Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

BMC Public Health

Andrew Vallely¹  John Kaldor¹  Peter Siba³  Richard Naketrumb⁴  Herick Aeno⁴  Martha Kupul⁴  Angela Kelly⁴  Peter S Hill²  Anna Tynan² 

[1]Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, 2034 New South Wales, Australia

[2]Australian Centre for International & Tropical Health, School of Population Health, University of Queensland Herston Road, Herston, 4006 Queensland, Australia

[3]Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Eastern Highlands Province 441, P.O. Box 60, Goroka, Papua New Guinea

[4]International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

关键词: HIV;    Penile cutting;    Male circumcision;    Community participation;   

Others  :  1161933
DOI  :  10.1186/1471-2458-13-749

 received in 2013-05-16, accepted in 2013-08-06,  发布年份 2013

【 摘 要 】

Background

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

Methods

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

Results

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

Conclusions

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

【 授权许可】

   
2013 Tynan et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]De Savigny D, Adam T: Systems Thinking for Health Systems Strengthening. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2009.
• [2]Atkinson JA, Vallely A, Fitzgerald L, Whittaker M, Tanner M: The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination: implications for malaria elimination. Malar J 2011, 10(1):225. BioMed Central Full Text
• [3]Aggleton P: Roundtable: “Just a snip”? a social history of male circumcision. Reprod Health Matters 2007, 15(29):15-21.
• [4]Dunsmuir WD, Gordon EM: The history of circumcision. BJU Int 1999, 83(S1):1-12.
• [5]Peltzer K, Kanta X: Medical circumcision and manhood initiation rituals in the Eastern Cape, South Africa: a post intervention evaluation. Culture, Health & Sexuality: An International Journal for Research, Intervention and Care 2009, 11(1):83-97.
• [6]Kharwal S, Bharat S: Male circumcision within the context of HIV prevention in India: a qualitative study conducted among young men in Chandigarh, India. IOSR Journal of Nursing and Health Science 2013, 1(3):31-43.
• [7]Khumalo-Sakutukwa G, Lane T, Van Rooyen H, Chingono A, Humphries H, Timbe A, Fritz K, Chirowodza A, Morin SF: Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa. Cult Health Sex 2013. Epub ahead of print
• [8]Brown JE, Micheni KD, Grant EMJ, Mwenda JM, Muthiri FM, Grant AR: Varieties of male circumcision: a study from Kenya. Sex Transm Dis 2001, 28(10):608-612.
• [9]Hill P, Tynan A, Law G, Millan J, Browne K, Sauk J, Kupul M, Kelly A, Siba P, Kaldor J: A typology of penile cutting in Papua New Guinea: results of a modified Delphi study among sexual health specialists. Aids Care 2012, 24(1):77-86.
• [10]Wamai R, Morris B, Bailis S, Sokal D, Klausner J, Appleton R, Sewankambo N, Cooper D, Bongaarts J, de Bruyn G, Wodak A, Banerjee J: Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa. J Int AIDS Soc 2011, 14(1):49. BioMed Central Full Text
• [11]WHO/UNAIDS: Progress in scale-up of male circumcision for HIV prevention in Eastern and Southern Africa: focus on service delivery - 2011. Geneva: World Health Organisation; 2011.
• [12]Peltzer K, Niang CI, Muula AS, Bowa K, Okeke L, Boiro H, Chimbwete C: Editorial review: male circumcision, gender and HIV prevention in sub-Saharan Africa: a (social science) research agenda. Journal of Social Aspects of HIV/AIDS 2007, 4(3):658-667.
• [13]WHO/UNAIDS: WHO/UNAIDS technical consultation on male circumcision and HIV prevention: research implications for policy and programming: conclusions and recommendations. Montreux: World Health Organisation; 2007.
• [14]Lundsby K, Dræbel T, Wolf Meyrowitsch D: ‘It brought joy in my home as in the area of my wife: how recently circumcised adult men ascribe value to and make sense of male circumcision. Glob Public Health 2011, 7(4):352-366.
• [15]Gilliam FD, Brooks RA, Leibowitz AA, Klosinski LE, Sawires S, Szekeres G, Weston M, Coates TJ: Framing male circumcision to promote its adoption in different settings. AIDS Behav 2010, 14(5):1207-1211.
• [16]Plotkin M, Castor D, Mziray H, Kuver J, Mpuya E, Luvanda PJ, Hellar A, Curren K, Lukobo-Durell M, Ashengo TA, Mahler H: “Man, what took you so long?” Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania. Global Health: Science and Practice 2013, 1(1):108-116.
• [17]Kelly A, Kupul M, Aeno H, Neo J, Naketrumb R, Fitzgerald L, Hill PS, Kaldor JM, Siba P, Vallely A: More than just a cut: a qualitative study of penile practices and their relationship to masculinity, sexuality and contagion and their implications for HIV prevention in Papua New Guinea. BMC International Health and Human Rights 2012, 12(1):10. BioMed Central Full Text
• [18]Kelly A, Kupul M, Fitzgerald L, Aeno H, Neo J, Naketrumb R, Siba P, Kaldor JM, Vallely A: "Now we are in a different time; various bad diseases have come." Understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting. BMC Publ Health 2012, 12(67):1-13.
• [19]Maclaren D, Tombe R, Redman-Maclaren M, Browne K, Mafile`o T, Manineng C, McBride WJH: A research based classification of penile cutting in Papua New Guinea: A synthesis of research findings from the ADRA and NHMRC studies. In the Joint National Policy Forum on Male Circumcision for HIV prevention in Papua New Guinea. Port Morseby; 2011.
• [20]MacLaren D, Tombe R, Redman-MacLaren M, Browne K, Mafile'o T, Manineng C, McBride WJH: "Stronger or tougher:" reasons for penile cutting in Papua New Guinea. Canberra: Australasian HIV/AIDS Conference; 2011:75.
• [21]Dinnen S: "Restoring Justice and Law and Order in Papua New Guinea" paper delivered to Island State Security 2003. Honolulu: Oceania at the crossroads Conference; 2003.
• [22]Fitzpatrick J, Ako W: Project report: empowering the initiation of a prevention strategy to combat malaria in Papua New Guinea. Rural Remote Health 2007, 7:693-706.
• [23]Tivinarlik A, Wanat CL: Leadership styles of New Ireland high school administrators. Anthropology & Education Quarterly 2006, 37(1):1-20.
• [24]Simet J, Iamo W: Cultural diversity and the united Papua New Guinea. National Research Institute: NRI Discussion Paper No64: Port Morseby; 1992.
• [25]Wendt N: Article for human rights feature: development in Papua New Guinea. Canberra: Australian Council for International Development; 2005.
• [26]Vallely A, Page A, Dias S, Siba P, Lupiwa T, Law G, Millan J, Wilson DP, Murray JM, Toole M, Kaldor J: The prevalence of sexually transmitted infections in Papua New Guinea: a systematic review and meta-analysis. PLoS ONE 2010, 5(12):e15586.
• [27]Gray RT, Murray JM, Vallely A, Lote N, Lupiwa T, Millan J, Daoni E, Kaldor J, Siba P, Wilson D: The PNG HIV Model: explaining the past, describing the present, and forecasting the future of the HIV epidmic in PNG. Canberra, Australia: 23rd Australasian HIV and AIDS Conference; 2011:74.
• [28]Barclay A: Problems measuring community health status at a local level: Papua New Guinea's health information system. Rural Remote Health 2010, 10(4):1539.
• [29]WHO: Papua New Guinea: health situation. Western Pacific Region: World Health Organisation; 2006.
• [30]Tynan A, Vallely A, Kelly A, Law G, Millan J, Siba P, Kaldor J, Hill PS: Vasectomy as a proxy: extrapolating health system lessons to male circumcision as an HIV prevention strategy in Papua New Guinea. BMC Health Serv Res 2012, 12(1):299. BioMed Central Full Text
• [31]Tynan A, Vallely A, Kelly A, Kupul M, Law G, Milan J, Siba P, Kaldor J, Hill PS: Health workers, health facilities and penile cutting in Papua New Guinea: implications for male circumcision as an HIV prevention strategy. Papua New Guinea Medical Journal 2011, 54(3–4):109-122.
• [32]Macfarlane J: Common themes in the literature on traditional medicine in Papua New Guinea. Papua New Guinea Medical Journal 2009, 52(1):44-53.
• [33]MacLaren D, Tommbe R, Mafile’o T, Redman-MacLaren M, Manineng C, Browne K, McBride WJH: Acceptability of Male Circumcision for HIV Prevention at Four Sites in Papua New Guinea. Kimbe, West New Britain, Papua New Guinea: Papua New Guinea Medical Society; 2011. [47th Papua New Guinea Sexual Health Society Symposium]
• [34]Jenkins C: HIV/AIDS, Culture, and Sexuality in Papua New Guinea. In Cultures and Contexts Matter Understanding and Preventing HIV in the Pacific. Manila: Asia Development Bank; 2006:1-69.
• [35]NACS: National HIV and AIDS strategy 2011–2015: Papua New Guinea national AIDS council: Port Moresby. Port Morseby: National AIDS Council Secretariat, Government of Papua New Guinea; 2010.
• [36]Chimere-Dan GC: Public views on community involvement in local health services in South Africa. Public Health 1997, 111(6):399-404.
• [37]WHO: People-centred health care: a policy framework. Manilla: World Health Organisation Regional Office for the Western Pacific; 2007.
• [38]Beard TC, Redmond S: Declaration of Alma-Ata. Lancet 1979, 313(8109):217-218.
• [39]Rifkin SB: Lessons from community participation in health programmes: a review of the post Alma-Ata experience. International Health 2009, 1(1):31-36.
• [40]WHO: Primary health care: now more than ever. Geneva: World Health Organisation; 2008.
• [41]Filho RM, de Araújo JLC: Discussing community participation in health: an approach from the Brazilian experience. Revista Brasileira de Saúde Materno Infantil 2002, 2:91-103.
• [42]MacQueen KMME, Metzger DS, Kegeles S, Strauss RP, Scotti R, Blanchard L, Trotter RT: What is community? an evidence-based definition for participatory public health. Am J Public Health 2001, 91(12):1929-1938.
• [43]Woelk GB: Cultural and structural influences in the creation of and participation in community health programmes. Soc Sci Med 1992, 35(4):419-424.
• [44]Tatar M: Community participation in health care: the Turkish case. Soc Sci Med 1996, 42(11):1493-1500.
• [45]Madan TN: Community involvement in health policy; socio-structural and dynamic aspects of health beliefs. Soc Sci Med 1987, 25(6):615-620.
• [46]Ugalde A: Ideological dimensions of community participation in Latin American health programs. Soc Sci Med 1985, 21(1):41-53.
• [47]Merzel C, D’Afflitti J: Reconsidering community-based health promotion: promise, performance, and potential. Am J Public Health 2003, 93(4):557-574.
• [48]Perez D, Lefevre P, Sanchez L, Sanchez L, Boelaert M, Kouri G, Van der Stuyft P: Community participation in Aedes aegypti control: a sociological perspective on five years of research in the health area ''26 de Julio'', Havana, Cuba. Trop Med Int Health 2007, 12:664-672.
• [49]Stone L: Cultural influences in community participation in health. Soc Sci Med 1992, 35(4):409-417.
• [50]Khun S, Manderson L: Community participation and social engagement in the prevention and control of dengue fever in rural Cambodia. Dengue Bulletin 2008, 32:145-155.
• [51]Jacobs B, Price N: Community participation in externally funded health projects: lessons from Cambodia. Health Policy Plan 2003, 18:399-410.
• [52]Morgan LM: Community participation in health: perpetual allure, persistent challenge. Health Policy Plan 2001, 16(3):221-230.
• [53]Tanner M, Vlassoff C: Treatment-seeking behaviour for malaria: a typology based on endemicity and gender. Soc Sci Med 1998, 46:523.
• [54]Mchunu G: The levels of Community Involvement in Health (CIH): a case of rural and urban communities in KwaZulu-Natal. Curationis 2009, 32(1):4-13.
• [55]Molyneux S, Atela M, Angwenyi V, Goodman C: Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy Plan 2012, 27(7):541-554.
• [56]Israel BA, Schulz AJ, Parker EA, Becker AB: Review of community based research: assessing partnership approaches to improve public health. Annual Reviews Public Health 1998, 19:172-202.
• [57]Shagi C, Vallely A, Kasindi S, Chiduo B, Desmond N, Soteli S, Kavit N, Vallely L, Lees S, Hayes R, Ross D: A model for community representation and participation in HIV prevention trials among women who engage in transactional sex in Africa. Aids Care 2008, 20(9):1039-1049. on behalf of the Microbicides Development, Programme
• [58]Connor D: A new ladder of citizen participation. Natl Civ Rev 2007, 77:249-257.
• [59]Arnstein S: A ladder of citizen participation. J Am Inst Plann 1969, 35:216-224.
• [60]Sleigh A, Xueming L, Jackson S, Huang K: Eradication of schistosomiasis in Guangxi, China. Part 1: Setting, strategies, operations, and outcomes, 1953–92. Bull World Health Organ 1998, 76:361-372.
• [61]Barber K: The Bugiau community at eight-mile: an urban settlement in Port Moresby, Papua New Guinea. Oceania 2003, 73(4):287-297.
• [62]Chand S, Yala C: Making land work. In Informal land systems within urban settlements in Honiara and Port Moresby. 1st edition. Edited by Steven W, Daniel F, Theo L, O'Connor P. Canberra: AusAID; 2008.
• [63]Gare J, Lupiwa T, Suarkia DL, Paniu MM, Wahasoka A, Nivia H, Kono J, Yeka W, Reeder JC, Mgone CS: High prevalence of sexually transmitted infections among female sex workers in the Eastern Highlands Province of Papua New Guinea: correlates and recommendations. Sex Transm Dis 2005, 32(8):466-473.
• [64]Foley WA: The Papuan languages of New Guinea. Cambridge: Cambridge University Press; 1986.
• [65]Tuzin DF: The Voice of the Tambaran: Truth and Illusion in Ilahita Arapesh Religion. Berkeley: University of California Press; 1980.
• [66]Williamson MH: Gender in the cosmos in Kwoma culture. Sepik Heritage: Tradition and Change in Papua New Guinea. Sydney: Crawford House Press; 1990.
• [67]Hogbin I: The island of menstruating men: religion in Wogeo. Chandler Pub. Co: New Guinea Prospect Heights; 1970.
• [68]Tuzin D: Rituals of Manhood: Male Initiation in Papua New Guinea. Edited by Herdt GH. New Brunswick, New Jersey: Transaction Publishers; 1982:321-355.
• [69]Newman P, Boyd D: The Making of Men: Ritual and meaning in Awa male initiation. In Rituals of Manhood: Male Initiation in Papua New Guinea. Edited by Herdt GH. New Brunswick, New Jersey: Transaction Publishers; 1982:239-285.
• [70]Kelly A, Kupul M, Aeno H, Neo J, Naketrumb R, Fitzgerald L, Hill PS, Kaldor JM, Siba P, Vallely A: If he cuts his skin he won't think of his wife: why women object to male circumcision to prevent HIV in a moderate-prevalence setting. Qualtitaive Health Research 2013, 23(2):180-193.
• [71]Vallely A, MacLaren D: Male circumcision for HIV prevention in Papua New Guinea: a summary of two research projects. A Briefing Document prepared by the investigator teams. Port Moresby, Papua New Guinea; 2011. [National Policy Forum on Male Circumcision for HIV Prevention]
• [72]Vallely A, MacLaren D, Kaleva W, Millan J, Tommbe R, Marape W, Buchanan H, Amos A, Kelly A, Kupul M, Aeno H, Trowalle E, John L, Redman-MacLaren M, Ryan C, Browne K, Tynan A, Hill PS, Gray R, Murray J, Wilson D, Siba P, McBride J, Farley T, Kaldor JM: Male circumcision for HIV prevention in PNG: a summary of research evidence and recommendations for public health following a national policy Forum. Papua New Guinea Medical Journal 2011, 54(3–4):1.
• [73]Vallely A, Lees S, Shagi C, Kapiga S, McCormack S, Hayes R: Ethics, justice and community participation in the Microbicides Development Programme (MDP) Phase III Trial in Mwanza, Tanzania. Am J Bioeth 2012, 12(11):46-48.
• [74]Atkinson J, Fitzgerald L, Toaliu H, Taleo G, Tynan A, Whittaker M, Riley I, Vallely A: Community participation for malaria elimination in Tafea Province Vanuatu: Part I. Maintaining motivation for prevention practices in the context of disappearing disease. Malar J 2010, 9:93. BioMed Central Full Text
• [75]Mshana G, Wambura M, Mwanga J, Mosha J, Mosha F, Changalucha J: Traditional male circumcision practices among the Kurya of North-eastern Tanzania and implications for national programmes. Aids Care 2011, 23(9):1111-1116.
• [76]Weiss H, Dickson K, Agot K, Hankins C: Male circumcision for HIV prevention: current research and programmatic issues. AIDS 2010, 24(suppl 4):S61-S69.
• [77]Vincent L: ‘Boys will be boys’: traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa. Culture, Health & Sexuality: An International Journal for Research, Intervention and Care 2008, 10(5):431-446.
• [78]Tedrow VA, Zelaya CE, Kennedy CE, Morin SF, Khumalo-Sakutukwa G, Sweat MD, Celentano DD: No “Magic Bullet”: exploring community mobilization strategies used in a multi-site community based randomized controlled trial: project accept (HPTN 043). AIDS Behav 2012, 16(5):1217-1226.
• [79]Gysels M, Pool R, Nnalusiba B: Women who sell sex in a Ugandan trading town: life histories, survival strategies and risk. Social Science and Medicine 2002, 54:179-192.
• [80]Mills E, Nixon S, Singh S, Dolma S, Nayyar A, Kapoor S: Enrolling women into HIV preventive vaccine trials: an ethical imperative but a logistical challenge. PLoS Med 2006, 3(3):94.
• [81]Gargioni G: Chapter 64 - role of communities in tuberculosis care and prevention. In Tuberculosis. Edited by Schaaf H, Zumla A, Grange J, Raviglione M, Yew W, Starke J, Pai M, Donald P. Edinburgh: W.B. Saunders; 2009:660-667.
• [82]Rocha EM: A Ladder of Empowerment. J Planning Educ Res 1997, 17(1):31-44.
• [83]Tynan A, Atkinson J, Toaliu H, Taleo G, Fitzgerald L, Whittaker M, Riley I, Schubert M, Vallely A: Community participation for malaria elimination in tafea province, vanuatu: part ii: social and cultural aspects of treatment-seeking behaviour. Malar J 2011, 10(1):204. BioMed Central Full Text
• [84]Ramdas S: Cruel disease, cruel medicine: self-treatment of cutaneous leishmaniasis with harmful chemical substances in Suriname. Soc Sci Med 2012, 75(6):1097-1105.
• [85]Vallely A, Lees S, Shagi C, Kasindi S, Soteli S, Kavit N, Vallely L, McCormack S, Pool R, Hayes R, et al.: How informed is consent in vulnerable populations? Experience using a continuous consent process during the MDP301 vaginal microbicide trial in Mwanza, Tanzania. BMC Med Ethics 2010, 11(1):10. BioMed Central Full Text
• [86]Vallely A, Shagi C, Kasindi S, Desmond N, Lees S, Chiduo B, Hayes R, Allen C, Ross D: The benefits of participatory methodologies to develop effective community dialogue in the context of a microbicide trial feasibility study in Mwanza, Tanzania. BMC Publ Health 2007, 7(1):133. The Microbicides Development Programme BioMed Central Full Text
• [87]Bridges JP, Searle S, Selck F, Martinson N: Designing family-centered male circumcision services. Patient 2012, 5(2):101-111.
• [88]Jones D, Cook R, Arheart K, Redding C, Zulu R, Castro J, Weiss S: Acceptability, knowledge, beliefs, and partners as determinants of Zambian men’s readiness to undergo medical male circumcision. AIDS Behav 2013. Epub ahead of print
• [89]Wilcken A, Miiro-Nakayima F, Hizaamu NB, Keil T, Balaba-Byamsi D: Male circumcision for HIV prevention – a crosssectional study on awareness among young people and adults in rural Uganda. BMC Publ Health 2010, 10(209):1-11.
• [90]Westercamp M, Agot KE, Ndinya-Achola J, Bailey RC: Circumcision preference among women and uncircumcised men prior to scale-up of male circumcision for HIV prevention in Kisumu, Kenya. Aids Care 2011, 24(2):157-166.
• [91]Tarimo E, Francis J, Kakoko D, Munseri P, Bakari M, Sandstrom E: The perceptions on male circumcision as a preventive measure against HIV infection and considerations in scaling up of the services: a qualitative study among police officers in Dar es Salaam, Tanzania. BMC Publ Health 2012, 12(1):529. BioMed Central Full Text
• [92]Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T: Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya. Aids Care 2005, 17(2):182-194.
• [93]Green LW, Mercer SL: Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health 2001, 91(12):1926-1929.
• [94]Niang CI, Boiro H: Roundtable: “You can also cut my finger!”: Social construction of male circumcision in West Africa, a case study of Senegal and Guinea-Bissau. Reprod Health Matters 2007, 15(29):22-32.
• [95]Mark D, Middelkoop K, Black S, Roux S, Fleurs L, Wood R, Bekker L: Low acceptability of medical male circumcision as an HIV/AIDS prevention intervention within a South African community that practises traditional circumcision. S Afr Med J 2012, 102(6):571-572.
• [96]Wilcken A, Keil T, Dick B: Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications. Bull World Health Organ 2010, 88(12):907-914.
• [97]Darmstadt GL, Lee ACC, Cousens S, Sibley L, Bhutta ZA, Donnay F, Osrin D, Bang A, Kumar V, Wall SN, et al.: 60 million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths? Int J Gynecol Obstet 2009, 107(0):S89-S112.
• [98]Byrne A, Morgan A: How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. Int J Gynaecol Obstet 2011, 115(2):127-134.
• [99]Nyanzi S, Manneh H, Walraven G: Traditional birth attendants in rural Gambia: beyond health to social cohesion. Afr J Reprod Health 2007, 11:43-56.
• [100]Kaingu C, Oduma J, Kanui T: Practices of traditional birth attendants in Machakos District, Kenya. J Ethnopharmacol 2011, 137:495-502.
• [101]Mbaruku G, Msambichaka B, Galea S, Rockers P, Kruk M: Dissatisfaction with traditional birth attendants in rural Tanzania. Int J Gynaecol Obstet 2009, 107:8-11.
• [102]Sacks E, Bailey JM, Robles C, Low LK: Neonatal care in the home in Northern rural Honduras: a qualitative study of the role of traditional birth attendants. J Perinat Neonatal Nurs 2013, 27(1):62-71.