Clinical versus community-based care
As they gained independence in the 1950s and 60s, most countries in Africa and Asia were investing in facility-based care for the rich in urban settings. During the1970s and 80s, emphasis shifted to primary health care and mass training of community health workers (CHWs) and traditional birth attendants (TBAs), with the aims of reaching the poor and empowering communities. This approach was championed in the Declaration of Alma Ata in 1978. However, many CHWs and TBAs were trained only briefly and then left unsupervised, often without links to a referral system.
Training of TBAs has been associated with a small but significant decrease in perinatal mortality and birth asphyxia-specific neonatal mortality (Sibley et al). Other studies have demonstrated the effectiveness of well trained and supported CHWs in reducing neonatal mortality, especially late neonatal mortality (Bang et al and Sazawal et al). However, a measurable impact of trained TBAs on maternal mortality has not been demonstrated, although measurement is more complex as maternal deaths are a relatively rare event (Sibley et al). Another approach is to deploy midwives in the community: this is how Sweden reduced maternal and perinatal mortality so successfully a century before the USA.
Community and clinical care are both important components of a functional health system
By the end of the 1990s, policy and investment interest in community health systems was waning. The global priority was now single-focus solutions, such as global funds for vaccines and selected infectious diseases. In safe motherhood programmes, the strong message was the need for skilled care in childbirth (de Brouwere et al). Governments were advised to stop training TBAs, as this was seen as ineffective and an obstacle to investment in skilled care (World Health Organization). Much emphasis was put on emergency obstetric care, often without parallel efforts to promote demand for care (Paxton et al).
Current position
Initially many governments ceased support for TBAs. However, even in countries working hard to increase skilled care, there is an inevitable time lag: the global gap of 330,000 midwives takes time to fill, and filling it requires new midwifery schools and teachers. Even once more midwives are trained, maintaining coverage in rural areas is a challenge. In some countries, such as India, this has led to public demonstrations by TBAs and women. If TBAs were not allowed to assist at delivery, who would provide care for half the country's deliveries?
Now several large countries with high mortality and low coverage of skilled care have selected community-based policies for maternal, newborn and child health (MNCH) as an approach to reach the poor which can be achieved within a short time-frame. Ethiopia, for example, has decided to invest in two cadres of community-based worker: a health extension worker to provide services such as family planning and immunisations, and a health promoter to work with families and communities to encourage healthy family practices. India has also decided to add home-based newborn care to her main reproductive and child health programme (Lancet neonatal survival 3). Will these policies be a stepping stone to increasing skilled care or will they be a diversion?
A win-win for the future
Global policy has swung between skilled facility-based care and community-based care, detracting from steady progress in both. This policy conflict is unnecessary and unhelpful. Community and clinical care are both important components of a functional health system.
By applying a phased approach to programme planning, professional clinical care should be strengthened and made more equitable. By cutting out community care, the poor lose what care they have now and will wait the longest for skilled care. Some countries, such as Malaysia, used TBA training as a stepping stone towards skilled care; others did not progress to increasing skilled care (Koblinsky et al). Simple community-based approaches could save up to 32 per cent of neonatal deaths and most child deaths, as well as benefiting maternal health (Lancet neonatal survival 3).
Balancing the development of both community and clinical care allows early success in reducing deaths now, including for the poor, and at relatively low cost (Lancet neonatal survival 2). Meanwhile, serious investment is required to increase human resources, especially midwives, and strengthen the system for skilled care. However, by not progressing to skilled care, the health system will not reach the mortality impact required to achieve MDGs 4 and 5, and particularly to reduce maternal deaths. Even when high availability of skilled care becomes reality, community-based approaches are necessary to promote demand for services, and encourage healthy behaviours (Manandhar et al).
