Task shifting of traditional birth attendants in rural China: a qualitative study of the implementation of institution-based delivery policy

Abstract Background Institution-based delivery, with the ultimate goal of universal access to skilled birth attendance, has been selected as a key strategy to reduce maternal mortality rate in many developing countries. However, the question of how to engage traditional birth attendants in the advocacy campaign for skilled birth attendance poses several challenges. Here, we use the experience of task shifting of traditional birth attendants in rural Guangxi Zhuang Autonomous Region, China, as a case study to illustrate how traditional birth attendants could be well integrated into the health system in rural regions. Methods We used qualitative research methods, including 28 document reviews (17 published manuscripts, six policy documents, one research report, one doctoral dissertation, and three websites) and 32 individual in-depth interviews with regional and local politicians, policy makers, health-care managers, health-care providers, civil society members, village women cadres, traditional birth attendants, village maternal health workers, mothers, and mother-in-laws. The research has been approved by the Ethical Board of School of Public Health, Fudan University, China. Findings From 1998 to 2012, the rate of institutional-based childbirth increased from 45·7% to 99·7%, and maternal mortality rate decreased from 86·0 per 100 000 livebirths to 27·2 per 100 000 livebirths in Guangxi Zhuang Autonomous Region. Traditional birth attendants' role of providing in-home care during childbirth was restructured, and their social role was strengthened as a result of task shifting. Traditional birth attendants were shifted to act as village maternal health workers to promote perinatal care and institution-based delivery. They were designed to function at the bottom level of the rural health network (county–township–village), acting as the link between women and the health system. A key policy document formalised the role of village maternal-health workers and supported the task-shifting process, which involved engaging with all government and non-governmental organisations (eg, women's federation, youth organisations, and academic associations), training traditional birth attendants for their new role, and providing incentives and sanctions for human resources management. Interpretation The task-shifting experience, implemented in accordance with the key policy document, in Guangxi was an example of successfully engaging traditional birth attendants in the promotion of institution-based delivery. Funding The study was supported by the China–UK Global Health Support Programme (GHSP-CS-OP1-02) and partly by the European Union Sixth Framework Programme HEPVIC (EU517746).