Role of traditional birth attendants in preventing perinatal transmission of HIV Commentary: Involving traditional birth attendants in prevention of HIV transmission needs careful consideration

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Involving traditional birth attendants in preventing HIV transmissionIn sub-Saharan Africa about 63% of pregnant women have at least one antenatal visit and 42% are attended by a professional healthcare worker at delivery.11 High quality maternity care is often unavailable.12 Home birth remains a strong preference and often is the only option.13 Of 22 countries surveyed in Africa, only in Botswana had a professional healthcare provider attended more than 75% of deliveries.11 Between 60% and 90% of deliveries in rural areas are assisted by traditional birth attendants.13–15 Worldwide, more than one million women infected with HIV are estimated to deliver their babies without the help of professional healthcare workers.Over the past decade, traditional birth attendants in many regions have been trained in midwifery and basic hygiene as part of a safe motherhood initiative aimed at reducing maternal mortality.13 Traditional birth attendants speak the local languages, allow traditional birthing practices, and often have the trust and respect of the community.13–15 Although providing highly skilled medical attendants for all deliveries in poor communities remains a long term goal, an intermediate solution is to identify, support, and train birth attendants who are already practising in local communities. For example, traditional birth attendants in rural Cameroon are selected by a village committee, and, after specialised training for up to six weeks, they are given a certificate, instruction book, and delivery kit. Retention of birth attendants is high because they share cultural and health beliefs with the women and have strong ties with the community. In our experience, the competence and skills of traditional birth attendants may vary widely across settings. As with professional midwives in geographically isolated clinics, traditional birth attendants require continuing education and supervision, and they need to be able to refer patients and help transport them to hospitals for second line care during delivery. 13 16The ability to prescribe short courses of antiretroviral therapy presupposes that the infrastructure for antenatal care is able to provide quality care, including HIV counselling and testing.10 While most pregnant women in poor settings attend antenatal clinics at least once before delivery, few of these women are offered and receive HIV counselling and testing. Practical obstacles such as travelling distances and fear of violence or discrimination may also affect a woman's decision to get tested.17 Rapid HIV testing services—strategies that provide an HIV test, its result, and counselling specific to the result during a single antenatal visit—seem to be effective and acceptable to pregnant women, and they can be expanded to include counselling of couples. 18 19 Programmes to prevent perinatal transmission of HIV aimed at women in rural areas will need thorough preparation involving the community, dissemination of information on effective strategies for preventing perinatal transmission of HIV, training of community health workers, and strengthening of links between home care and available antenatal and maternity clinics.Making facilities for HIV testing and counselling more widely available in poor settings undoubtedly remains one of the most important challenges in combating the HIV and AIDS epidemic in poor parts of the world. Traditional (or “trained”) birth attendants could play a critical role by reaching pregnant women not currently receiving formal antenatal care and by assisting with delivery of primary services designed to prevent HIV transmission. If rapid HIV testing could be made more widely available to pregnant women (for example, in primary healthcare centres and mobile clinics), trained birth attendants could oversee the provision of nevirapine to women infected with HIV who give birth at home and to their newborn infants. Traditional birth attendants could also counsel women and their partners on how to reduce the risk of HIV being transmitted to the child, focusing particularly on the postpartum period.To increase efforts to implement measures to reduce paediatric AIDS in areas with a high prevalence of AIDS and in poor settings, research is urgently needed to assess how best to provide nevirapine in a single dose to women delivering at home and their neonates. In areas where the prevalence of HIV is high (for example, ≥20%) and HIV counselling and testing are not yet widely available, nevirapine might be offered, in the short term, to all mothers and newborns. 1 7 8 20 However, any potential long term risks from exposing large numbers of uninfected infants to nevirapine at birth have not yet been studied. With this approach, women and infants would be treated presumptively, and women and their partners could still be offered HIV testing after the baby is born. Such an approach has the potential to greatly simplify effective prevention of HIV transmission, while still maintaining the recognised benefits of HIV counselling and testing for the individual woman and her community. Counselling and testing are critical to allow women and their families to make informed decisions about breast feeding, reproductive health choices, and other interventions to prevent HIV transmission.1Footnotes Competing interests None declared.