Maternal mortality is high in most African countries, particularly in
rural areas where access to formal health care is limited. The sociopo
litical and economic environment complicates the medical factors direc
tly responsible for this high rate. Since the 1970s many African count
ries have addressed this problem by training traditional birth attenda
nts (TBAs) in health promotion and in the basics of safe delivery and
referral. The Danfa Rural Health Project in Ghana has trained and supe
rvised TBAs since 1973. It is located relatively close to the health s
ervices of the capital city of Accra, providing an ideal environment f
or the practice of trained TBAs. Thirty-seven trained TBAs currently p
ractice in the area. Most provide patient education and encourage wome
n to go to the health center for preventive services. However, many re
port routinely performing the high risk deliveries that they have been
taught to refer to higher level care and that when they do refer, the
ir patients may not go. Reasons for referral refusal frequently cited
by TBAs include financial limitation or lack of transportation and the
patients fear of disrespectful or painful treatment from medical pers
onnel. In the rural environment, the trained TBA's greatest contributi
on to lower maternal mortality rates may lie in the area of health pro
motion rather than disease intervention.