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.
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.
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.
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).