Volume 127, Issue 1, October 2014, Pages 41–46
Clinical Article
- Open Access funded by Department for International Development
- Under a Creative Commons license
Open Access
Abstract
Objective
To
explore the feasibility of changing the role of the traditional birth
attendant (TBA) to act as birth companion and promoter of skilled birth
attendance.
Methods
Between 2008
and 2012, 75 TBAs received 3 days of training and were paid US $5 for
each patient brought to any of five healthcare facilities in Maroodi
Jeex, Somaliland. Health facilities were upgraded (infrastructure, drugs
and equipment, staff training, and incentivization). Eight key
informant interviews (KIIs) and 10 focus group discussions (FGDs)
involving 32 TBAs and 32 mothers were conducted. A framework approach
was used for analysis.
Results
TBAs
adopted their new role easily; instead of conducting home births and
referring women to a facility only at onset of complications, they
accompanied or referred mothers to a nearby facility for delivery,
prenatal care, or postnatal care. Both TBAs and mothers accepted this
new role, resulting in increased deliveries at health facilities.
Facilitating factors included the creation of an enabling environment at
the health facility, acceptance of the TBA by health facility staff,
and monetary incentivization.
Conclusion
Changing
the role of the TBA to support facility-based delivery is feasible and
acceptable. Further research is needed to see whether this is replicable
and can be scaled-up.
Keywords
- Birth companion;
- Health promoter;
- Skilled birth attendance;
- Somaliland;
- Traditional birth attendant;
- Training role change
1. Introduction
Access to a skilled birth attendant (SBA) is critical for improving maternal and newborn health [1].
In low-resources settings and rural areas, professionally trained staff
are often in short supply and there is a tendency for women to rely on
traditional birth attendants (TBAs) for delivery [2].
Studies have shown that, although a modest reduction in newborn deaths
can be achieved when TBAs are trained and supported, a reduction in
maternal deaths does not occur [3], [4] and [5].
Discussion continues around, first, the role of the TBA; second, the
best way to include these experienced women, who are respected and
trusted by the community in the provision of the continuum of care; and
third, if they are to continue to act as community-based providers or
promoters of maternity care, how to ensure that they are linked with the
existing health system [6].
A
TBA is defined as a person who assists a mother during childbirth and
has acquired her skills by delivering babies herself or through
apprenticeship to other TBAs [7].
TBAs provide care during pregnancy, childbirth, and the postpartum
period; and are well established, living in close proximity to the women
who require maternity care in the community. They have detailed
knowledge of community norms and are paid “in kind.” These
characteristics are increasingly considered as strengths that the formal
health sector has sought to leverage [2].
Many
women living in low-resource and rural settings continue to seek the
care of a TBA, despite the knowledge that a health facility delivery is
often safer [8] and [9].
Until recently, the scope of TBA training was designed to prepare them
to recognize “at risk” mothers and newborns, to conduct a safe home
birth for low-risk women, and to refer women considered to be at risk or
to have recognized obstetric complications to a health facility [6] and [10].
WHO’s new guidelines for the practice of TBAs suggest that providing
companionship and support during pregnancy and birth, in addition to
health promotion are the roles best suited to the TBA skills [11].
Somaliland, which has comparatively poor health indicators (Table 1),
relies heavily on TBA-assisted maternity care owing to a shortage of
all cadres of skilled healthcare providers including SBAs [12].
In 2008, a program to improve the reproductive and sexual health of
internally displaced people (IDP) was implemented in the Maroodi Jeex
region of Somaliland. In this program, TBAs received training and
orientation in order to practice as health promoters and birth
companions, instead of their traditional role of conducting deliveries
at home and referring women to a healthcare facility only when
complications arose.
- Table 1. Maternal and child health indicators for Somalia and Somaliland.a
Indicator Value Somalia Average life expectancy at birth 50 yr Maternal mortality ratio (MMR) 1000 per 100 000 live births Risk of a woman dying during child birth 1 in 16 Mortality rate: under 5 yr 180 per 1000 live births Mortality rate: infant 43 per1000 live births Somaliland Prenatal clinic attendance (at least one visit) 32% Skilled birth attendance 44% Home birth 75% Overall fertility rate 5.9%
The
primary aim of the present study was to examine the acceptability and
feasibility of reorienting the TBA role by documenting the experiences
of both TBAs in their new role and mothers who had received care from a
TBA, in addition to the perceptions of key health system stakeholders.
Documentation of experiences and lessons learnt will inform
international practice and help to decide whether this model can be
replicated in other low-resource settings.
