Uganda officially banned traditional birth attendants (TBAs) in 2010 but they have continued to practice. Eighty per cent of rural women prefer TBAs to skilled attendants according to officials at the Ministry of Health, and 10% of them are delivered by TBAs.
While the government’s focus in the past two decades was on training TBAs, studies on training impact have shown conflicting results in maternal outcomes with many studies showing little to no impact on high maternal mortality outcomes. As a result, there has been a shift toward skilled birth attendants, capable of averting and managing child birth complications.
However, studies have shown that TBAs are still preferred to skilled health workers for their better handling of mothers, politeness, counseling and comfort during labour and child birth. “They are affordable, available, accessible and approachable” says Geturida, a mother of five assisted by a TBA on all the five deliveries.
The role of TBAs is vital to a rural woman and should not be under-looked: they are highly respected members of the community and proven assets in addressing poor maternal outcomes. TBAs have been unsuccessful in handling obstetric complications, but have contributed to successful maternal, neonatal and child health interventions in hard-to-reach areas. This is a fact we should not ignore. I keep wondering: after the TBAs were completely abolished and this abolition was enforced with imprisonment when caught assisting in childbirth, have maternal outcomes gotten better? Has the maternal mortality ratio reduced to 210 per 100,000 live births, thus achieving the MGD 5 target to reduce maternal mortality by three quarters by 2015? Or have the new cases of fistula reduced to 0 as opposed to 4,300 new cases every year?
The answer is “no”! My mother, who is 65 years old, is a government-trained TBA, and even became chairperson of TBAs, until recently when TBAs were told to stop practicing. I realised that during her long period of practice, she had been trained to keep records of mothers she assisted. In her records, she safely assisted 21 mothers at our home. She never lost a mother or a child. She kept the birthing place hygienic, never allowed any other persons there; she always used new razorblades, gloves, and jik. She never delivered a prime gravid (mothers delivering their first baby); she always referred them to the hospital, which is two kilometres away from our home. “Even when the government stopped us from practicing, mothers still came to me and I help them. I never had a death or heard any of the mothers complaining about my services thereafter” she adds.
There are so many TBAs like my mother who have done a great job. Of course there are also cases where mothers have been mismanaged by TBAs and died with many ending up with serious morbidities such as fistulae. TBAs are not the cause of high maternal mortality nor can they be the sole solution to the problem. However, they are a good link between the community and the health facilities, especially if they have been sensitized to know their limits. For instance, they can be instructed on when it is advisable to refer mothers to the health facilities. In so doing, they will be acting as health team-mates to support skilled attendants. They can also work with Village Health Teams at the village (community) level.
Community participation in selecting well-known mothers who can perform the TBA-role in communities is critical. TBAs should be part of the health system because they are mother-friendly and useful. They could be a solution to maternal deaths from direct causes, if they could quickly identify these complications and refer the mothers for skilled care. On average, half of deliveries in Uganda have a TBA presence.
With many deliveries occurring outside of the health centre and an estimated proportion of only 9-15% of deliveries requiring emergency intervention, the role of TBAs in providing convenient, easy-to-reach maternal delivery services can’t be overlooked. Access to transportation and communication are critical to improving maternal and infant outcomes. Major contributing factors to maternal death are delays in recognising danger signs, deciding to seek care, reaching care, and receiving care at health facilities. These are health system components that must be addressed by the Government.
TBAs can become very instrumental when they are formally integrated in the health system to assist in normal deliveries, and to refer mothers to health facilities or skilled health workers when there are complications. Their role should be in promoting change in societal attitudes towards birth, and providing friendly care arising from their natural, maternal and compassionate instincts. This would reduce the cases that have to go through the rather threatening environment of over-medicalisation, economisation and politicisation of this natural event.
The writer is a Makerere University School of Public Health-CDC Fellow
By Joan Kabayambi,