A total of 20 papers comprising six studies identified through the systematic review process, and 14 additional sources, were included in this secondary analysis. The six research studies involved complex interventions, evaluated the use of different study designs and focused to varying degrees on improving MNH outcomes through interventions which included new roles for TBAs and TBA partnership . Table 1 summarises the characteristics of these studies and the 14 additional sources. The countries represented in the six studies were: Bangladesh , Indonesia [4, 5], Myanmar , Peru  and Pakistan . These studies report on various interventions to link TBAs with health services, increase partnerships with or find new roles for TBAs. Four studies evaluated community-based partnership interventions where midwives were trained and posted to work in poor, remote, or vulnerable communities and encouraged to work in collaboration with TBAs [4,5,6,7]. The other two studies evaluated new roles for TBAs within broader safe motherhood programmes; one culturally appropriate childbirth care model with TBAs and family members to encourage women to deliver in facilities  and the other multifaceted programme involved TBAs in raising awareness of services and reproductive health issues at community level . The additional sources provided information on implementation of new roles or partnerships with TBAs in: East Africa (n = 3); West Africa (n = 1); South Asia (n = 1); South East Asia (n = 4); Central America (n = 3); South America (n = 1); and multiple countries (n = 1). The interventions described include: promoting partnerships between midwives, doctors, or health services and TBAs [11, 12, 20,21,22,23,24]; and creating new roles for TBAs including accompanying women to services [25, 26], supporting women during labour or childbirth [27, 28], and offering financial incentives to TBAs to refer women [12, 28].
Stakeholder experiences of partnerships and new roles for TBAs
The stakeholders most often identified in the interventions are TBAs, community-based SBAs (trained midwives), facility-based SBAs, women service users, family members and local communities including men and religious leaders. The perspectives of each of these groups on partnership and new roles for TBAs are not detailed in depth in any of the included sources, but our analysis identified some insights into how these interventions are received and experienced.
TBA, community-based SBAs, and facility-based staff experiences
Interventions to develop collaborative partnerships between TBAs, SBAs and facility-based staff have involved relationship-building integrated into midwifery training in Indonesia , and integration of TBAs into a ‘referral chain’ with nurse midwives in Bangladesh . TBA-facilitated sessions on traditional birth and medications and village midwives working ‘side-by-side’ with TBAs have been used to promote partnership in Peru  and Indonesia [4, 5] respectively, and in Sudan incentive schemes to motivate TBAs to work collaboratively have been introduced . In Myanmar links with TBAs have been strengthened through a network of community-based provision in which maternal health workers have responsibility for overseeing the work of TBAs .
Reports suggest that TBA experiences of new partnership working with SBAs and facility-based staff are varied. In Guatemala, TBAs describe their increased confidence, for example when giving information to families and persuading husbands to support use of facility care . But others in the same programme report suspicion of their new roles by some members of their communities and a lack of consideration for their personal needs when accompanying women to a hospital facility (e.g. food and accommodation) . Further evidence from the Guatemala case study suggests that TBAs collaborate with the facility and accompany women as an ‘obligation’ to women who need help, and because it helps give the hospital a ‘good image’ with the population . In Malaysia collaborative working between TBAs and SBAs was reported to have improved previously poor relations as TBAs had been gradually shifted to ‘a more exclusively family supportive role’ since 1973 .
There are also reports of facility staff having a low opinion of TBAs, and thereby making them feel unwelcome . But improved relationships between TBAs and facility personnel were reported in Mexico and Peru [11, 19] following a broad participatory approach, and the design of a culturally appropriate model of care which included TBAs in Peru . Integrating TBAs as birth companions (to give traditional massage and drinks) [11, 19] and as interpreters [19, 28] was accepted positively by facility staff and TBAs.
Women service users, family members and wider community experiences
Few papers report directly or in detail on women’s experiences of new roles or interventions to promote partnerships with TBAs. The need to include ‘key decision-makers’ from communities including men (who are often household decision-makers) and religious leaders in TBA partnership interventions was noted in some papers [5, 6, 13], but only scant reporting of their experiences was included in the analysed papers. Involving household stakeholders (women, mothers-in-laws and husbands) and TBAs in assessing reproductive health information materials was a strategy used in Indonesia to foster collaboration . Community empowerment and an increase in men’s awareness of maternal and neonatal health was also reported following partnership working in Indonesia . The need to establish ‘strong links with the community’ when implementing changes to models of care was reported more generally  and in particular the importance of community ‘consideration’, ‘consultation’, ‘mobilisation’ and ‘inclusion’ noted in relation to TBA partnership in Peru , Nigeria , Guatemala  Myanmar  and Indonesia [4, 5], even though detailed reporting of community stakeholder experiences was limited, with the exception of a case study conducted in Guatemala . Some studies emphasised the value of ‘intercultural adaptation’  and ‘culturally appropriate’ skilled care provision which retained TBAs as companions and interpreters [11, 19, 27, 30]. For example, in Guatemala, hospital workers were observed to show more patience, consideration, and respect to the women using their services, and for women, having access at the facility to an interpreter who spoke their language was ‘deemed extremely positive’ . Trust between the hospital staff and local women was reported to have increased as a result of the changes to the organisation of care including recognising TBAs as a culturally acceptable bridge between women and the health system . In Peru, family members being allowed to stay at the facility was also regarded positively by the families . But in Myanmar concern was expressed by some family members about the financial costs (including loss of work time) and disruption to family life associated with childbirth at a facility and the need to leave the family home .
Barriers and facilitators to implementation of new roles for TBAs
Implementation challenges exist at the individual, community, facility and wider health system levels. The factors identified in the papers broadly focus on the importance of sensitising key stakeholders in order to change traditional TBA practices and achieve partnership with health service personnel, shifting attitudes and strengthening working relationships between TBAs and other health workers, and finding ways to adequately reward and incentivise TBAs in their new roles. It was also recognised that it could take time for new ways of working to become accepted and for behaviours to change.
Changing traditional TBA roles and practices
The continued adherence to traditional practices and a ‘greater degree of traditionalism’ in some communities  and countries [6, 23] have been identified as barriers to change and reasons why TBA partnership and anticipated shifts to SBA have not occurred in ways, or at a pace, anticipated [4, 28]. A continued preference for TBAs and traditional birth practices was noted in Eritrea  and Myanmar  and cultural practices in some regions [11, 19, 20, 23, 27, 28, 30] have been recognised as a barrier to skilled care use as women and community members still trust and prefer to use TBAs. A lack of available or accessible skilled care in some remote communities is also a reason given for continued use of TBAs [21,22,23, 26].
In contrast, several countries have experienced gradual shifts in traditional practices and cultural beliefs towards acceptance of new roles for TBAs and greater trust in midwives for technical aspects of childbirth . This has been achieved through sharing of knowledge between TBAs, community-based SBAs, and facility-based staff and through community involvement especially in relation to designing culturally-appropriate facility care in Peru , Guatemala , Mexico [11, 30] and Bolivia . This has led to improved relationships between multiple stakeholders . But changing traditional practices in some communities has been slow [4, 26, 28] and community involvement was widely identified as essential in changing behaviours towards skilled care at birth [11, 19, 27]. The inclusion of key decision makers, including men, in information campaigns to increase demand for skilled care at birth and raise awareness of new roles for TBAs was also noted in Pakistan  and in Indonesia . In Peru using an inclusive, ‘participatory approach’ to identify local needs facilitated the introduction of culturally-appropriate skilled care, and ensured that service use was sustained . Involving TBAs and community members in the assessment of information materials as a means to facilitate partnership and community support was reported in Indonesia, where local radio was also used as a community information tool .
Working relationships between TBAs and other health workers
As new roles for TBAs lead to closer working with SBAs and facility-based staff, rivalry and negative attitudes among the different cadres have been reported . A review paper summarising different models of childbirth care highlights that in countries where home birth is predominant and the government attempts to link with TBAs, they are likely to view government staff as competitors for the same clients; government health workers on the other hand may have a low opinion of TBAs . There are however examples in the included studies of how TBAs and other health workers have developed mutually respectful working relationships. For example, in Brazil TBAs were made to feel part of the formal health system by being granted access to a telephone for arranging transport to a facility and (in some cases) provision of a uniform, and this reportedly helped to overcome negative attitudes towards TBAs among skilled birth attendants . In Myanmar integrating TBAs into a three-tiered network of care providers  and allocating them specific roles in providing antenatal care, conducting uncomplicated births, and creating links with upper-tier workers helped to promote good partnership working within the context of camps for internally displaced populations in the eastern border. The supervision of partnership working together with strong referral mechanisms was acknowledged more generally as a way to facilitate good working relations . As part of the TBA-midwife partnership project in Indonesia, TBAs no longer help women give birth but their ‘social status’ has been retained helped by the formal acknowledgement of the TBA in the health system . In many countries identifying new roles for TBAs (for example adapting facility care to include TBAs as birth companions) involved consultation with all stakeholders, which was found to facilitate better partnership working and helped to overcome rivalry between TBAs and skilled attendants [7, 11, 19, 27, 28, 30]. Many reports emphasised the importance of defining new roles for TBAs (for example, ANC, family health, postpartum care, breastfeeding and weaning, as advocates for MNH needs) and committing to these at the policy level . The introduction of formal agreements (‘contracts’) between TBAs, SBAs and health services was reported to facilitate implementation in Brazil  and Indonesia .
Rewards and incentives for TBAs in new roles
As TBAs take up new roles and transition to partnership working they can experience an erosion of income and payment-in-kind previously received for conducting childbirth in the community. Performing new roles such as referring and accompanying women to facilities [25,26,27] and acting as a birth companion also involves new costs (e.g. transport and food) which some TBAs expressed concern about . The need to ensure financial remuneration for TBAs was noted in several countries [4, 12, 28] and addressed through a formal signed agreement in Indonesia . In Bolivia , Sudan , Indonesia  and Nigeria  payment for TBA referral or post-partum care  was introduced or recommended. Paid referral included encouraging TBAs to provide lists of pregnant women and referring women for skilled care in Indonesia , Peru  and Sudan . In Indonesia, TBAs were encouraged to work collaboratively with midwives and report pregnancies to the health centre so that midwives could invite the woman for antenatal care by personal letter , and in Guatemala TBAs agreed to prepare lists of pregnant women for the health committee . In Bolivia TBAs received payment for referral of pregnant women to a medical institution . TBAs were also encouraged to refer women to Maternity Waiting Homes in Eritrea . The introduction of performance based incentives for TBAs was recommended in Nigeria as a means to build capacity in their new social support role .