Monday, December 10, 2012

Traditional Birth Attendants Filling the blank space in rural Cameroon

Author: Ngala Elvis Mbiydzenyuy
Address: Maternal and Child Aid Cameroon
Position: Founder/CEO Maternal and Child Aid Cameroon
Tel: (237) 99 13 84 44

Traditional birth attendants have been a subject of discussion in the provision of maternal and newborn health care, especially in developing countries where there is a lack of infrastructure and trained health personnel. According to the WHO Alma Ata definition, ‘a traditional birth attendant (TBA) is a person - usually a woman - who assists the mother at child birth and who initially acquired her skills delivering babies by herself or working with other TBAs 4. Studies have classified three major types of TBAs. There is the TBA who is a full-time worker who can be called upon by anyone and expects to be paid either in cash or in kind. Secondly there is the TBA who is a woman’s elderly relative or neighbour who does not make a living from the work and will only assist with the birth if the mother is a relative or a daughter or a daughter-in-law of a neighbour or close friend. This TBA assists in the birth as a favour and does not expect to be paid, but may receive a token or gift in appreciation. Lastly there is the family birth attendant who only delivers babies of close friends. In any society, the role of the TBA often reflects the culture and the social organization 5
In many African communities, TBAs are highly respected; they perform important cultural rituals and provide essential social support to women during childbirth 3, 9. In all cases their beliefs and practices are influenced by local customs and sometimes by religion.
In recent years the value of TBA training has been increasingly questioned although there are still many groups who remain enthusiastic. There often appears to be little common ground between the proponents and opponents of TBA training9. Outcomes from studies on the relevance of TBAs present mixed and often controversial pictures. We should note however that before the establishment of the primary health care, several TBAs were already practising. So if trained, followed-up, supervised, supplied with materials and motivated TBAs can fill in the blank spaces in the Cameroon health care systems at the same time complimenting in areas modern interventions might never access in decades.
The Status Quo
Plausible efforts have been made to improve the health of children around the world over the past decades, with some notable successes. Achievements have not been as expected and maternal and child mortality rates are still high. Two-thirds of newborn deaths are due to infections, pre-maturity and asphyxia, which are preventable. Of these deaths, 99% occur in the lower and middle income countries 10. The quality of care, both health-facilities based and household-based, available during pregnancy, delivery and post partum period has much impact on maternal and newborn health 11
Governments all over Africa are introducing/ announcing free healthcare for pregnant women and children less than 5 years in the bid to meet the United Nation’s millennium development goals on reducing maternal and child mortality 1.  Despite the commitments of African countries to improve maternal health, maternal mortality remained high at 1,000 deaths per 100,000 live births against 9 / 100 000 in developed countries. In 2005, WHO estimated that if nothing was done by 2015, there would be 2.5 million maternal deaths, 7.5 million infant deaths and 49 million maternal disabilities in the Saharan region. 6
In Cameroon, the mortality rate has worsened in recent times, from 430 deaths /100 000 live births in 1998 to 669 deaths /100 000 in 2004, even though recent UN statistics records 600 deaths per 100000 live births6. In 2007, the Ministry of Public Health estimated that in the absence of any intervention, and assuming that the maternal mortality rate stagnated at the same level, 41,000 maternal deaths and 250,000 neonatal deaths would be recorded between 2007 and 2015. Surely, all trained health hands must be on deck to deal with this emergency, including the hands of trained and monitored traditional birth attendants? Not to do so is unethical 1.
The causes of the poor health outcome for pregnant women and children are many, but the most important reason is the severe shortage of trained and skilled health workers. The national arms of the Cameroon health care system are amputated by several socio-economic and political factors as they approach rural areas.  In rural Africa, between sixty and ninety percent of deliveries are assisted by a TBA. High quality maternity care is often unavailable and home birth remains a strong preference for many.  In sub-Saharan Africa, the presence of skilled birth attendants at all births is an unforeseeable goal. Skilled birth attendants conduct less than half of deliveries, with an estimated 22.2% of deliveries attended by traditional birth attendants, 26.8% by family members, and 5.9% of women delivering alone 13. The problem is worsened by the unwillingness of professional health personnel to accept positions in rural areas because of lack of tools and facilities to perform their job and of an inadequate social environment.
A sequestration
Social upheavals, political unrest, dictates of international bodies, reform policies, dependency syndromes, corruption and multi-faceted poverty have gradually negatively impacted African communities; variously exhausting the existing limited resources which are critical to the establishment and sustenance of development efforts. Consequently, there exists a disproportionately high demand upon scanty resources, which is replicated in the health care system of sub-Saharan African countries 14.

The health care system is further impoverished by severe brain drain as professionally trained, highly qualified and experienced health personnel not only die from the HIV/AIDS epidemic, but also either seek more fulfilling careers out of Africa due to several ‘pull factors’ in more developed countries, or they are forced out by inherent ‘push factors’ including political insecurity, sub-standard levels of amenities or diminishing returns from service. Furthermore, there is a disproportionate number of qualified health personnel to provide for a large population with ill-health, particularly in the rural areas because of limited training facilities, insufficient capacity building, and the few professional elite tend to congregate in the urban centres where the benefits accruing are relatively higher.
As governments struggle to find staff to run their free healthcare schemes, administrators of health facilities have tried local skill mix arrangements. In primary health centres community health workers conduct consultations and treatment, including deliveries. But unfortunately, these workers tend to shun home visits, preferring to practise like hospital based nurses and midwives. This lack of contact with the community leaves a vacuum that is filled by various groups, including traditional birth attendants, religious groups, herbalists, and native doctors 1
In the light of depleted resources, shattered infrastructure and insufficient numbers of professionally trained health care personnel, traditional birth attendants (TBAs) offer a relatively low cost, locally appreciated social group that could intervene to redress the gap in resources and improve African reproductive health 14
Fact Sheet
For most rural families, TBAs are a cheaper option than domiciliary professional midwives and will often accept payment in kind. Mothers in rural communities prefer to give birth at home because most TBAs do not charge anything for deliveries and are willing to make house visits, which allow the mother the privacy that many prefer. Usually, pregnant women will inform their closest adult relatives once they realise the delivery is imminent, who will then contact the TBA.12The Traditional Birth Attendant is usually an older woman, almost always past menopause and who must have borne one or more children herself. She lives in the community in which she practices. They have no formal training and some are illiterate, and are always accessible at all hours of the day and night. Because traditional birth attendants are from the village, they understand the traditions, cultures, and languages of the women that they attend to, an obvious advantage during antenatal care and childbirth 15. They deliver more babies than the skilled midwives and the skilled midwives soon become deskilled because they stop regular delivery and concentrate more on administrative nursing duties as their careers progress. The village pregnant women and their families tend to trust traditional birth attendants and rely on their opinion.8
It is true that their activities are marred with a lot of risky interventions but rather than effacing them, building their capacities will be a logical intervention. Although WHO recognises that it is not ideal to allow untrained villagers to conduct deliveries, it points out that prohibiting or banning them is unwise and potentially dangerous. Joe Ana also recounts that maternal mortality rose after Malawi banned traditional birth attendants, who went underground and were lost to regulatory authority. A few years ago, the country reversed the ban and started training traditional birth attendants,2 and mortality seems to be falling again.
The services of TBAs are not always valued by the health facility workers. The Cameroon Health Care system does not recognize their role. It should be noted that mothers to be referred to a health facility need to travel long distances in most cases. This distance is compounded by poor infrastructure and lack of transport. Most of the health centres are understaffed and ill-equipped and therefore it is likely that on arrival at the health centre, the patient will receive upward referral to another facility.
Beyond Rhetoric
Throughout history, traditional birth attendants (TBAs) have been the main health care providers for women during childbirth in Africa. They attend to the majority of deliveries in rural areas of developing countries. There is little doubt that they play a significant role when it comes to cultural competence, consolation, empathy and psychosocial support during pregnancy and labour, with important benefits for the mother and the newborn child9. Because there is a family-like relationship between the TBA and her social place in the community and to those to whom she gives assistance, her influence is felt in the daily life of the family and the community.  Integrating TBAs into the health care system most especially in family planning services will have double digit impact

TBAs in rural Cameroon should be trained in midwifery and basic hygiene as part of the Safe Motherhood Initiative aimed at reducing maternal mortality. This include performing deliveries in more hygienic environments, discouraging harmful practices, recognizing danger signs and referring women with complications to facilities where essential obstetric care is available.

This training has comparative advantages in attempting to provide professional health care for each birth because of the popularity of and easy access to TBAs who not only speak the local languages and allow traditional birthing practices, but also often have the trust of the local communities 7. This will constitute a local strategy that redresses issues of access to, equity over, and sustainability of reproductive health. TBAs should be an integral part of the primary health care system in Cameroon. We should note that before the establishment of the primary health care, several TBAs were already practising.
                                                                                                                                            
The plight of TBAs in Cameroon if ever considered is usually the concern of NGOs and private health organizations. The Cameroon government has not paid much attention to the activities of TBAs. Where trainings are available (often offered by NGOs) sustainability and follow-up training and refresher courses are lacking.  More so these trainings are not long enough to address all the important issues. Trained traditional birth attendants remain a vital resource in rural Cameroon, particularly in the provision of maternal and child health care services. With availability of requisite tools and equipment, close supportive supervision, access to continuing education and recognition by the formal health system, trained traditional birth attendants can effectively contribute towards efforts to decrease maternal and newborn mortality rates in Cameroon.

Borrowing a leaf from Sierra Leone where the World Bank is funding a scheme that pays traditional birth attendants about £1 for every woman they bring to hospital, the Cameroon government should endear such a venture as well as supply TBAs with communication tools. The Maternal and Child Aid Cameroon is underway with an m-health project tagged “call a midwife”  which TBAs will be incorporated in a bid to avert deaths in the hands of TBAs due to complications. This on one hand can be maximally possible if the system recognizes TBAs and there are associations of TBAs, like what is going on in Cross River State of Nigeria where Dr Bassey Kubiangha Education Foundation helped the traditional birth attendants to form an association. At the end of 2010 it had over 400 members. The association holds monthly meetings, at which skilled health practitioners are invited to lecture and train members. The association has also produced a training CD, which members are required to own, watch, and follow.1

It appears reasonable to assume that for decades to come the traditional birth attendant will continue to have a substantial influence and role to play in the health practices and life habits of rural populations even when modern health services are made available to them.
I will wish to round-off this summary with this quote:
“I am one of 13 born to our mother in the house and in a village where there was no health facility and no motorable road until 1980. My family, like many others, depended on women who were skilled in assisting women in labour. I later came to know that these women are called traditional birth attendants. My father was one of them because he assisted our mother to give birth to some of us. In fact, our father told us that I was born when my mother was alone. I know of families in my village where women died at child birth, right at home, they died from bleeding, from retained placenta, or breech births. All the male circumcisions including mine were done by parents or neighbours. I lived through all this and remember some of the bloody sites from delivery with horror and depression. Many people, who only talk about this and never saw a difficult delivery in the 1960s and 1970s in a village, will not know what we are talking about. Villages without roads and without health centers still exist in 2006. A well trained traditional birth attendant will do a lot of good to evaluate a high-risk pregnant woman and refer on time to the hospital. It takes days to move from one of these villages (Tinta) to the nearest hospital (Akwaya). Please, I wish to invite WHO and other advocates of the abolition of traditional birth attendants to live in one of these villages and have one baby there”13



Conflicts of Interest
The author declares that he has no competing interests and no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work. The author declares that he has signed the ICJME Form for Disclosure of Potential Conflicts of Interest and can be provided on request

References:

1 Joseph A.  Are traditional birth attendants good for improving maternal and perinatal health? Yes
BMJ 2011; 342 :d3310
2 Ngozo C. Malawi: uncertainty over role for traditional birth attendants. Global Issues March 2011. .

3. Bisika T The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi; East African Journal of Public Heath; Issue 2008 5(2): 103-110

4. World Health Organisation, Report of the Alma Ata Conference on Primary Health Care,
Health for All Series, No. 1, Geneva, WHO 1978

5. Maternal Neonatal Health, ‘Traditional Birth Attendants: Linking Community and Services’, 2004 www.Mnh.Jhpiego.Org/Best/Tba.Asp

6. Cameroon: Focus on maternal and neonatal deaths Monday,  10 May 2010 12:15

7 Revisiting the exclusion of traditional Birth attendants from formal health Systems in Ethiopia
Amref Discussion Paper No. 003/2010

8 Kongnyuy EJ, Mlava G, Broek van den N. Facility-based maternal death review in three districts in the central region of Malawi: An Analysis of Causes and Characteristics of Maternal Deaths; Women’s Health Issues; Issue  (2009) 19: 14-20


9. Bergström S and Goodburn E  The role of traditional birth attendants in the reduction of maternal mortality: Studies in Health Service organization and Policy (HSO&P) Issue  (2001)17: 85-89

10. Kippenberg, R., Lawn, J., Darmstadt, G., Begkoyian, G., Fogstad, H, Walelign, N, &Paul, V.
Neonatal survival 3: Systematic scaling up of neonatal care in countries. The Lancet 2005; Vol 365:1087-98

11 Population Reference Bureau & Save the Children (2006) The Maternal–Newborn–Child
Health, Continuum of Care: A Collective Effort to Save Lives. Policy perspectives on newborn health, March 2006

12 Essential Services for Maternal and Child Survival in Ethiopia Mobilising the Traditional and Public Health Sectors and Informing Programming for Pastoralist Populations Ethiopia Mid-Term Evaluation, Save the Children (2003)

13  Benjamin W., Emmanuel D, Pius M., and Patricia M. Birth Attendants Trained in “Prevention of Mother-to-Child HIV Transmission” Provide Care in Rural Cameroon, Africa J Midwifery Womens Health 2007;
52:334–341

14 Nyanzi: Empowering Traditional Birth Attendants in the Gambia

15 World Health Organization: The Traditional Birth Attendant in Maternal and Child Health and Family Planning: A guide to her training 1975

16 Ana J. Whole system change of failing health systems : experience of 4-year pilot of clinical governance, quality & safety in Cross River State of Nigeria. BMJ West Africa 2009.


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