syrup at remains a center of African traditional religions in each primary health center has been more challenging, many of these communities. A final challenge to HIV because the syrup cannot be stored in small amounts for prevention programs is that, in much of Africa, the distribution and has a short shelf life of 1 month once myth remains that HIV can be cured by sexual opened. CBCHB Pharmacy continues to seek a cost- intercourse with a virgin. All HIV/AIDS program effective methodology in which the syrup can be kept in workers, including the trained birth attendants, con- small (e.g., 5-dose containers) or in individual droppers tinue to work to eliminate this myth. In the villages or syringes at the primary health center, maintaining served by the primary health centers, the HIV-infected nevirapine syrup at PMTCT sites continues to remain a mother frequently seeks the support and assistance from the primary health center staffs who do their best In this program, 42 women were successfully deliv- to positively assist these women, their children, and ered by trained birth attendants at the primary health their families, as well as serving as their advocate centers. Women who are HIV-positive and asymptomatic are not referred to deliver elsewhere. The trained birthattendants are taught to recognize risk factors and phys- CONCLUSION
ical signs and symptoms of HIV/AIDS. Women withrisks or symptoms are referred to alternative facilities for The impact of HIV in Africa continues to be dishearten- delivery. The trained birth attendants and nurse supervi- ing. The prevalence of HIV-positive women in the Life sors must base their judgment on physical findings, Abundant Primary health care PMTCT program (3.5%) because they do not have laboratory capability to detect is similar to that found in other rural areas of Cameroon (4.0%). However, it is less than the HIV prevalence The goal of any PMTCT program is to prevent HIV among all antenatal patients who receive PMTCT ser- infection in children. The final outcome of this program vices through the Cameroon Baptist Convention Health is that 15.3% of these infants had positive HIV tests after Board (8.2%). It is important to note that 4.0% of the 15 months of age, which is comparable to that of the HIV-positive women have died since their positive HIV original nevirapine study (15.7%) in and the test, each being a notable loss to these small villages. Of hope to their families is the survival of most of the must be interpreted cautiously because of the small children aided through the PMTCT program. In the number of children included in the population. However, present circumstances, these are now children who will it is a remarkable outcome, because of the known use of eventually face life without their mothers and usually mixed feeding in this Cameroonian population. The without their fathers. Though antiretroviral treatment is Journal of Midwifery & Women’s Health
becoming more available and affordable, it remains acknowledge the Cameroon Baptist Convention Health Board AIDS Control unattainable to those individuals living in these isolated Program’s ongoing support for implementing and maintaining PMTCT in rural areas, and especially the leadership provided by Joseph Nkfusai, Finally, the role of TBAs and trained birth atten- BSc, Program Director, and Drs. Tom and Edie Welty, Associate Directors.
We recognize Mr. Tancho Sam and his able training of the trained birth dants in maternity care remains controversial. In the attendants to perform the HIV testing. Finally, a special thanks to the 1980s and 1990s, many TBAs were given training as Elizabeth Glaser Pediatric Foundation, which funds the PMTCT program part of the WHO Safe Motherhood initiative. How- and Bread for the World, which provides financial support and encour- ever, their training seemed to have no impact on agement to the Cameroon Baptist Convention Health Board Life Abundant decreasing maternal mortality with WHO now advo- Primary health care program. As required by the Cameroon BaptistConvention Health Board, approval of manuscript submission for publi- cating for skilled care in pregnancy and the postnatal cation was requested and granted by the Cameroon Baptist Convention There have been multiple publications ques- Health Board Institutional Review Board on March 3, 2006.
tioning the benefit of TBA training programs ascompared to other health There havebeen an equal number of publications showing the REFERENCES
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This paper is dedicated to the memory of Menjara Elisabeth, trained birth Entry into this world: Who should assist? Birth attendants and new- attendant; her dedication to and care for her people continue to serve as born health. Arlington VA: Basic Support for Institutionalizing a positive example to us. We wish to recognize and thank each trainedbirth attendant who has implemented the PMTCT program in her village.
Child Survival Project (BASICS II), 2004.
This is very difficult work, which they have willingly and selflessly 8. World Health Organization. Safe motherhood policy alert.
assumed in addition to their other duties and tasks of daily living. These Geneva: World Health Organization, 2003. pp. 4.
trained birth attendants receive no financial compensation for performingPMTCT care but do so solely to save the children and help their neighbors.
9. Patel B, World Health Organization Web site. Regional The authors recognize and appreciate the able support and assistance of Office for South-East Asia. Where is the ‘M’ in MCH? Regional the nurse field supervisors who are pivotal to this program’s success. We also wish to recognize Ruby Eliason, DrPH, and Laura Edwards, MD, who worked tirelessly in training and supporting trained birth attendants from the Life Abundant Primary health care program’s inception in 1984 untiltheir tragic death in a motor vehicle crash in Cameroon during a primary 10. Bailey P, Szaszdi J, Glover L. Obstetrical complications: health center site visit in 2000. They developed the organizational Does training traditional birth attendants make a difference? Pan infrastructure that made this program possible. We appreciate and 11. Sibley L, Sipe T. What can a meta-analysis tell us about Volume 52, No. 4, July/August 2007
traditional birth attendant training and pregnancy outcomes? 12. Bulterys M, Fowler MG, Shaffer N, Tih PM, Greenberg AE, 26. CTA Qualitative Outcome and Performance Markers. Cam- Karita E, et al. Role of traditional birth attendants in preventing eroon Baptist Convention Health Board PMTCT/AID Program transmission of perinatal HIV. BMJ 2002;324:222– 6.
13. Berer M. Traditional birth attendants in developing countries 27. de Paoli MM, Manongi R, Klepp KL. Factors influencing cannot be expected to carry out HIV/AIDS prevention and treat- acceptability of voluntary counseling and HIV-testing among preg- ment activities. Reprod Health Matters 2003;11:36 –9.
nant women in Northern Tanzania. AIDS Care 2004;16:411–25.
14. Walraven G. Commentary: Involving traditional birth atten- 28. Report on the Study Tour for Visitors from Zambia and dants in prevention of HIV transmission needs careful consider- USA. Cameroon Baptist Convention Health Board PMTCT/AIDS 15. Msaky H, Kironde S, Shuma J, Nzima M, Mlay V, Reeler A.
29. Jackson JB, Musoke P, Fleming T, Guay LA, Bagenda D, Scaling the frontier: Traditional birth attendant involvement in Allen M, et al. Intrapartum and neonatal single-dose nevirapine PMTCT service delivery in Hai and Kilombero District of Tanza- compared with zidovudine for prevention of mother-to-child trans- nia. Poster presented at the XV International AIDS Conference, mission of HIV-1 in Kampala, Uganda: 18-month follow-up of the Bangkok, Thailand, July 11–16, 2004.
HIVNET 012 randomised trial. Lancet 2003;362:859 – 68.
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E, Kfutwa A, et al. Low rate of mother-to-child transmission ofHIV-1 after nevirapine intervention in a pilot public health pro- 17. Republic of Cameroon Ministry of Public Health. National gram in Yaoundé, Cameroon. J Acquir Immune Defic Syndr HIV/AIDS Control Strategic Plan 2006 –2010. Ministry of Public Health, National AIDS Control Committee, Central TechnicalGroup, 2006.
31. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women 18. Welty TK, Bulterys M, Welty ER, Tih P, Ndikintum G, in developing countries: Implications for prevention of mother-to- Nkuoh G, et al. Integrating prevention of mother-to-child HIV child transmission programmes. Bull World Health Organ 2004; transmission into routine antenatal care: The key to program expansion in Cameroon. J AIDS 2005;40:486 –93.
32. World Health Organization Web site. Making pregnancy safer: 19. Eliason RN. Toward sustainability in village health care in The critical role of the skilled attendant. A joint statement by WHO, rural Cameroon. Health Promot Int 1999;14:301– 6.
20. Granade T, Parekh B, Tih PM, Welty T, Welty E, Bulterys M, et al. Evaluation of rapid prenatal human immunodeficiency virus testing in rural Cameroon. Clin Diagn Lab Immunol 2005; 33. Smith JB, Coleman NA, Fortney JA, Johnson JD, Blumha- gen DW, Grey TW. The impact of traditional birth attendant 21. Women, Children, and HIV Web site. Healthy babies, happy training on delivery complications in Ghana. Health Policy Plan mothers: Prevention of Mother-to-Child Transmission of HIV (PMTCT) Training Manual. Cameroon Baptist Convention Health 34. Bergström S, Goodburn E. The role of traditional birth Board (CBCHB) PMTCT Program. Available from: attendants in the reduction of maternal mortality. In: de Brouwere V, van Lerberghe W, editors. Safe motherhood strategies: A review of the evidence. Antwerp: ITG Press, 2001. pp. 77–96.
22. World Health Organization Web site. WHO/HIV AIDS.
35. Goodburn E, Chowdhury M, Gazi R, Marshall T, Graham Prevention of mother-to-child transmission of HIV: Selection and W. Training traditional birth attendants in clean delivery does not use of nevirapine. Technical notes. Available from: prevent postpartum infection. Health Policy Plan 2000;15:394 –9.
36. Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Effect of home-based neonatal care and management of sepsis on neonatal 23. World Health Organization Web site. WHO/HIV AIDS.
mortality: Field trial in rural India. Lancet 1999;345:1955– 61.
WHO reconfirms its support for the use of nevirapine to preventmother-to-child transmission of HIV. Available from: 37. Greenwood B, Greenwood A, Snow R, Byass P, Bennett S, Hatib-N’Jie A. The effects of malaria chemoprophylaxis given by traditional birth attendants on the course and outcome of preg-nancy. Trans R Soc Trop Med Hyg 1989;83:589 –94.
24. Kakute P, Ngum J, Mitchell P, Kroll K, Forgwei G, Ngwang L, et al. Cultural barriers to exclusive breastfeeding by mothers in 38. Jagota P, Chandrasekaran S, Sumathi G. Follow-up of pul- a rural area of Cameroon, Africa. J Midwifery Womens Health monary tuberculosis patients treated with short course chemother- apy through traditional birth attendants (Dais). Indian Journal ofTuberculosis 1998;45:89 –93.
25. World Health Organization. WHO HIV and infant feeding technical consultation held on behalf of the Inter-agency Task Team 39. Jokhio A, Winter H, Cheng K. An intervention involving (IATT) on prevention of HIV infections in pregnant women, mothers traditional birth attendants and perinatal and maternal mortality in and their infants Geneva, October 25-27, 2006. Available from: Pakistan. N Engl J Med 2005;352:2091–9.
Journal of Midwifery & Women’s Health


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