Throughout African history, traditional birth attendants (TBA's) have provided maternity care for women despite having no formal training. Unicef figures show 1 in every 126 Tanzanian women dying due to maternity complications, and the story is the same in Ghana. Are women putting their lives at risk unnecessarily?
For many women, tradition and local customs prevent them attending hospital. For others it is the proximity to medical facilities - there is just no way they could reach a hospital in time to give birth. TBAs provide them with all the care they need, both during and after pregnancy and childbirth and there is no doubt they provide a much needed resource . The problem is that many of these TBAs inherit the job from their mothers or are simply respected older members of the community. In the majority of cases the women are illiterate and have learnt their skills from other TBAs or just through the course of their lives. They may consider themselves to be like private health practitioners, but can they spot complications or cope with problems any better than you or I?
The answer is they can't. The June copy of The Practising Midwife commented that a woman is 14 times more likely to die in childbirth than in a developed country. Although many people believe the problem is a lack of education amongst rural villagers, and that the answer is to raise awareness amongst rural women that hospital births are dramatically safer, that is not the answer. A massive lack of healthcare workers and minimal resource means that if every woman turned up at hospital, they would be unable to cope. Our students have seen how overwhelmed the maternity wards can be, and how quick the turnaround is. It just would not be possible and women would perhaps be at greater risk.
Rather than educate against the use of TBAs, the United Nations Population Fund believe that working with them is the best solution and wrote a study about the benefits of supporting and training across the world. The TBA programme in the Upper East Region in Ghana, tracked antenatal visits and deliveries conducted by trained TBAs during 1990 to 1993.
"Antenatal visits increased from 20,000 to 180,000. Deliveries reported by TBAs increased from less than 10,000 to 50,000. Nationally, the percentage of TBA deliveries as a percentage of supervised deliveries, increased from 16.4 percent to 22.2 percent between 1992 and 1993. Policy makers and programme managers state that TBAs have contributed to: improve pre-natal care, increase contraceptive acceptance rate, and decrease neonatal tetanous admissions".
Although there is much work to be done, the training programmes appear to have resulted in cleaner, safer birth practices. Trained TBAs can advise mothers on basic pre-natal care, identify risk signs and most importantly, make referrals. Cases reviewed by UNPFA showed that
"TBAs can make the most impact in preventing maternal and neonatal infections. They can prevent post-partum sepsis by applying the “three cleans” during delivery and following placenta management procedures. They also can contribute to decreasing maternal and neonatal deaths due to tetanus by referring women for tetanus toxoid immunization and by conducting an aseptic delivery. In locations where referral is feasible, TBAs can save lives through identifying risks and conducting required preventive measures before arrival at the referral site."
Many health professionals do not agree with this study though, believing there is no conclusive evidence that trained TBAs can prevent maternal deaths unless they are closely linked with the health services. A study by Staffan Bergström,a professor of International Health and Elizabeth Goodburn, a Reproductive Health Advisor, commented that
"The role of TBAs should not be ignored but TBA training should be given low priority and precedence given to other programme options that are based on stronger evidence of effectiveness including the provision of essential obstetric care and of a skilled attendant at delivery".
But do we really want to give it low priority? How quickly could the age-old reliance on TBA's be overturned? It is a complex subject matter, but one that does need to be addressed. A second article in The Practising Midwife highlights exactly why. Talking about training TBA's in Ethiopia, the author - Alice Ciolino says that many of the complications experienced in the region were due to prolonged and obstructed labours.
"Often mothers would be presenting at the hospital after several days of an abnormal labour with a dead baby and a ruptured uterus. Additionally there were high rates of maternal death from post-partum haemorrhage. TBA's often tried to manage these problems with traditional and sometimes inappropriate methods such as tying the mothers fingers together. Sadly they would bring the women to hospital when they were almost dead."
thcare Experiences in rural communities so that students can understand the difficulties faced by labouring women. In Ghana there is may also be an opportunity to see TBAs in action. Although our students work alongside midwives, the villages we partner with still regularly call on TBAs during night births, and they may well be on the scene when you arrive during the day with the experienced professional. It may sound scary, but is a part of traditional life.