Socio-economic factors associated with delivery assisted by traditional birth attendants in Iraq, 2000
© Siziya et al; licensee BioMed Central Ltd. 2009
Received: 28 August 2008
Accepted: 02 April 2009
Published: 02 April 2009
Traditional birth attendants (TBAs) are likely to deliver lower quality maternity care compared to professional health workers. It is important to characterize women who are assisted by TBAs in order to design interventions specific to such groups. We thus conducted a study to assess if socio-economic status and demographic factors are associated with having childbirth supervised by traditional birth attendants in Iraq.
Iraqi Multiple Indicator Cluster Survey (MICS) data for 2000 were used. We estimated frequencies and proportions of having been delivered by a traditional birth attendant and other social characteristics. Logistic regression analysis was used to assess the association between having been delivered by a TBA and wealth, area of residence (urban versus rural), parity, maternal education and age.
Altogether 22,980 women participated in the survey, and of these women, 2873 had delivery information and whether they were assisted by traditional birth attendants (TBAs) or not during delivery. About 1 in 5 women (26.9%) had been assisted by TBAs. Compared to women of age 35 years or more, women of age 25–34 years were 22% (AOR = 1.22, 95%CI [1.08, 1.39]) more likely to be assisted by TBAs during delivery. Women who had no formal education were 42% (AOR = 1.42, 95%CI [1.22, 1.65]) more likely to be delivered by TBAs compared to those who had attained secondary or higher level of education. Women in the poorest wealth quintile were 2.52 (AOR = 2.52, 95%CI [2.14, 2.98]) more likely to be delivered by TBAs compared to those in the richest quintile. Compared to women who had 7 or more children, those who had 1 or 2 were 28% (AOR = 0.72, 95%CI [0.59, 0.87]) less likely to be delivered by TBAs.
Findings from this study indicate that having delivery supervised by traditional birth attendants was associated with young maternal age, low education, and being poor. Meanwhile women having 1 or 2 children were less likely to be delivered by TBAs. These factors should be considered in the design of interventions to reduce the rate of deliveries assisted by TBAs in favour of professional midwives, and consequently reduce maternal and neonatal mortality rates and other adverse events.
Maternal and neonatal morbidity and mortality arising from inadequate health services is an important global health concern. Mortality rates are often higher in low- and mid-income countries where investment in human resources and medical resources are limited . In the past decade, the importance of maternal health has been rekindled following its expected inclusion within the Millennium Development Goals (MDGs); eight in total, the fifth of which is on the reduction of maternal mortality [2, 3]. Rasch has argued that skilled birth attendants are a necessity for the reduction of maternal mortality .
Darmstadt et al  have reported a study in Egypt that while most mothers usually received antenatal care from physicians, traditional birth attendants (TBAs) conducted most deliveries. Anwar et al  have reported that low-income families were less likely to have skilled birth attendants at birth, thus raising an equity issue. Using data from Bangladesh, Fonczak et al  reported that TBAs with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home.
Of all causes of maternal deaths in 1999 in Iraq, 46.4% of them were due to bleeding . While the literature is certainly not short of articles that demonstrate the adverse effects of being supervised in delivery by traditional attendants, in many settings of the world however, many women continue to be supervised by this group of health care providers. Women may choose to be delivered by TBAs because of culturally appropriate and respectful care that traditional birth attendants provide . Women may also have TBAs for assistance during delivery because that may be the only option when health facilities and professional trained staff may be less available. In 2002, in Iraq, there were only 7.0 physicians/10,000 population and 8.8 nurses/10,000 population. It is estimated that 50% of all births are home delivered, and TBAs attend 18% of the total deliveries. Neonatal mortality rate/1000 live births and maternal mortality ratio/100000 live births for Iraq have been estimated to be 67.0 and 294, respectively .
Using data from the 2000 Multiple Indicator Cluster Survey (MICS) of Iraq, we aimed to assess factors associated with having a delivery supervised by a TBA within the past 12 months. The MICS is coordinated by UNICEF and has as its primary objectives the following: to provide up-to-date information for assessing the situation of children and women at the end of the decade and for looking forward to the next decade; "to furnish data needed for monitoring progress toward goals established in 1990 at the World Summit for Children and as a basis for future action and; to contribute to the improvement of data and monitoring systems a country and to strengthen technical expertise in the design, implementation, and analysis of such systems" .
A description of the MICS methodology is reported elsewhere [9, 10]. However, in brief, the sample was drawn using a 3-stage stratified sampling method. During the first stage of sampling, mahallas (villages) were selected with probability proportional to population size in each sub-district (Qada'a). In the second stage, mahallas were divided into compartments with population of about 500 people, and one or more compartments were then selected from each mahalla. Further, each compartment was divided into Majals (blocks) of 25–30 households in urban area and 20–25 households in rural areas. One Majal was then selected by simple random sampling from each compartment. Finally, a cluster of 10 households was selected from each Majal using a systematic random sampling technique. All18 governorates of the country were represented in the sample.
A standardized MICS questionnaire provided by UNICEF was translated into Arabic by the Middle East and North Africa Regional Office of UNICEF (MENARO), with some revisions and adaptations. The revised questionnaire was pretested in August 2000.
Of the 13,220 women who had delivered a child 13,114 (99.2%) were eventually interviewed as women who had delivered a child within the last 12 month.
The Iraqi MICS survey of 2000 was conducted by the government with technical support from UNICEF. We obtained de-identified data from UNICEF which we analysed within the current secondary study. Our analysis of de-identified secondary data was exempted from full institutional review board.
We conducted weighted analysis using SPSS version 11.5 (Statistical Package for Social Sciences, Chicago, Illinois, United States). We obtained frequencies and proportions to describe the sample with regard to the outcome of interest (i.e. having been supervised by a TBA in delivery occurring within the last 12 months) and other socio-demographic characteristics.
The outcome variable was categorized into being assisted during delivery by TBAs and being assisted by health professional (doctor, nurse/midwife, and auxiliary midwife) or relative/friend. Marital status was categorized as: currently married/in union and not currently married. The not currently married included women who were widowed, divorced, separated or had never been married. Age was taken as completed years at the time of the survey. Wealth was measured by using household assets (such as radio, bicycle, car, television, type of roofing, and floor) rather than income as has been done in other community surveys such as the Demographic and Health Survey [11–13]. Each asset was assigned a weighting value, using principal component analysis as described by the World Bank and ORC Macro. A household was assigned a standardized score for each owned asset, and these scores were summed and households ranked into five wealth quintiles.
We conducted bivariate and multivariate logistic regression methods to assess associations between predictor variables and the outcome. The unadjusted odds ratio (OR), and adjusted odds ratio (AOR) together with their 95% confidence intervals (CI) are reported. For the purpose of our study, traditional birth attendants were not considered skilled or professional birth attendants.
Socio-demographic description of on women who delivered within the last 12 months in the Iraq MICS of 2000
Maternal education level
secondary or higher
Area of residence
Wealth index (Quintiles)
Number of children ever born
1 or 2
3 or 4
5 or 6
7 or more
Delivery assisted by Traditional birth attendant
Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) and 95% confidence interval (CI) of the association of socio-demographic variables and delivery assisted by traditional birth attendant in Iraq, 2000
0.83 (0.64, 1.06)
1.03 (0.86, 1.24)
1.19 (0.95, 1.49)
1.22 (1.08, 1.39)
0.73 (0.46, 1.17)
Maternal education level
1.86 (1.64, 2.12)
1.42 (1.22, 1.65)
1.08 (0.96, 1.22)
1.05 (0.92, 1.20)
Secondary or higher
Area of residence
0.66 (0.60, 0.72)
Wealth index (Quintiles)
2.90 (2.49, 3.39)
2.52 (2.14, 2.98)
1.27 (1.06, 1.52)
1.14 (0.95, 1.37)
0.74 (0.61, 0.89)
0.75 (0.62, 0.92)
0.79 (0.65, 0.96)
0.85 (0.69, 1.03)
Number of children ever born
1 or 2
0.66 (0.57, 0.76)
0.72 (0.59, 0.87)
3 or 4
1.01 (0.88, 1.16)
1.04 (0.89, 1.21)
5 or 6
1.11 (0.95, 1.30)
1.07 (0.90, 1.28)
7 or more
In a study of Iraq women in which data on delivery supervision at the most recent delivery was available for 2,873 women, 26.9% reported that they had been delivered by TBAs. In multivariable analysis we found that younger women in the age group 25 to 34 years were 22% more likely to report having been delivered by TBAs compared to women 35 years and older. We also found that higher parity, middle-income category, low education and rural residence were positively associated with delivery by traditional birth attendant.
The finding that women in the middle wealth category were less likely to be delivered by TBAs compared to women in the richest category may be a spurious finding because the odds of being delivered by TBAs were not significantly different between women in the second and fourth categories on one hand and women in the richest category on the other. Women in the lowest wealth quintile were more likely to deliver under TBA supervision than women in the richest wealth category. This finding is similar to what has been published elsewhere where data have shown that women in poor households are less likely to receive professional medical care [14, 15].
Access to health care facilities may be limited as a result of transport and hospital fees . Lawoyin  has reported high neonatal adverse outcomes among deliveries occurring out of health care facilities. While facility deliveries are preferred wherever possible, Leigh et al  have reported on poor maternal outcomes in Malawi within health facilities, largely because of low quality of care. Furthermore, supervised midwifery deliveries at home must be differentiated from low-skilled traditional birth attendant supervision. Just because a delivery occurs at home should not necessarily imply it is of low quality. In an environment where transport and communication facilities are available, delay can be minimised, safe home deliveries can be provided, while expecting that transfer to a facility with capabilities to provide higher level care is possible [19, 20].
We also found that parity i.e. the number of children a woman has ever delivered was associated with TBA supervisions. Women who may have previous non-eventful deliveries may be complacent and expect that TBA assisted deliveries are safe. Primiparas may have been less likely to be delivered by TBAs because they may not have been sure of their pregnancy outcome, and would have liked to be attended by professional skilled persons during delivery.
Women with low education were more likely to be delivered under the supervision of TBAs. The higher likelihood of TBA deliveries by low education women may also be associated with limited appreciation by women with limited education to understand the need for professional supervision during delivery. Our findings is similar to that reported by Tann et al  that skilled birth attendants remain difficult to be accessed by less educated women.
While this study has obvious strength such as the design being tailored to produce nationally representative data and use of a standard MICS questionnaire, there are a number of limitations worth considering. In comparing these results with similar studies in which rural versus urban residence status was assessed, it is important to remember that the definitions of urban versus rural may differ from country to country [22–24]. In the Iraq MICS, an urban area was defined as any administrative setup lying within the municipality boards; areas other than these were considered rural. Furthermore, data were collected via self-reports.
To the extent that study participants intentionally or inadvertently misreported, our findings may be biased. Finally, although the data collected were cross sectional in nature, and we are not able to ascertain causation between any of the variables and the outcome  i.e. having been delivered by a traditional birth attendant, the current findings are consistent with those of the previous studies. These factors should be considered in designing interventions to reduce the rate of TBA assisted deliveries, and hence reduce neonatal and maternal mortality rates, rather than generating hypotheses and considering similar future research using study designs that are higher than cross sectional studies. Missing information in the Iraq 2000 MICS data is of concern, and our findings may be biased to the extent that non-respondents differed from those that responded to the questionnaire items we considered in our analysis.
Findings from this study indicate that having delivery supervised by traditional birth attendants was associated with young adult age, low education, and being poor. Meanwhile, women having 1 or 2 children were less likely to be delivered by TBAs. These factors should be considered in the design of interventions aimed to promote professional delivery with the consequent aim of reducing the proportion of deliveries assisted by TBAs. This may result in the reduction of maternal and neonatal mortality rates.
We thank the United Nations Children's Fund (UNICEF) for making these data available to us for analysis. This study would not have been possible without the participation of the women in Iraq.
- Rasch V: Maternal death and the Millennium Development Goals. Dan Med Bull. 2007, 54: 167-9.PubMed
- Countdown Coverage Writing Group; Countdown to 2015 Core Group, Bryce J, Daelmans B, Dwivedi A, Fauveau V, Lawn JE, Mason E, Newby H, Shankar A, Starrs A, Wardlaw T: Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet. 2008, 371: 1247-58. 10.1016/S0140-6736(08)60559-0.View Article
- Mpembeni RN, Killewo JZ, Leshabari MT, Massawe SN, Jahn A, Mushi D, Mwakipa H: Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth. 2007, 7: 29-10.1186/1471-2393-7-29.PubMed CentralView ArticlePubMed
- Darmstadt GL, Hussein MH, Winch PJ, Haws RA, Gipson R, Santosham M: Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal periods. J Health Popul Nutr. 2008, 26: 36-45.PubMed CentralPubMed
- Anwar I, Sami M, Akhtar N, Chowdhury ME, Salma U, Rahman M, Koblinsky M: Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh. Bull World Health Organ. 2008, 86: 252-9. 10.2471/BLT.07.042754.PubMed CentralView ArticlePubMed
- Fronczak N, Arifeen SE, Moran AC, Caulfield LE, Baqui AH: Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh. J Health Popul Nutr. 2007, 25: 479-87.PubMed CentralPubMed
- Maternal, Child and Reproductive Health Strategy in Iraq 2005–2008. Ministry of Health, Iraq. 2008, [http://www.emro.who.int/iraq/pdf/Maternal_ChildHealth.pdf]
- UNICEF (United Nations International Children's Education Fund): Report on the consultation on attendance at birth: community birth attendants. 1997, Health Section, Programme Division, United Nations Children's Fund/New York
- United Nations Children's Fund (UNICEF): Multiple Indicator Cluster Survey (MICS), Tajikistan. 2000, Dushanbe: UNICEF
- Republic of Iraq and United Nations Children Fund: Multiple Indicator Cluster Survey for the year 2000 (Detailed report). Baghdad. 2001, [http://www.childinfo.org/files/iraq1.pdf]
- Filmer D, Pritchett L: Estimating wealth effects without expenditure data or tears: an application to educational enrolments in states of India. Demography. 2001, 38: 115-32.PubMed
- Sahn DE, Stifel DC: Poverty comparisons over time and across countries in Africa. World Development. 2000, 28: 2123-55. 10.1016/S0305-750X(00)00075-9.View Article
- Rutstein SO, Johnson K: The DHS Wealth Index. DHS Comparative Reports No. 6. 2004, Calverton, Maryland: ORC Macro, [http://www.nso.malawi.net/data_on_line/demography/mics/MICS%20Report.pdf]
- Kruk ME, Prescott MR, Galea S: Equity of skilled birth attendant utilization in developing countries: financing and policy determinants. Am J Public Health. 2008, 98: 142-7. 10.2105/AJPH.2006.104265.PubMed CentralView ArticlePubMed
- Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, Achadi E, Adjei S, Padmanabhan P, Marchal B, De Brouwere V, van Lerberghe W, Lancet Maternal Survival Series steering group: Going to scale with professional skilled care. Lancet. 2006, 368: 1377-86. 10.1016/S0140-6736(06)69382-3.View ArticlePubMed
- Tlebere P, Jackson D, Loveday M, Matizirofa L, Mbombo N, Doherty T, Wigton A, Treger L, Chopra M: Community-based situation analysis of maternal and neonatal care in South Africa to explore factors that impact utilization of maternal health services. J Midwifery Womens Health. 2007, 52: 342-50. 10.1016/j.jmwh.2007.03.016.View ArticlePubMed
- Lawoyin TO: Infant and maternal deaths in rural south west Nigeria: a prospective study. Afr J Med Med Sci. 2007, 36: 235-41.PubMed
- Leigh B, Mwale TG, Lazaro D, Lunguzi J: Emergency obstetric care: how do we stand in Malawi?. Int J Gynaecol Obstet. 2008, 101: 107-11. 10.1016/j.ijgo.2008.01.012.View ArticlePubMed
- Leslie MS, Romano A: Appendix: Birth can safely take place at home and in birthing centers: The coalition for improving maternity services. J Perinat Educ. 2007, 16 (Suppl 1): 81S-88S. 10.1624/105812407X173236.PubMed CentralView ArticlePubMed
- Lindgren HE, Hildingsson IM, Christensson K, Rådestad IJ: Transfers in planned home births related to midwife availability and continuity: a nationwide population-based study. Birth. 2008, 35: 9-15. 10.1111/j.1523-536X.2007.00206.x.View ArticlePubMed
- Tann CJ, Kizza M, Morison L, Mabey D, Muwanga M, Grosskurth H, Elliot AM: Use of antenatal services and delivery care in Entebbe, Uganda: a community survey. BMC Pregnancy Childbirth. 2007, 7: 23-10.1186/1471-2393-7-23.PubMed CentralView ArticlePubMed
- Muula A: How do we define 'rurality' in the teaching on medical demography?. Rural Remote Health. 2007, 7: 653-PubMed
- Rourke J: In search of a definition of 'rural'. Can J Rural Med. 1997, 2: 113-115.
- Roos N, Fransoo R, Bogdanovic B, Friesen D, Frohlich N, Carriere KC: Needs-based planning for Manitoba's generalist physicians. 1996, Winnipeg: Manitoba Centre for Health Policy and Evaluation, University of Manitoba
- Kaufman JS, Kaufman S: Estimating causal effects. Int J Epidemiol. 2002, 31: 431-2. 10.1093/ije/31.2.431.View ArticlePubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/9/7/prepub
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