Further Information: Tradition Birth Attendant Training Programme
TBAs dancing in break time, Fenoarivo!
II.What is a traditional birth attendant ?
III.Why is training needed ?
IV.The benefits of training
V.The TBA Training Programme
VI.Training Programme Aim
VIII.Equipment provided & the reference system
IX.Follow up and Evaluation
Much of Feedback's health work has involved the training of traditional birth attendants in remote rural areas of SE Madagascar, with the aim of promoting safe motherhood and a reduction in morbidity and mortality rates.
The term 'traditional birth attendant' or 'TBA' is used to describe someone (usually female, but sometimes male) who assists childbirth in and around their village. Their 'talent' is almost always inherited from their parents or another relative, who pass it on to them when they feel they can no longer practice. Often, however, TBAs say that they were never taught how to attend births, but that the skill just 'came' to them like in a dream. It is quite rare to find young TBAs, the majority being over 40 years old, and many very elderly. Their catchment areas can be quite large, the more renowned TBAs serving villages several kilometres away. Usually TBAs' rolesxtend to more than just attending childbirth, women consulting them in pregnancy and after, concerning the health of both mother and child. Traditionally most TBAs practice massage and administer medicinal plant remedies. The majority attend births in peoples' homes.
TBAs are often the preferred health practitioners for pregnant women because they are easy to identify with culturally, in terms of such things as classification of illness, use of therapeutic resources such as herbs, massage, and psychosocial support. They are also more economically accessible; usually there is no fixed fee but just a donation. However, TBAs are limited in their identification of risk signs, provision of sanitation and the necessary materials for childbirth, and their use and knowledge of medicines. Certain established practices are potentially harmful (see below).
Although TBAs often have extensive knowledge gained through experience, they often do not recognise the circumstances under which pregnant woman should be sent to hospital. Certain traditional practices are potentially very dangerous, including:
- massaging of the womb in order to change the position of the foetus during pregnancy (this risks misplacing the baby and wrapping the umbilical cord around its neck),
- inserting ones' hands or fingers up the woman's vagina before or during childbirth (forcing it open and thus risking ripping the perineum and spreading infection). There is commonly a total lack of protection for the perineum tissue during childbirth.
- the administration of medicinal plants during labour may harden the vagina or may force the baby out when it is not ready or when the vagina has not naturally expanded enough, causing ripping.
- waiting until the placenta has been released before cutting the umbilical cord, or trying to force the placenta out by pulling on the cord and massaging the woman's stomach, being afraid that it will get stuck internally.
- advising women not to move much after birth so as to prevent haemorrhage, which risks causing blood circulation problems and paralysis.
- washing new-born babies also removes the mucus which protects them from infection.
- often TBAs pay little respect to cleanliness and hygiene,
- examinations of the woman in post-partum are rare, and very little advice is given to them.
- ignorance as to the cause of many diseases.
- ignorance as to services available at the hospital and the benefits of prenatal check-ups.
- lack of knowledge concerning a balanced diet (the imposing of taboos for pregnant women) and the importance of iodine in salt.
The benefits of enhanced co-operation between TBAs and the formal medical sector include:
- lower costs,
- more health workers,
- greater accessibility
- therefore, a health care system that is better distributed and more efficient.
- TBAs are already trusted in their communities, there is potential for their role to be expanded.
The realisation of public health goals is likely to be impossible without the participation of TBAs, considering current trends whereby government resources are decreasing whilst population increases. Considering that 39% of births in Madagascar are attended by TBAs, rising to 6O% in the Fianarantsoa region; compared to 34% at health centres, they are considered to be important health workers. Working with existing community-based practitioners allows the design of development projects that use appropriate health messages, incorporating local practices and beliefs, and are therefore more effective in reaching their audience.
Efforts to incorporate TBAs into the health system are aimed at tackling the high rates of preventable illness and death from complications in pregnancy and childbirth, as well as high infant mortality rates. In Madagascar, almost one quarter of deaths among women in their childbearing years are attributed to reproductive causes, whilst almost one in ten children die before their first birthday. Non-attendance of antenatal care is one of the main risk factors for pregnancy-related death.
This TBA training programme, the first of its kind in Madagascar, was initiated in 1999 having noted the small number of women giving birth at the hospital and the nature of childbirth at the village level. Since then, twenty two training sessions have been carried out in three different districts, involving 503 TBAs from 20 different communes.
This region of Madagascar, Fianarantsoa, comes worst off in all the poverty indicators, having for example the highest mortality rate of children up until the age of 5 (204 / 1000) as well as the highest infant mortality rate (121/1000) (DHS, Health & Demographic Study, 1997).
The aim of the programme is to promote safe motherhood, to decrease the rate of maternal and infantile mortality, through minimising the risks involved in childbirth. To increase the knowledge and skill of traditional birth attendants (TBAs) concerning maternal and infantile care, and the precautions necessary to take before, during and after childbirth.
After the training, each participant should know how to :
- Recognise from the symptoms that a women is pregnant.
- Keep a watchful eye on those pregnant women in their village.
- Practice safe childbirth.
- Give advice and warnings to both mother and child postpartum.
- Recognise the diseases / conditions that may appear during pregnancy, childbirth and after childbirth.
- Raise awareness about safe motherhood.
- Explain the role and the responsibility of TBAs.
Sissia, a Feedback fieldworker, with a reference system ticket book.
Exercise books and pens for note-taking, brochures on family planning and health gazettes are all distributed to TBAs during the training. Referral 'ticket' books were distributed to all TBAs on completion of the training. These tickets are given to women whose births TBAs attend, as well as to women they send to the hospital for prenatal consultations or due to pregnancy-related problems. They can also be given to women interested in starting family planning. On reception at the hospital, the ticket enables staff to know either who attended the birth, allowing registration of the birth with the Commune, or the reason for the woman's consultation. The reference system is also a means of programme evaluation as it allows the hospital to keep a check on TBAs' work.TBAs also receives an exercise book, each page of which has a table which they are to complete on a monthly basis, listing the work they have done during that month (childbirth attendance as well as different awareness-raising work). This report is to be taken to the hospital in order to keep personnel informed of TBA activities and any problems they have encountered.
TBAs are required to complete a practical training at the hospital, which involves attending at least two births (using the correct, safe procedure) in the presence of hospital personnel, after which they can receive their 'kit' (as well as be eligible for a certificate). TBA 'kits' contain basic equipment; scizzors, razor blades, eye medicine for new-born babies, soap, a glass bottle for alcohol, plastic sheeting on which to give birth, nail brush, a bandage & gauze swab.
TBAs applauding each other during training, Fenoarivo.
Follow-up meetings are held at the respective hospitals, normally every two or three months, so as to give TBAs a chance to share experiences and revise what they learnt in the training. A thorough evaluation of the TBA programme in Ambohimahamasina was carried out between April and June 2001, and follow-up visits to each TBA's village are carried out. The Feedback - Ny Tanintsika fieldworker has been, and continues to be, in the field assisting TBAs to carry out their awareness-raising tasks, and reinforcing lessons from the training. Spending a month in each commune post-training, each TBA is visited in turn and village meetings organised to explain the new system and get community feedback. Findings of monitoring are generally very positive, and are presented to the Service of Family Health, a division of the Ministry of Health, for their information..
TBAs learning about human biology and reproductive health in a participatory way, Ambohimahamasina
A role-play; acting out what should be done when attending a childbirth, Ambohimahamasina.
Exploring family planning methods, Ambohimahamasina.