Increasing the Use of Skilled Health Personnel Where Traditional Birth Attendants Were Providers of Childbirth Care: A Systematic Review Claudia Vieira 1,2 *, Anayda Portela 3 *, Tina Miller 4 , Ernestina Coast 5 , Tiziana Leone 5 , Cicely Marston 6 1 Independent consultant, Lisbon, Portugal, 2 Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland, 3 Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland, 4 Department of Social Sciences, Oxford Brookes University, Oxford, United Kingdom, 5 Department of Social Policy, London School of Economics, London, United Kingdom, 6 Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom Abstract Background: Improved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked? Methods and Findings: We systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care. Conclusions: The interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist. Citation: Vieira C, Portela A, Miller T, Coast E, Leone T, et al. (2012) Increasing the Use of Skilled Health Personnel Where Traditional Birth Attendants Were Providers of Childbirth Care: A Systematic Review. PLoS ONE 7(10): e47946. doi:10.1371/journal.pone.0047946 Editor: C. Mary Schooling, University of Hong Kong, China Received May 22, 2012; Accepted September 18, 2012; Published October 24, 2012 Copyright: ß 2012 Vieira et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The United Kingdom Department for International Development (http://www.dfid.gov.uk/) provided financial support. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: c_lima_vieira@hotmail.com (CV); portelaa@who.int (AP) Introduction Maternal deaths remain unacceptably high in many parts of the world. Some progress has been made: the proportion of births attended by skilled health personnel increased in developing regions from 55% to 65% between 1990 and 2009 [1], and worldwide the maternal mortality ratio has fallen since 1990– probably related to improved access to skilled care and to antenatal care [2]. Nevertheless, in 2010, approximately 287,000 women died in childbirth or from pregnancy complications, most of them in poorer countries [2]. Better access to skilled health personnel for childbirth is a priority strategy and a key indicator for Millennium Development Goal (MDG) 5a to improve maternal health. Where skilled health personnel and institutional facilities for childbirth are absent, one strategy to improve access has been to train traditional birth attendants (TBAs) [3]. In the 1970s, international organizations, including the World Health Organi- zation (WHO), invested in TBA training. Training TBAs for childbirth care, however, has been found not to reduce maternal mortality [4–6], and by 1997, attention turned towards ‘‘skilled birth attendants’’ [7]. A ‘‘skilled attendant’’ was defined in a joint statement issued by the WHO, the International Confederation of Midwives and the International Federation of Gynaecology and Obstetrics in 2004 [8]. The statement identified the skills and abilities required for a skilled attendant, and does not include TBAs, although countries are encouraged to work with TBAs to define new roles for them, and ensure good working relations between TBAs, skilled attendants, and staff in referral facilities. In PLOS ONE | www.plosone.org 1 October 2012 | Volume 7 | Issue 10 | e47946