Maternal mortality, infant mortality and neonatal mortality are high in Pakistan where maternal health services depend upon traditional birth attendants (TBAs). We examined the practices of TBAs in Dadu district in rural Sindh from September to November 1998 by interviewing and hosting focus group discussions with 17 TBAs. Health care personnel and other important members of the community were also interviewed. TBAs worked in areas demarcated by extended families, ethnicity or geographical access and a system of seniority was observed. Only one TBA was formally trained and antenatal and postnatal care concepts, cleanliness and equipment were inadequate. Communities trusted the TBAs and remunerated them according to factors particular to each birth. TBAs need training and to be linked with the formal health sector to effect change and to decrease maternal and neonatal mortality.