• Rozina Mustafa
  • Haleema Hashmi
  • Rubina Mustafa


Background: In Pakistan 90% of births are conducted by TBA’s. In most cases, TBA’s are unable todiagnose the complications and are often unable to take decisions on timely referral. The objective ofthis study was to determine the prevalence, nature and outcome of life threatening obstetricalconditions in referrals by Traditional Birth Attendants (TBAs). Methods: This Observational,Descriptive study was conducted from January to December 2007, in the obstetrical unit of FatimaHospital, Baqai Medical University, a tertiary care community based hospital. The study includedpatients referred by TBA’s who developed life threatening obstetric conditions (LTOCs). Results:Total 64 patients were referred by TBA’s. The prevalence was 7.8%. Out of them, 53 (82.8%)patients admitted with life threatening obstetric conditions. The near-miss morbidities andmortalities were 45 (84.9%) and 8 (15%) respectively. Maternal mortality to Near-miss morbidityratio was 1:6. Obstructed labour caused near-miss morbidity in 32 (60.3%) patients with nomortality. Postpartum haemorrhage as life threatening condition developed in 16 (30.1%) patientswith 10 (18.8%) near-miss morbidities and 6 (11.3%) mortalities. Puerperal sepsis accounted for 1(1.88%) near-miss morbidity and 2 (3.76%) mortalities. The mortality index for puerperal sepsis is(66.6%) almost double of postpartum haemorrhage (37.5%). Conclusion: Mortality to near missmorbidity ratio is high. Misidentification and late referrals of complicated cases by TBA’s wereresponsible for near-miss morbidities and mortalities.Keywords: Traditional Birth Attendants, Life threatening obstetric conditions, Maternal mortality


Siddiqi S, Kielmann A, Khan M, Ali N, Ghaffar A, Sheikh U, et

al. The effectiveness of patient referral in Pakistan, Health Policy

Plan 2001;16(2):193–8.

Islam A, Malik FA. Role of traditional birth attendants in

improving reproductive health: lessons from the family health

project, Sindh. J Pak Med Assoc 2001;51:218–22.

Leedam E. Traditional Birth Attendants. Int J Gynecol Obstet


Chalo RN, Salihu HM, Nabukera S, Zirabamuzaale C. Referral

of high-risk pregnant mothers by trained traditional birth

attendants in Buikwe County, Mukono District Uganda. J Obstet

Gynecol 2005;25(6);554–7.

Islam A. Health related millennium Development Goals: policy

challenges for Pakistan. J Pak Med Assoc 2004;54:175–81.

Mahmud G, Nakasa T, Haq A, Khan S. Comprehensive maternal

health data of Islamabad capital territory. Int J Gynecol Obstet


Sibley LM, Sipe TA, Brown CM, Diallo MM, MeNatti K,

Habarta N. Traditional birth attendant training for improving

health behaviors and pregnancy outcomes. J Am Coll Obstet

Gynecol 2007;110:1017–8.

Bailey PE, Szaszdi JA, Glover L. Obstetric complications: Does

training traditional birth attendants make a difference? Rev

Panam Salud Publica. 2002;11(1):15–23.

Bang RA, Bang AT, Reddy MH, Deshmuk MD, Baitule SB,

Fillipi V. Maternal morbidity during labour and puerpeurium in

rural homes and the need for medical attention: A prospective

observational study in Gadchinoli, India. BJOG 2004;111:231–8.

Naheed T, Akbar N. Patients with postpartum complications

admitted in a medical ward of Mayo Hospital, Lahore. Pak J Med

Sci 2002;18(2):126–30.

Vanneste AM, Ronsmans C, Chakraborty J, de Francisco A.

Prenatal screening in rural Bangladesh: from prediction to care.

Health Policy Plan 2000;15(1):1–10.

Olufemi TO, Adewale O, Adetola O, Olusoji JD. “Near-miss”

obstetric events and maternal deaths in Sagamu, Nigeria: a

retrospective study. Reprod Health 2005;2:1186–95.

Minkauskiene M, Nadisauskiene R, Padaiger Z, Makari S.

Systemic review on the incidence and prevalence of severe

maternal morbidity. Medicina (Kaunas) 2004;40:299–309.

Gessessew A, Mesfin M. Obstructed Labor in Adigrat Zonal

Hospital, Tigray Region, Ethiopia. J Health Dev 2003;17:175–80.

Chhabra P, Guleria K, Saini NK, Anjur KP, Vaid NB. Pattern of

severe maternal morbidity in a tertiary hospital of Delhi, India: a

pilot study. Trop Doct 2008;38:201–4.

Magann EF, Evans S, Chauhan SP, Lanneau G, Fisk AD,

Morrison JC. The length of the third stage of labor and the risk of

postpartum hemorrhage. Obstet Gynecol 2005;105:290–3.

Lynch CM, Sheridan C, Breathnach FM, said S, Daly S, Byrne

B. Near miss maternal morbidity. Ir Med J 2008;101(5):134–6.

Sheikh L, Zuberi NF, Riaz R, Rizvi JH. Massive Primary

Postpartum Hemorrhage: Setting Up Standards of Care. J Pak

Med Assoc 2006;56:26–31.

Kydona C, Timiliotou Ch, Papazafiriou E, Papanikolaou A.

Near-miss maternal mortality in North Greece During the past

decade. Crit Care 2003;79:248.

Begum S, Nisa A, Begum I. Analysis of maternal mortality in a

Tertiary care Hospital to determine causes and preventable

factors. J Ayub Med Coll Abbottabad 2003;15(2):49–52.

Riaz GS. Revised approach in the management of puerperal

sepsis. Pak J Med Sci 1992;8(3):51–4.

Pattinson RC, Buchmann E, Mantel G, Schoon M, Rees H. Can

enquiries into severe acute maternal morbidity act as a surrogate

maternal death enquiries? BJOG 2003;110:889–93.

Andrew W, Tina L, Enid N, Florence M. Personal accounts of

near-miss maternal mortalities in Kampala, Uganda. BJOG


Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J,

Tumbahangphe KM, et al. Effect of a participatory intervention

with women’s groups on birth outcomes in Nepal: clusterrandomized controlled trial. Lancet 2004;364;970–9.

Jokhio AH, Winter Hr, Cheng KK. An intervention involving

traditional birth attendants and perinatal and maternal mortality in

Pakistan. N Engl J Med 2005;352:2091–9.