Why traditional birth attendants will keep thriving

Above, Nancy Arach, Enrolled Comprehensive Nurse, attends to a pregnant mother in Koch Goma Health Centre III, Nwoya District and left, mothers who have come for post-natal care at the same facility. Although women are encouraged to visit such facilities, lack of certain services force them to use TBAs. Photo by Gawaya Tegulle

What you need to know:

Though the government banned traditional birth attendants from giving services to expecting mothers, many women still go to them because of the inconsistencies and gaps in the main health-care system

Who is a traditional birth attendant?

Much of the world is still dependent on female traditional birth attendants (TBAs), sometimes referred to as indigenous midwives. These women gain knowledge through practical experience and the oral tradition, rather than formal learning.

TBAs tend to be older women with children of their own. They usually hold status and respect within their community, and often have additional medical knowledge, particularly in herbalism and other traditional healing techniques. TBAs are involved at the birth itself and may assist during pregnancies and in the early post-birth period. They can also help with other health issues and act as a link between a geographically isolated local population and more formal health services.

Recent decades have seen greater regulation and licensing brought to the TBA profession. Major health organisations such as the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) are involved. They instigated programmes to improve the medical skills of TBAs, and closer relationships have been formed with modern health-care providers. They have also introduced formal training and improved provision of medical supplies to communities served by TBAs. However, many TBAs are reluctant to submit to greater regulation, fearing they may lose their traditional roles.

When the labour pains came, they showed up with vigour and vengeance, taking Anna by surprise, in the middle of the night. Anna didn’t even have time to wonder why they hadn’t waited till morning. Within a few minutes she was writhing in pain on the floor of her hut.
Her family was quick to put her on a bicycle and move, with difficulty, to Alero Health Centre III in Nwoya District.

They knocked, first politely, then hard and fast; but there was no response. Then they made enough noise to wake the dead, to no avail. When it is time for a baby to emerge, the situation changes from urgency to emergency; babies don’t wait.

Anna’s grandmother who had gone with her to the hospital simply dragged her to the verandah and told her to push as hard as she could. There on the verandah, with only the stars as the other witnesses, the baby was ushered into the world, angry with everybody, and bawling at the top of its voice.

It turned out the nurse-cum- midwife, Brenda Atimangho, who is an Enrolled Comprehensive Nurse (meaning she is trained in both fields), was very much around. But as she was the only qualified staff, she had worked for several days, almost non-stop, with barely time to catch even a wink. She was too tired to hear anything.

“I have too much work,” she says. “I have to do antenatal care, delivery, take care of HIV-exposed infants and also sort out the post-natal care. Sometimes, I have three mothers delivering at the same time, but there’s only one bed; so the others have to go on the floor.”
Ideally, every Health Centre III must have 19 trained staff, out of which two are midwives. But this centre has only four staff in total – a Senior Clinical Officer, a psychiatric nurse and a nursing assistant. Though Atimangho’s workload is four or five times what it should be, the salary is the same – small and consistently late.

Where the TBAs come in
Alero HC III is a typical upcountry health facility, chronically understaffed. The story of shortage of medical workers all over the country and especially in the upcountry areas, with the greater north certainly the worst hit, is a fairly old one.

But in the area of reproductive health, it does carry with it an important sub-plot – the importance of Traditional Birth Attendants (TBAs). Though they have been discouraged, they still continue to play a big role in reproductive health. And the sub-plot pursues the trajectory of a constant tango between the mainstream medical workers on one hand, and the TBAs, discouraged by the government, but yet in great demand, if for no other reason, at least the fact that they are always available when needed.

Dr Francis Runumi, Commissioner for Planning in the Ministry of Health says, TBAs were initially co-opted as partners in reproductive health, as medical workers could not reach mothers everywhere especially in upcountry areas. This was part of a new policy of Public-Private Partnership (PPP) in health, where the government recognised four groups – the herbalists, spiritualists, birth attendants and bone setters.

“Those TBAs who had been trained, tried to use scientific methods, like in the area of hygiene and safety. But many didn’t care about that and ended up delaying mothers who had developed complications,” says Dr Runumi.

“A study was done a few years ago, to check compliance and it was established that the majority had returned to their old habits – with a high cost in terms of life. From then on we decided to discourage the practice.”

In an era where HIV/Aids is widespread, using TBAs has been proved to encourage Mother to Child Transmission (MTCT) at the point of delivery, thereby being unfriendly to efforts to curb the pandemic. But that aside, mothers who develop complications in labour either die (especially due to over-bleeding), or remain permanently impaired in some way because they did not receive proper medical care in time. Many of the babies in such cases do not survive the ordeal.

Government services wanting
But Dr Runumi admits, “Government still doesn’t have capacity to enforce the ‘ban’ on TBAs. But even where we have reached, our services are wanting, leaving the mothers to go to TBAs who are not properly trained.”

There is a lot of work being done by non-state actors, to encourage women to attend health centres. In Alero, the Health Rights Action Group (HAG) and Action Group for Health, Human Rights and HIV/Aids (AGHA) are partnering with the District Local Government and local communities to sensitise mothers (using Village Health Teams, VHTs and Community Resource Persons, CRPs) about the importance of antenatal, delivery and post-natal care at health centres instead of remaining with TBAs. This is part of efforts in four districts of greater north – Amuru, Oyam, Nwoya and Soroti. This is done through community dialogues and home visits.

“Our target is to ensure that every mother completes at least four antenatal visits before delivery, which must be done at the health centres,” says Claire Mugisha, a programme officer with AGHA.

These efforts are in many ways bearing fruit. Koch Goma Health Centre III now registers more than 60 births a month, a figure unheard of before. Similar success reports are echoed from health centres all over the greater north.

Eunice Laker, a Community Resource Person (CRP) in Nwoya District says, “Many TBAs are working with us by way of helping mothers get to the health centres. They escort them, help the midwives attend to them and then go back together after delivery.”
“Many women are now delivering at health centres,” says Castro Kinyera, a CRP in Alero. “After a lot of sensitisation, they are now aware that certain services are offered at the health centres.”

Francis Ojara, another CRP says, Alero is now recording 20 to 30 antenatal visits daily, up from just five to 10 previously. A lot of success has been registered. But there’s lots of room for improvement, because the inconsistencies of the health care system then create immediate relevance and importance for the TBAs, inevitably.

Sarah Okwi, a TBA in Atura Parish, Oyam District, has given up the practice, after sensitisation from HAG officials, but there is a drawback. “When we TBAs were banned, I stopped attending to patients; I refer them to the health centres for antenatal care and medication to prevent mother-to-child-transmission. The only problem is that when they go, they find no help there in many cases.”

Although treatment is free, sometimes patients are asked to pay money and when they fail to pay, they are shown the door, even when in labour. In some cases, casual workers have taken it upon themselves to superintend delivery.

The shortage of medical workers means that TBAs remain very much in business.
There is also another good reason why: “They are civil and motherly,” says Oyam District Medical Officer, Dr Vincent Owiny. They don’t slap the mothers around in their labour suites (which often take the form of anything like a bedroom, a shed behind the house or a maize garden). They are readily accessible – they are out of town just when you need them most.

And heck, if you do not have the money, you can always pay when you get it. Cultural beliefs still play a big role too, with all kinds of myths discouraging some women from attending health centres. And there is also the small problem that most of the present day mothers were born with the help of TBAs and they see no reason why their children should be handled differently.

The long distances to health centres and unavailability of health workers in many health centres at night has also played a great part in keeping TBAs relevant. Although the government and CSOs have tried to provide solar lighting systems at many health centres, thieves in places like Aber (Oyam District) have been happy to make off with them. As a result, there are many cases where many women attend antenatal sessions at the health centres, then go to TBAs for delivery, especially if it is at night.

Josephine Auma, a CRP in Nwoya cites many cases where women in labour showed up at the health centres and found them closed, either because it was a Sunday, or the health workers were away on a week-long immunisation tour. As a matter of course, during immunisation periods, health centres around here go for an entire week without opening, leaving TBAs happy to fill in the gap.

The government has invested a lot of effort in turning things around. Even though, the funding for health is still small, falling far short of the 15 per cent of the national budget stipulated in the 2001 Abuja Declaration, rules are being relaxed to suit patients. “Ideally delivery is at the Health Centre IIIs,” says Dr. Owiny. “But it has been rolled out to HC IIs to ensure availability and access to and by the common person.”

This is a battle that the TBAs are certainly not winning, yet one they cannot be said to be losing. If the TBAs are to die out, it can only be with the re-emergence of the mainstream health care system as a robust, all-round and fulfilling option that people can rely on.