Saving mothers giving life: tackling the issue of traditional birth attendants

Jane Nattabi, 45, is a traditional birth attendant based in Kyabasaija, located in Kibaale district in south western Uganda. The small dirt path to her home is surrounded by thick greenery on each side and a swamp.

As we walk there we come across two children, carrying water from a swamp. No one else is in sight. We climb a gentle slope and come to a clearing in the thicket, where I see a number of buildings that Jane calls home. Part of her house is painted light green. There is also a mud and wattle building in front of her house where Jane does much of her cooking. Two children can be seen playing in her small compound while a few chickens are idly grazing.

Jane is the official traditional birth attendant (TBA) in her area. This means she is a traditional midwife who has helped deliver babies in her home or in the homes of the women she is helping. Jane has given birth to ten children and has been a TBA since she can remember. She says she got interested in assisting women in deliveries when she was a young woman. She has helped deliver over 100 babies in her time.

“I even delivered two of my own children,” she says with pride. Jane has operated her practice formally through the years. She also has a book where she records the date of delivery, the name of the mother and father, the name of the village, the age of the mother, the number of pregnancies she has had, the baby’s sex and health condition and any future course of action.

The health facility is less than half a kilometre away but Jane believes she has been able to attract a large clientele because items such as blades and gloves are not readily available at the clinic and many women cannot afford to buy these items themselves.

“The women don’t usually have what [they need] to use. When they would come here, I could share soap with them to use, a cloth to wrap the baby immediately it is born. Here the felt that they were at home.”

Furthermore, some women live far from the health facility, which means they have to walk long distances to access it. This means they have no option but to utilise the services of the TBAs located at the local council, which is the lowest recognised political division.

Teddy Bikwansinweho, 27, has given birth to two of her children at home. She went to the nearby health facility for her last but found that the health workers had gone. She called Jane, who hurriedly went to her house, where her baby was delivered.

“She delivered my baby well. The child is doing well. All the things I needed to use, I had,” Teddy says.

Although the services of TBAs are not always free, some mothers can access the maternal health services without any money. This makes the services very attractive. Those who do pay are charged between 6000-10000($5-$10) Uganda shillings per delivery, based on the financial ability of the mother.

Jane says the campaign by the Government of Uganda geared at increasing facility based deliveries has reduced the number of deliveries she has carried out in the last year.

Jane has received training as a Village Health Team member of her community. This is a team of health workers based within each community responsible for encouraging pregnant women to attend at least four antenatal visits, and to understand what danger signs to look out for that mean they should go to the health unit immediately. VHTs will also speak to women about preventing malaria and provide after birth care for mothers and babies. They will also keep a record of any birth and death in the community.

Uganda has been slow in reaching millennium development goal 5 of reducing maternal health by 2015. According to estimates from UNICEF, 435 women per 100,000 live births die as a result of complications during pregnancy and childbirth. Many of the cases go unreported because women in rural areas continue to have their babies at home with the help of their relatives or TBAs.

Danger signs during pregnancy are some of the leading causes of death for pregnant women. They include vaginal bleeding, fever, severe headaches, blurred vision, swelling of fingers, face and leg convulsions and sharp pain in the lower part of the belly. All are easily identified by a trained health worker.

Jane admits that, although she has not experienced any challenges in her practice, she was not well equipped to handle high risk pregnancies.

“Sometimes, when I was called into an emergency situation, I would carry out the delivery procedures without protection. And another thing is that; I could not ask whether a mother was HIV positive. Sometimes it is my relative that I am working on. I would just have to help. We have learnt that babies can contract HIV at birth.”

Dr. Dan Kyamanywa, the District Health Officer of Kibaale district, admits that TBAs have been active in the region for many years. Initially, TBAs were involved in offering antenatal services throughout the duration of the pregnancy and delivering babies. However, the Ministry of Health is advocating for a change in their operations.

“We trained traditional birth attendants to assist in normal deliveries. But now, we encourage them to identify mothers with high risk pregnancies for referral to the nearest health facility. Their role is gradually changing,” Dr Kyamanywa said.

Kiconco Evelyn, 20, came to the Kagadi District Hospital to deliver her baby.

“We were discouraged on the radio from giving birth at home and requested to come to the nearest hospital for delivery. I was assisted and given everything I needed,” she says.

Ngabirano Erias, her husband, is grateful for all the services rendered by the facility although he adds “I expected transport and some towels from the hospital which I have not received.”

In an attempt to reduce maternal mortality in Africa, Uganda and Zambia have been selected as the two countries in which the Saving Mothers, Giving Life (SMGL) project of the United States Government’s Global Health Initiative is being launched. The project, which in Uganda is being implemented under the stewardship of the Ministry of Health, with support from the US Center for Disease Control and Prevention (CDC) and USAID, seeks to reduce maternal and neonatal mortality by up to 50% in one year. The project focus includes the districts of Kibaale, Kyenjojo, Kabarole and Kamwenge. In Kibaale district. The lead implementing partner is the Infectious Diseases Institute.

The project attempts to alleviate three major impediments to improved maternal and neonatal outcomes: delay by mothers in seeking care; delay in accessing health facilities due to challenges such as transportation and preparation, and delay in receiving care at the health facility when mothers arrive for services.

So far, the project has provided support in these focus areas through the refurbishment of health facilities, recruitment of critical resources for health (including midwives, medical officers and other health workers), training and mentoring of health workers at the facilities and training of VHTs in maternal and neonatal health issues. The project also provides the community with information on maternal and child health through radio talk shows, and providing ambulances and tricycles at health facilities in order to support the referral system.

The battle for better maternal and child health in Uganda is far from being over but through efforts such as these lives are being saved.