Author: Ngala Elvis Mbiydzenyuy
Address: Maternal and Child Aid Cameroon
Position: Founder/CEO Maternal and Child Aid Cameroon
E-mail: elngala@yahoo.co.uk
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
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Health
for All Series, No. 1, Geneva, WHO 1978
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