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HEALTH INTERACTIVE WITH DR. AMINU MAGASHI
TBAs versus Skilled Midwives
In Africa, Nigeria inclusive, there is a continues and reoccurring debate about the role of Traditional Birth Attendants (TBAs) towards reducing maternal death. As we all know that the rising maternal mortality ratios in Africa mostly due to preventable illnesses are one or even the highest in the world. In some areas, it has reach an alarming figure of having up to 3000 women dying out of every 100, 000 live births. In a simple language, out of every 100 live deliveries, 3 women are perishing attributed to pregnancy related illnesses, a natural phenomenon that is supposed to be simple and devoid of any serious problems. Among the major causes of maternal death in Africa are: Prolonged/Obstructed Labour, Excessive Bleeding, Unsafe Abortion, Pregnancy Induced Hypertension and Eclampsia and Infections such as Malaria and HIV/AIDS.
Other factors leading to high maternal death in Africa, which we are still grappling with, are within the community, Delay in deciding to seek for care which is related to Poverty, Ignorance and Male dominance and other Cultural Norms and Values. Even when a pregnant woman decides to go for Ante-Natal Care , another risks factor of Delay in Transportation will pose a stumbling block due to distance from the affected community to the secondary health center where such free services are being provided . When such woman arrives the center, at times the problem is already complicated to either lead to death before instituting management or leads to morbidity after intervention, notable among such is V.V.F/R.V.F. Majority of the Local Governments and Districts owned health centers (Comprehensive Health Centers and Health Posts) are devoid of skilled midwives, medical doctors and facilities to respond to emergencies. All these contribute to the high maternal mortality ratio (Delay in Management)
It is with respect to the low availability of Skilled Midwives at birth, that development workers begin to invest in Training of TBAs and even make them part of Health Intervention. Even though TBAs have been known since time immemorial and are assisting women during Labour, however, they only acquire their skills by delivering more babies and through apprenticeship to other TBAs. It is obvious that such methodology will not produce competent skilled workers. The debate in Africa came as a result of the fact that a lot of International Development Organizations after investing huge resources to train TBAs, but still the maternal deaths are on the increase every year and people begun to doubt whether all along they are wasting resources and need to look for another alternate intervention.
That’s what led to the 3rd Regional Reproductive Health Task Force Meeting that was held in Harare between 4th - 8th October 2004 and at the end of the meeting a Statement of Consensus on the Role of TBAs in the African Region was adopted and circulated. It will not be out of point if I mention some of such statements. While recalling the pivotal role of skilled attendants in reducing maternal and newborn mortality and morbidity and recognizing that our head of states have signed the Millennium Development Declaration and by so doing adhere to the MDGs that call for an increase in the proportion of deliveries assisted by a skilled attendant to 90 % by 2015 . Aware that the majority of deliveries occur outside the health facilities with a significant proportion of women assisted by TBAs. It was also observed that TBAs are not skilled attendants according to the international definition of the term ‘Skilled Attendant and convinced that women might turn to TBAs because of unmet needs in terms of access to health services ranging from understanding of health centers to negative attitude of health workers and considering that the training of TBAs has not made a positive impact on the maternal and newborn health care. The meeting attempted to redefine the scope of work of TBAs, amongst others as follows
In another two articles and studies on the same subject matter, the first which is titled ‘Does Traditional Birth Attendant Training Improve Referral Of Women With Obstetric Complications: A Review Of Evidence published in Social Science and Medicine 59(2004 ) 1757-1768 by Lynn Sibley and Co . The study observed that approximately 53 million women give birth at home every year without the help of a skilled attendant and the real effect of TBA training on TBA and maternal behavior are likely to be small and also there is medium , positive or non significant association between training and TBA knowledge of risk factors and conditions requiring referral and small , positive , significant associations between TBA referral behavior and maternity services use . Overall the review suggests a more promising research agenda which would reposition the questions surrounding referral in to a broader ecological perspective.
The second article “ The Impact Of Traditional Birth Attendant Training On Delivery Complications In Ghana written by Jason B Smith and Co and published by Oxford University Press 2000 in Health Policy and Planning ; 15(3): 326-331 . The conclusion of that report shows that despite some inherent design limitations, the study has found out that the evidence for a benefit impact of TBA training was not compelling and Training sponsors should consider alternative health investment and, where TBA training remains the intervention choice, people should be realistic about expectation of impact.
To conclude this discourse, let me paraphrase what one Senior World Bank official mentioned in April 2005 at a Health Sector Reform Course in Arusha, Tanzania “I think we are not being fair to TBAs by concluding that their training is not contributing in reducing maternal death in our communities, we trained them without providing them with the adequate facilities and there were no closer monitoring of their activities and refresher courses.
Let me say further that having unskilled TBAs in communities poses the risks of complicating deliveries leading to massive bleeding , damage of birth canal which may lead to Vesico-Vaginal Fistula or Recto-Vaginal Fistula and also transmission of infections such as Tetanus , HIV , and other Genital Infections . As such in trying to replace TBAs with Skilled Midwives in Africa, it must be done with caution. This is because majority of our Primary Health Care units are devoid of adequate health personnel, as such some communities for now can only rely on TBAs. So I am of the opinion that we should continue to train TBAs to understand danger signs and when to intervene and when to refer difficult cases and to improve the policy environment of training and employing Skilled Midwives, so that in the near future, TBAs will assume the role of Peer Health Educators while Skilled Midwives are all over our communities doing what they are supposed to do
Dr Magashi is the Executive Director of Community Health and Research Initiative , Kano , Nigeria and can be reached at healthinteractive@hotmail.com
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