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The traditional birth attendant: a reality and a challenge
International Journal of Gynecology & Obstetrics 63 Suppl. 1 Ž1998. S43᎐S52
The traditional birth attendant: a reality and a challenge I.T. KamalU Sindh Pro¨ incial Chapter, Maternity and Child Welfare Association of Pakistan, Pathfinder International, Karachi, Pakistan
Abstract The traditional birth attendant ŽTBA. is an institution as old as the birthing process in the human species. Generally a female, in the absence of a better alternative, continues to deliver two thirds of the world’s babies. A number of studies generated international interest in training TBAs. A review of TBA training and utilization programs in more than 70 countries over the past three decades revealed that there are very limited examples of their successful utilization. If unsupervised the TBA tends to slide back into her old ways and if unsupported she is rendered helpless when a killer strikes during child birth. The impact of trained TBAs on maternal mortality ratios is not palpable because of other factors such as accessibility of essential obstetric services. The challenge for the policy makers is to make the best use of this available human resource but simultaneously plan and implement a definite replacement strategy. 䊚 1998 International Federation of Gynecology and Obstetrics Keywords: Traditional birth attendant; Midwifery; Obstetrics; Mother and child health; Home delivery
1. Introduction As the name suggests the traditional birth attendant ŽTBA. is a person who is a product of tradition and is associated with reproduction. One could assume that the existence of TBAs dates back to the birthing process in the human species. The internationally accepted definition of a TBA is, ‘ . . . a person Žnormally a female., who assists mothers during childbirth and who initially learns her skills delivering babies by herself or by working with another, more experienced TBA’ w4x. Even today TBAs exist in all the developing coun-
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tries and deliver two thirds of the world’s babies w10x. This paper reviews the reasons for existence of TBAs, their basic and extended role, the development of current interest in them, and their training and utilization over the past four decades in more than 70 countries of the third world w2x. 2. Reasons for continued existence of TBAs
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The developing countries are struggling to provide basic health services to their population. Mother and Child Health ŽMCH. services are expanding and the number of MCH centers or health centers providing MCH services is increasing. While these facilities offer
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ante-natal and post-natal services, only a limited number provides assistance during childbirth. The city-bred andror city-educated health personnel prefer to work in the cities unless a certain period of rural service is obligatory e.g. in Egypt. In spite of the rural to urban internal migration, more than 60% of the population in most developing countries is rural, with very little access to maternity services. Nursing and midwifery do not enjoy much professional prestige in the third world. Therefore there is extreme shortage of these categories in most developing countries and particularly in the Muslim world e.g. the doctor᎐nurse ratio in Pakistan and Syria is 4:1 w5,11x. It should be the other way around. The number of nurses and midwives is not enough even to staff the curative services adequately at the secondary and tertiary level health institutions most of which are situated in cities. The gap in the social and economic status of the trained health personnel and the poor illiterate masses is quite intimidating. The TBA is a part of the community. She is socially and culturally acceptable and available when needed. She provides assistance to the mother over and above her midwifery role e.g. cooking, cleaning and washing etc. during the puerperium should the mother require it. At times even when trained health personnel are available the cultural, financial and some personal factors of the families and communities limit the utilization of modern health facilities. Limited or lack of means of communication and transportation are the two crippling factors for those who might overcome all the above factors and wish to utilize preventive care during the maternity cycle or to transfer the woman to a health facility when an obstetrical emergency arises. In some places the nearest source of health services is at a day’s walking distance or even farther than that e.g. Malawi w11x.
In the light of the above scenario it is not difficult to perceive why the majority of the moth-
ers have no choice but to depend upon the TBA for assistance during pregnancy, labor and child birth. It has been documented that in most developing countries TBAs deliver more than 80% of the rural and more than 60% of the urban babies w4x. Some governments have tried to ban them legally e.g. Syria, Egypt and Lebanon w4x. Medical and nursing professions have ridiculed them and sneered at them. The TBA could not be eliminated in spite of the laws which are unrealistic and the humiliating behavior of the health personnel which reflects tunnel vision. If the majority of mothers decided or when necessary could be persuaded to get a trained health professional for home delivery or to deliver their babies in a health facility, which developing country of the third world has enough health manpower or institutional facilities for every delivery to be handled by a trained person? Hence the TBA will continue to exist because she is meeting a vital need of the communities. This state of affairs is not likely to change in a decade or two. It will take much longer. According to a 1973 report of WHO’s Executive Board the quality and quantity of the world’s public health services was deteriorating instead of improving. The point of comparison being quite modest to begin with. The picture is even more dismal in most of the developing countries where no amount of health care reforms can keep pace with the rapidly growing population. 3. Historical background of the current interest in the TBA In the last four decades there has been a great deal of interest shown in this available category of health manpower. Many countries have realized that the TBAs will continue to exist for a few more decades to come and that even legal constraints on the practice of midwifery of the TBA have not succeeded in the extinction of this institution. Some lawsrdecrees which were passed could not be enforced because the need of the community was much stronger than the force of the law or that the lawrdecree was just not realistic because no better substitute was available to the community. Sometimes even when
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substitutes were made available, their teaching and practices were so alien to the community that the hold of the traditional practices and traditional health workers proved much stronger than what the ‘outsiders’ were trying to do. The efforts of the health orrand development workers were often negated by the TBA or the village healer. It took time for the health planners and the social scientists to realize that the mere provision of health services does not ensure their acceptance and usage by those for whom they are established. The gap between the familiar and the alien remains and bridges are needed sometimes to cross even a street to get to the health Center. Realizing that a TBA enjoys a special position and status in the community in which she practices, health planners have been exploring ways and means of mobilizing and utilizing this available human resource for the best possible advantage to the underprivileged and underserved communities, particularly in the context of Primary Health Care and towards the goal of HFAr2000. The primary approach of the countries committed to HFAr2000 is the provision of basic health services to its population in general and to its rural population in particular. The child bearing women, infants and children still remain the most vulnerable groups. Dependence of the rural population on traditional health care system is now recognized as a reality in most of the developing countries of the world. The traditional birth attendant still remains a strong element of the traditional health care system and will continue to remain so unless an acceptable, better trained, accessible and economically feasible substitute is provided to the communities, not only rural but urban as well. Most countries have faced the reality that the TBA is providing a much needed service to the community. The quality of this service, however, needs improvement. While some of the TBAs’ practices are positively useful or harmless, there are some which carry an element of risk of varying degrees contributing to the maternal andror infant morbidityrmortality. The damage done is definitely not deliberate. The TBA works with the best of intentions but with limited or erroneous
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understanding. This understanding can be increased and or corrected as needed with training. 4. Developments during the past four decades In 1972 WHO had conducted a review of the role of the TBA through a questionnaire and field visits, and by literature search. In 1982 a review through another literature search was carried out. In 1983, WHO’s Eastern Mediterranean Regional Office conducted a survey of the situation of training and utilization of TBAs in the 23 countries of the region w4x. In 1987, UNICEF also carried out a review of 77 selected countries w3x. In 1995᎐1996 UNFPA conducted a thematic evaluation of seven selected countries in Asia, Africa and Latin America where it was providing assistance to TBA training programs w11x. The comparison of the information revealed that there has been a great deal of expansion in the training and utilization of TBAs w3x. The number of countries training them had more than doubled and of those registering andror licensing them had nearly doubled. The countries tend to talk less about the TBAs as a stopgap arrangement e.g. only 13% of the countries in the Eastern Mediterranean Region of WHO had definite plans to gradually replace the TBA by a better trained category w4x. Though in a few countries e.g. Kuwait and Oman according to their response to a questionnaire and Jordan according to a review carried out by WHO in 1984, without any specific planning the TBAs are automatically decreasing in numbers gradually. This downward trend is due to a combination of availability of health care facilities, and positive attitudes of the families towards utilization of these facilities. The majority of the countries, however, are using innovative approaches for the improved utilization of the trained TBAs in an extended role in addition to their midwifery role. Some of the successful TBA training programs have demonstrated that the average TBA is keen to learn and though illiterate she is trainable. It has also demonstrated to some extent, to the policy makers, that, if well-planned and properly implemented, provision of basic minimum mater-
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I.T. Kamal r International Journal of Gynecology & Obstetrics 63 Suppl. 1 (1998) S43᎐S52
nal health facilities can be made accessible to the community without high costs.
tribes e.g. in the Northern areas of Pakistan, or among the nomads e.g. in Somalia and Syria.
5. The categories of traditional birth attendants
5.4. The trained TBA
In the past the untrained TBAs fell in three categories w3,4,8x. A fourth category emerged when programs started for training of TBAs. 5.1. Category I: the traditional birth attendant or the untrained ‘midwife’ She practices midwifery for a living. The term ‘untrained’, however, is a misnomer. She is trained but not in a formal way. The urban TBA falls in this category. She sometimes has set minimum rates per delivery depending on whether the mother delivers a boy or a girl. Sometimes she leaves the question of payment to the mother. Depending on the financial position of the parents, sex of the child and how ‘precious’ the newborn happens to be, the TBA gets some extras over and above her ‘fees’. 5.2. Category II: the rural traditional birth attendant She is often an elderly relative or a neighbor who is called upon to assist during child birth. She does not make a living out of midwifery and she does not deliver just anyone. The delivering mother has to be a relative, or the daughter or daughter-in-law of a neighbor, or of a close friend. She assists in childbirth as a ‘favor’ or as a ‘good deed’. She does not expect to be paid. She does, however, receive a gift as a token of appreciation. The rural areas might have both of the above categories depending on the size and the type of the village. Those known as ‘midwives’ can be called upon by anyone and expect to be paid, but in rural areas the payment can be in cash or kind or a bit of both. 5.3. Category III: the family birth attendant She delivers babies of her close relatives only. This category is found in most remote villages but is more common in traditional and conservative
This category has emerged over the past few decades when the existence of TBAs was accepted by the national policy makers and planners, by the United Nation’s health and development organizations and by the bilateral donor agencies. Financial and technical assistance was made available to the desirous countries to provide formal training to the practising TBAs to make child birth as safe as possible in the given circumstances in which the TBA practices. The trained TBA is now found both in the rural and the urban areas of almost all the developing countries w3,4,8,11x. The conditions of and compensation for their service delivery have not changed significantly. All those countries with functioning TBAs, now have a mixture of trained and untrained TBAs. The ratio of trained and untrained TBAs varies from situation to situation. The term traditional birth attendant ŽTBA. is now used widely for all the categories mentioned above to distinguish TBA from the educated and formally trained midwife with a diploma in midwifery from a recognized school. In the case of those TBAs who have received some formal training, generally the prefix ‘Trained’ is used. Each country however, has a local name for the TBA w3x. It is interesting to note that the local names given to the TBAs usually carry a connotation of caring or a close relationship. When translated the name might mean governess, grandmother, mother, wise women and companion etc. 6. Current overall picture of training of TBAs This section discusses information about the training of those TBAs only who are already practising midwifery and who are given training courses of short duration. 6.1. National patterns of TBA training programs and their place within the health infrastructure Patterns of training courses include occasional lectures e.g. UNRWA and Jordan, ad hoc train-
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ing, e.g. Zambia and Yemen, and regional training e.g. Sudan. Most countries which train TBAs have national or regional programs excepting those that are in the pre-testing stages and have pilot projects e.g. Egypt and Kampuchea w3x. The majority of the programs are a part of the MCH Departments of the Ministries of Health or sister departments like Public Health Directorates. In Bolivia PAHO is in charge of the UNFPA funded TBA Project w11x. Most TBA training programs are implemented as vertical programs.
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cost of travel and time away from home. It is not always so. Sometimes convenience of the trainers to be able to commute daily to the training site becomes a deciding factor. This somewhat defeats the purpose because TBAs in remote areas need to be trained on priority basis. Normally only the trainees are expected to commute daily. Occasionally residential facilities have to be arranged for them as daily commuting is not possible. They go home for the weekends depending on the length of training. 6.4. Duration of training
6.2. Criteria for and the process of identification and selection of TBAs for training Generally the TBAs are identified and recommended by the community. If stipends are involved, the sponsoring andror the organizing authorities may arrange to interview the recommended individuals to ensure that the potential trainees meet the selection criteria. Usually age, sex, marital status, years of practice in delivering mothers and the current workload are the basic consideration for selecting TBAs for training. Literacy may or may not be a requirement depending on the literacy rate in the country particularly among the females e.g. in the Philippines literacy is a requirement w9x. Maximum age requirement for practising TBAs is between 55 to 60 years. For training courses of longer duration i.e. a year long or more, previous experience in delivering mothers is not a requirement and the age requirement for entry is as low as 18 years e.g. Iran and Sudan w4,11x. Married female TBAs are preferred in most countries. There are male TBAs in a few countries e.g. the Philippines, Ghana and Nigeria w3,9x. 6.3. Training sites Various and multiple locations are used to train TBAs. These range between the home of a TBA e.g. in Syria, and teaching hospitals w3,4,9,11x. The commonest venues are the local health and MCH centers and sub centers. The location is supposed to be selected as close as possible to the places of residence of TBAs to cut down on the time and
Duration of training varies between 40 h spread over 10 days e.g. Egypt to 3 months e.g. Sudan w3,4x. In some courses daily sessions are conducted e.g. Pakistan, while in others two or three sessions a week are given and the course is spread over a longer period. The duration of courses is determined by the content to be covered, background of the trainers and availability of the visiting instructors. Sometimes convenience of the TBAs is also a deciding factor particularly if daily commuting is necessary and long distances are involved. It is documented however that the duration of training is not always proportionate to the needs of the trainees and to the objectives to be achieved. 6.5. Incenti¨ es for the TBAs during training Travel expenses, daily subsistence allowance or a fixed amount as a stipend, TBA delivery kits, and certificate of attendance are the most commonly used incentives for the trainees. Financial incentives have at times attracted unsuitable candidates. It has been experimented to offer training without financial incentives to the trainees and provide only kits and certificates. Results were quite encouraging. This demonstrated the TBAs’ motivation either for more learning or for improved status or a bit of both w11x. 6.6. Curricula All core curricula focus on care of the pregnant woman, safe delivery and care of the mother and
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the newborn during puerperium w3,4,9,11x. The emphasis is on dealing with the normal, recognizing the expected or actual deviations from the normal and seeking timely professional help. Some curricula include teaching᎐learning experiences which prepare the TBA for certain additional functions for an extended role. The options are left to the individual countries. With this in view, WHO’s guidelines for TBA training w6x include sessions on various additional topics e.g. health education for nutrition, vaccination, family planning and prevention of HIVrSTD, and oral rehydration therapy etc. It is left up to the trainers to make the selection depending upon the roles assigned to the TBAs by the planners. Very few countries have been able to standardize the TBA training curriculum. Since no ideal curricula have been developed so far, the planners use their judgment in each program. Some curricula are highly structured e.g. Malawi, others need modification e.g. Uganda and many others w11x. The reasons for this variety are the differences in the expected role of the TBA after training as well as unclear perception of these roles. Therefore some curricula are over crowded with unnecessary topics or detail. Inadequate preparation of the trainers also perpetuates some of the weaknesses in the curricula. The trainer who lacks confidence treats the curriculum as if it were written in blood. 6.7. The trainers The trainers might be full time or part time. By and large staff of the local health and MCH centers are used as trainers. This includes nurses, nurse midwives, health visitors and other paramedical staff. Occasionally doctors may participate in some sessions e.g. Bolivia w3,4,9,11x. Training of TBAs is a function added to the normal duties of the trainers. If monetary incentives are involved, this additional responsibility is taken seriously by the trainers, otherwise it does not receive due attention. Where mobile training teams are used e.g. in Syria, India, Pakistan there are full time trainers w3,4,11x. The trainers may or may not be trained train-
ers. Some countries or regions give 1-day orientation to the trainers and some give up to a 2 week long course in training methods. Inadequate preparation of trainers has emerged as a point of concern during most evaluations of TBA training programs. Moreover, TBA trainers generally get only a one time opportunity of learning how to teach. They are then left on their own to function as trainers. Monitoring of training activities is a rare practice even though experiments have shown very good results e.g. Sindh Dai Training Program in Pakistan. TBA trainers have a very unique and difficult responsibility. They are trying to teach illiterate adults without enough preparation in teaching adults. Their pupils most of the time are older than them. They are teaching midwifery skills to those pupils who have more experience in delivering babies than the trainers. Because of her own orientation the trainers emphasize ‘learning’, even though in certain areas ‘unlearning’ is more important. This needs to be identified and emphasized e.g. TBA’s harmful advice to the pregnant women regarding nutrition w1x.
6.8. Teaching methodologies
Lectures, illustrated lectures, lecture-demonstration, role play, actual and simulated practical experience in ante and post natal care and explanation of safe delivery technique are the methods used for training TBAs. Demonstration by the trainers of actually delivering a baby in the home or home-life situation is not always possible for some justifiable reasons. Demonstrations and return demonstrations on models are depended upon. Where possible, use is made of films on various aspects of the maternity cycle. In some courses record keeping and referrals are taught with the help of pictorial cards. In some situations the TBAs spend a specified period in a hospital’s maternity unit. With a few exceptions inadequate supervised practice in safe delivery is a gap in teaching as well as evaluating the actual amount of learning and unlearning as a result of training.
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6.9. E¨ aluation of the outcome of training By and large the evaluation consists of verbal assessment of the pieces of information gathered by TBAs during the training period. Where possible the TBA demonstrates the examination of a pregnant woman, hand washing technique, recording information on pictorial records of mothers and infants and health education to the mothers about nutrition, advantages of ante natal care and family planning etc. Presence of the trainer at the time of delivery for teaching safe delivery technique and for observation of learning outcome is very rare. This has, however been possible in those courses where trainers and transport were available 24 h and TBA could call upon the trainer to be present when a mother was ready to be delivered. This could be in a home or in a birthing station. Another method used by some examinersrtrainersrsupervisors, was to seek out mothers in the community who were delivered by the same TBA before and after training. The mother was asked to describe the differences in the TBA’s practice and behavior as a result of training. Though not the ideal method of evaluation, still it provides some very useful information not only about the effectiveness of training but also about the reaction of the mother and the family to the new or modified behavior of the TBA w11x. 6.10. Registration, certification and licensing of TBAs after training Some countries maintain registers of all practising TBAs, and some keep a record of only trained TBAs. The untrained TBA is either recognized by the government with or without an inventory or just accepted without any legal status e.g. Burma, Morocco. As mentioned earlier some countries have banned the TBA by law but the law could not be enforced so they are ignored and they continue to practice. The registration mechanism where it exists is quite varied. The registering bodies range from local governments to Ministry of Health w3x. In most cases a certificate of having completed the training, once awarded is the license to practice. No documented information
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was available as to the renewal of these licenses with the exception of Malaysia where renewal is obligatory. 7. Utilization of trained TBAs As mentioned earlier almost all the developing countries are training TBAs. A lot of effort is going into meeting the targets of trained TBAs. Yet very few countries have preplanned and organized systems to utilize the trained TBA effectively. This requires thorough planning for supporting the TBA in her work, active community participation, regular follow up and supervision. Not many countries have given a serious thought to the support needed by the TBAs to function effectively, on the top of the list being access to emergency obstetric care. 7.1. Expectations from a trained TBA Upon the completion of training, the TBA returns to her place of residence. She is left to function as an independent private practitioner yet is expected to meet the demands made on her time and make certain voluntary contributions, e.g. she is supposed to provide ante-natal care, screen the pregnant woman for high-risk conditions and refer them to a health center. She is to conduct deliveries as taught and seek immediate help when there is a suspected or actual complication. Whether this help is accessible is not given due consideration when she is taught with emphasis not to wait too long and refer the woman. Refer how, and refer where are issues which are not discussed in any detail during her training. She is expected to maintain and submit certain records and keep in regular contact with the nearest healthrMCH center. She is supposed to attend monthly meetings, to report on her activities and discuss her problems. She travels in her own time and with her own money and often receives a cold welcome from the health personnel at the health facility. Moreover her expected role is not restricted during the maternity cycle, she is assigned some additional tasks also. These extend her role beyond her original parameters.
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7.2. Extended role of the TBA after training Realizing her free access to most homes in the community where the TBA lives andror works, planners started assigning her roles in addition to her midwifery functions. These include health education for nutrition, family planning, prevention of STD HIVrAIDS, oral rehydration, encouraging breast feeding and immunization of pregnant women, infants and children. In some programs she distributes iron and folic acid supplements, packets of ORS and certain contraceptives. She is also expected to participate in immunization activities. While there are examples of trained TBAs functioning in some of these areas by and large it is felt that it is not justifiable to expect the average TBA to carry this load w3,11x. To fulfil her expected role in the maternity cycle and her extended role, there are hardly any vocational, human, psychological or financial incentives for her to meet the expectations of the planners. 7.3. Assumed roles of TBAs TBAs are well known for helping women to get rid of unwanted pregnancies. In addition they treat gynecological complaints, infertility and minor ailments of pregnancy. They provide traditional methods for spacing pregnancies. They perform female circumcision and provide sex guidance to the bride to be. In some cultures the TBA functions as a match maker also. She is present at rituals connected with pregnancy and child birth w4x. In some of the middle eastern countries she certifies virginity by rupturing the hymen of the bride and collecting the blood on a white piece of cloth. This blood stained cloth is then circulated in the community. 7.4. Incenti¨ es after training Incentives differ from country to country and sometimes within the country. Some incentives are promised to the TBA in her post training period. These include replenishment and or replacement of items in the TBA delivery kit, reimbursement of travel cost for attending monthly
meetings in the health facility, and technical support of the health personnel. These, however, seldom get implemented. Referral fees for motivating and referring client for tubal ligation are normally implemented, where such a system exits e.g. Bangladesh, India, and Pakistan. 8. Supervision of trained TBAs Every TBA training projectrprogram has a section on supervision but most supervisory mechanisms are not thought through to analyze the constraints of regular supervision. Trained manpower and available means of transport are the two most important requirements for TBAs’ supervision. Almost all the evaluation and study reports reviewed pointed out unanimously the problem of weak supervision. This results in the TBA slipping back into her old ways. This was substantiated by the examination of the UNICEF supplied delivery kits of the TBAs. The majority of the kits had either been used very little or not used at all w11x. 9. Impact of TBA training 9.1. On the TBA Immediate post training evaluations have always been encouraging. The retention levels of newly learned knowledge and skills are fairly high but these tend to decrease without continuous reinforcement in the form of regular and supportive supervision and periodic refresher courses. 9.2. On maternal mortality ratio (MMR) It is almost impossible to make a categorical statement about the impact of TBA training on MMR. There are however, indicators which point to the fact that training of TBAs produces positive results. Tetanus neonatorum is falling, more mothers are brought to the health facilities before it is too late etc. It must be acknowledged that it is not the impact of training only. Where TBA training has shown positive results in project areas e.g. Brazil, Philippines w7x, Bangladesh, these
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were due to a combination of factors i.e. TBA training, follow up and supportive supervision and accessibility of means of communication and transport.
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being conducted by a trainee TBA. Follow up of the TBAs after training to maintain regular contact with them, and periodic refresher training is necessary if learning is to be sustained and unlearning made permanent.
10. Some of the myths surrounding TBA training 10.1. ‘TBA are illiterate therefore it is difficult to make them understand scientific facts’ TBAs might be illiterate but they are not incapable of learning. Experiences from all over the developing world have proved that they are trainable. The problem by and large lies with planning and conducting of training. If the curricula are tailored to the needs of the TBAs, if training is conducted at the level of TBAs’ understanding and if teaching learning experiences are planned carefully, the TBAs learn, perhaps somewhat slowly, but they learn. These four ‘ifs’ are the challenge of the curriculum designers and of the trainers. 10.2. ‘TBA training is easy. Any health professional can train TBAs’ This erroneous belief is based on extremely limited knowledge of the multifarious factors involved in proper TBA training. It is a specialized activity for which trainers have to be specially prepared. The trainers who have been dependent upon the written word for teaching learning activities have to learn approaches to help the illiterate learner to acquire new knowledge and develop new skills. Not only learning but a lot of ‘unlearning’ of misinformation and harmful and undesirable practices of TBAs has to be ensured. The learner in most cases is much older than the trainer and has a lot more experience in delivering babies than the trainers. Special sensitivities are needed to develop desirable rapport. Specific training materials and methods are needed to train illiterate adult learners. To ensure that learning has taken place, supervised practice in safe delivery is needed of the skills taught. If the training is to be done properly the trainer and the transport have to be available 24 h. Only then the trainer can observe a delivery
10.3. ‘Maternal mortality can be reduced by training TBAs’ Training of TBAs is only one of the interventions necessary to make child birth safe. Unless it is combined with other essential elements of safe motherhood, MMR cannot be brought down. These elements are, regular supervision of and back up support to trained TBAs around the clock. Unless emergency obstetric care is available to the community the TBA is helpless when a killer strikes. No country has been able to reduce its MMR by TBA training alone. The supervision of and support to the trained TBA combined with training completes the triangle of ingredients required to make an impact on MMR. 10.4. Use of contraception by the couple goes against the interest of the TBAs, therefore they will not participate in family planning programs Many countries e.g. seven in the Middle East and North Africa region of IPPF have used the TBAs to provide family planning information to women and refer them to the source of service. Some countries have used them for providing condoms and re-supply of oral contraceptives. In a country like Pakistan, Pathfinder International funded two projects in two totally different areas using TBAs. Both were very successful ŽProject Reports.. 11. The challenge Grudgingly, the health policy makers, planners and implementers in the third world have accepted or should accept the existence of TBA as a reality which cannot be obliterated for some time to come. All those having a moral, human, religious, political, official, professional, personal interest in lowering maternal mortality are faced with the following challenge.
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Improve the TBA curricula and preparation of the trainers to teach the TBA effectively. The objective should be that the learning be sustained and the unlearning made permanent. Supervise the TBA to ensure continuity and reinforcement of learning. Ensure accessibility of emergency obstetric care. Get the community to realize that the TBA has been trained to serve them better. Therefore she should be compensated through reasonable fees for her service. She must be supported in her decision to transfer the woman in danger to a facility equipped to deal with that life threatening condition. The biggest challenge of all is to simultaneous include in the national health plans a replacement strategy. This should aim at providing the communities with a better trained alternative which is acceptable, accessible and affordable. When such an alternative becomes widely available and proves its worth the communities will gradually develop a taste for safety and quality. This will automatically eliminate the TBA as has already started to happen in countries which have met the challenge.
References w1x Edouard L, Foo-Gregory CLH. Traditional birth practices: an annotated bibliography. Geneva: WHO, 1985. w2x Feuerstein MTT. Turning the tide: safe motherhood. UK: Save the Children, 1993. w3x Hong S. Review of training programs for traditional birth attendants. UNICEF, 1987 Žmimeo.. w4x Kamal IT. A survey of the training and utilisation of the traditional birth attendant in the eastern mediterranean region of WHO. Geneva: World Health Organization, 1984. w5x Kamal IT. The traditional birth attendant. Geneva: World Health Organization, September᎐October 1992. w6x Kamal IT, Kumar V, Mahra L, Cabral M. Training of traditional birth attendants. Geneva: World Health Organization, 1992. w7x Leedam E. Traditional birth attendant. Int J Gynaecol Obstet 1985;23:291᎐303. w8x Mangay Maglacas A, Simons J, editors. The potential of the traditional birth attendant. Geneva: World Health Organization, 1986. w9x Mangay Maglacas A, Pizurki H, editors. Traditional birth attendants in seven countries: case studies in training and utilisation. Geneva: WHO, 1981. w10x Traditional birth attendant. A joint WHOrUNFPAr UNICEF Statement. Geneva: World Health Organization, 1992. w11x UNFPA. Traditional birth attendants Ž7 country. evaluation report. UNFPA, 1995᎐1996.
The traditional birth attendant: a reality and a challenge I.T. KamalU Sindh Pro¨ incial Chapter, Maternity and Child Welfare Association of Pakistan, Pathfinder International, Karachi, Pakistan
Abstract The traditional birth attendant ŽTBA. is an institution as old as the birthing process in the human species. Generally a female, in the absence of a better alternative, continues to deliver two thirds of the world’s babies. A number of studies generated international interest in training TBAs. A review of TBA training and utilization programs in more than 70 countries over the past three decades revealed that there are very limited examples of their successful utilization. If unsupervised the TBA tends to slide back into her old ways and if unsupported she is rendered helpless when a killer strikes during child birth. The impact of trained TBAs on maternal mortality ratios is not palpable because of other factors such as accessibility of essential obstetric services. The challenge for the policy makers is to make the best use of this available human resource but simultaneously plan and implement a definite replacement strategy. 䊚 1998 International Federation of Gynecology and Obstetrics Keywords: Traditional birth attendant; Midwifery; Obstetrics; Mother and child health; Home delivery
1. Introduction As the name suggests the traditional birth attendant ŽTBA. is a person who is a product of tradition and is associated with reproduction. One could assume that the existence of TBAs dates back to the birthing process in the human species. The internationally accepted definition of a TBA is, ‘ . . . a person Žnormally a female., who assists mothers during childbirth and who initially learns her skills delivering babies by herself or by working with another, more experienced TBA’ w4x. Even today TBAs exist in all the developing coun-
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tries and deliver two thirds of the world’s babies w10x. This paper reviews the reasons for existence of TBAs, their basic and extended role, the development of current interest in them, and their training and utilization over the past four decades in more than 70 countries of the third world w2x. 2. Reasons for continued existence of TBAs
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The developing countries are struggling to provide basic health services to their population. Mother and Child Health ŽMCH. services are expanding and the number of MCH centers or health centers providing MCH services is increasing. While these facilities offer
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ante-natal and post-natal services, only a limited number provides assistance during childbirth. The city-bred andror city-educated health personnel prefer to work in the cities unless a certain period of rural service is obligatory e.g. in Egypt. In spite of the rural to urban internal migration, more than 60% of the population in most developing countries is rural, with very little access to maternity services. Nursing and midwifery do not enjoy much professional prestige in the third world. Therefore there is extreme shortage of these categories in most developing countries and particularly in the Muslim world e.g. the doctor᎐nurse ratio in Pakistan and Syria is 4:1 w5,11x. It should be the other way around. The number of nurses and midwives is not enough even to staff the curative services adequately at the secondary and tertiary level health institutions most of which are situated in cities. The gap in the social and economic status of the trained health personnel and the poor illiterate masses is quite intimidating. The TBA is a part of the community. She is socially and culturally acceptable and available when needed. She provides assistance to the mother over and above her midwifery role e.g. cooking, cleaning and washing etc. during the puerperium should the mother require it. At times even when trained health personnel are available the cultural, financial and some personal factors of the families and communities limit the utilization of modern health facilities. Limited or lack of means of communication and transportation are the two crippling factors for those who might overcome all the above factors and wish to utilize preventive care during the maternity cycle or to transfer the woman to a health facility when an obstetrical emergency arises. In some places the nearest source of health services is at a day’s walking distance or even farther than that e.g. Malawi w11x.
In the light of the above scenario it is not difficult to perceive why the majority of the moth-
ers have no choice but to depend upon the TBA for assistance during pregnancy, labor and child birth. It has been documented that in most developing countries TBAs deliver more than 80% of the rural and more than 60% of the urban babies w4x. Some governments have tried to ban them legally e.g. Syria, Egypt and Lebanon w4x. Medical and nursing professions have ridiculed them and sneered at them. The TBA could not be eliminated in spite of the laws which are unrealistic and the humiliating behavior of the health personnel which reflects tunnel vision. If the majority of mothers decided or when necessary could be persuaded to get a trained health professional for home delivery or to deliver their babies in a health facility, which developing country of the third world has enough health manpower or institutional facilities for every delivery to be handled by a trained person? Hence the TBA will continue to exist because she is meeting a vital need of the communities. This state of affairs is not likely to change in a decade or two. It will take much longer. According to a 1973 report of WHO’s Executive Board the quality and quantity of the world’s public health services was deteriorating instead of improving. The point of comparison being quite modest to begin with. The picture is even more dismal in most of the developing countries where no amount of health care reforms can keep pace with the rapidly growing population. 3. Historical background of the current interest in the TBA In the last four decades there has been a great deal of interest shown in this available category of health manpower. Many countries have realized that the TBAs will continue to exist for a few more decades to come and that even legal constraints on the practice of midwifery of the TBA have not succeeded in the extinction of this institution. Some lawsrdecrees which were passed could not be enforced because the need of the community was much stronger than the force of the law or that the lawrdecree was just not realistic because no better substitute was available to the community. Sometimes even when
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substitutes were made available, their teaching and practices were so alien to the community that the hold of the traditional practices and traditional health workers proved much stronger than what the ‘outsiders’ were trying to do. The efforts of the health orrand development workers were often negated by the TBA or the village healer. It took time for the health planners and the social scientists to realize that the mere provision of health services does not ensure their acceptance and usage by those for whom they are established. The gap between the familiar and the alien remains and bridges are needed sometimes to cross even a street to get to the health Center. Realizing that a TBA enjoys a special position and status in the community in which she practices, health planners have been exploring ways and means of mobilizing and utilizing this available human resource for the best possible advantage to the underprivileged and underserved communities, particularly in the context of Primary Health Care and towards the goal of HFAr2000. The primary approach of the countries committed to HFAr2000 is the provision of basic health services to its population in general and to its rural population in particular. The child bearing women, infants and children still remain the most vulnerable groups. Dependence of the rural population on traditional health care system is now recognized as a reality in most of the developing countries of the world. The traditional birth attendant still remains a strong element of the traditional health care system and will continue to remain so unless an acceptable, better trained, accessible and economically feasible substitute is provided to the communities, not only rural but urban as well. Most countries have faced the reality that the TBA is providing a much needed service to the community. The quality of this service, however, needs improvement. While some of the TBAs’ practices are positively useful or harmless, there are some which carry an element of risk of varying degrees contributing to the maternal andror infant morbidityrmortality. The damage done is definitely not deliberate. The TBA works with the best of intentions but with limited or erroneous
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understanding. This understanding can be increased and or corrected as needed with training. 4. Developments during the past four decades In 1972 WHO had conducted a review of the role of the TBA through a questionnaire and field visits, and by literature search. In 1982 a review through another literature search was carried out. In 1983, WHO’s Eastern Mediterranean Regional Office conducted a survey of the situation of training and utilization of TBAs in the 23 countries of the region w4x. In 1987, UNICEF also carried out a review of 77 selected countries w3x. In 1995᎐1996 UNFPA conducted a thematic evaluation of seven selected countries in Asia, Africa and Latin America where it was providing assistance to TBA training programs w11x. The comparison of the information revealed that there has been a great deal of expansion in the training and utilization of TBAs w3x. The number of countries training them had more than doubled and of those registering andror licensing them had nearly doubled. The countries tend to talk less about the TBAs as a stopgap arrangement e.g. only 13% of the countries in the Eastern Mediterranean Region of WHO had definite plans to gradually replace the TBA by a better trained category w4x. Though in a few countries e.g. Kuwait and Oman according to their response to a questionnaire and Jordan according to a review carried out by WHO in 1984, without any specific planning the TBAs are automatically decreasing in numbers gradually. This downward trend is due to a combination of availability of health care facilities, and positive attitudes of the families towards utilization of these facilities. The majority of the countries, however, are using innovative approaches for the improved utilization of the trained TBAs in an extended role in addition to their midwifery role. Some of the successful TBA training programs have demonstrated that the average TBA is keen to learn and though illiterate she is trainable. It has also demonstrated to some extent, to the policy makers, that, if well-planned and properly implemented, provision of basic minimum mater-
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nal health facilities can be made accessible to the community without high costs.
tribes e.g. in the Northern areas of Pakistan, or among the nomads e.g. in Somalia and Syria.
5. The categories of traditional birth attendants
5.4. The trained TBA
In the past the untrained TBAs fell in three categories w3,4,8x. A fourth category emerged when programs started for training of TBAs. 5.1. Category I: the traditional birth attendant or the untrained ‘midwife’ She practices midwifery for a living. The term ‘untrained’, however, is a misnomer. She is trained but not in a formal way. The urban TBA falls in this category. She sometimes has set minimum rates per delivery depending on whether the mother delivers a boy or a girl. Sometimes she leaves the question of payment to the mother. Depending on the financial position of the parents, sex of the child and how ‘precious’ the newborn happens to be, the TBA gets some extras over and above her ‘fees’. 5.2. Category II: the rural traditional birth attendant She is often an elderly relative or a neighbor who is called upon to assist during child birth. She does not make a living out of midwifery and she does not deliver just anyone. The delivering mother has to be a relative, or the daughter or daughter-in-law of a neighbor, or of a close friend. She assists in childbirth as a ‘favor’ or as a ‘good deed’. She does not expect to be paid. She does, however, receive a gift as a token of appreciation. The rural areas might have both of the above categories depending on the size and the type of the village. Those known as ‘midwives’ can be called upon by anyone and expect to be paid, but in rural areas the payment can be in cash or kind or a bit of both. 5.3. Category III: the family birth attendant She delivers babies of her close relatives only. This category is found in most remote villages but is more common in traditional and conservative
This category has emerged over the past few decades when the existence of TBAs was accepted by the national policy makers and planners, by the United Nation’s health and development organizations and by the bilateral donor agencies. Financial and technical assistance was made available to the desirous countries to provide formal training to the practising TBAs to make child birth as safe as possible in the given circumstances in which the TBA practices. The trained TBA is now found both in the rural and the urban areas of almost all the developing countries w3,4,8,11x. The conditions of and compensation for their service delivery have not changed significantly. All those countries with functioning TBAs, now have a mixture of trained and untrained TBAs. The ratio of trained and untrained TBAs varies from situation to situation. The term traditional birth attendant ŽTBA. is now used widely for all the categories mentioned above to distinguish TBA from the educated and formally trained midwife with a diploma in midwifery from a recognized school. In the case of those TBAs who have received some formal training, generally the prefix ‘Trained’ is used. Each country however, has a local name for the TBA w3x. It is interesting to note that the local names given to the TBAs usually carry a connotation of caring or a close relationship. When translated the name might mean governess, grandmother, mother, wise women and companion etc. 6. Current overall picture of training of TBAs This section discusses information about the training of those TBAs only who are already practising midwifery and who are given training courses of short duration. 6.1. National patterns of TBA training programs and their place within the health infrastructure Patterns of training courses include occasional lectures e.g. UNRWA and Jordan, ad hoc train-
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ing, e.g. Zambia and Yemen, and regional training e.g. Sudan. Most countries which train TBAs have national or regional programs excepting those that are in the pre-testing stages and have pilot projects e.g. Egypt and Kampuchea w3x. The majority of the programs are a part of the MCH Departments of the Ministries of Health or sister departments like Public Health Directorates. In Bolivia PAHO is in charge of the UNFPA funded TBA Project w11x. Most TBA training programs are implemented as vertical programs.
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cost of travel and time away from home. It is not always so. Sometimes convenience of the trainers to be able to commute daily to the training site becomes a deciding factor. This somewhat defeats the purpose because TBAs in remote areas need to be trained on priority basis. Normally only the trainees are expected to commute daily. Occasionally residential facilities have to be arranged for them as daily commuting is not possible. They go home for the weekends depending on the length of training. 6.4. Duration of training
6.2. Criteria for and the process of identification and selection of TBAs for training Generally the TBAs are identified and recommended by the community. If stipends are involved, the sponsoring andror the organizing authorities may arrange to interview the recommended individuals to ensure that the potential trainees meet the selection criteria. Usually age, sex, marital status, years of practice in delivering mothers and the current workload are the basic consideration for selecting TBAs for training. Literacy may or may not be a requirement depending on the literacy rate in the country particularly among the females e.g. in the Philippines literacy is a requirement w9x. Maximum age requirement for practising TBAs is between 55 to 60 years. For training courses of longer duration i.e. a year long or more, previous experience in delivering mothers is not a requirement and the age requirement for entry is as low as 18 years e.g. Iran and Sudan w4,11x. Married female TBAs are preferred in most countries. There are male TBAs in a few countries e.g. the Philippines, Ghana and Nigeria w3,9x. 6.3. Training sites Various and multiple locations are used to train TBAs. These range between the home of a TBA e.g. in Syria, and teaching hospitals w3,4,9,11x. The commonest venues are the local health and MCH centers and sub centers. The location is supposed to be selected as close as possible to the places of residence of TBAs to cut down on the time and
Duration of training varies between 40 h spread over 10 days e.g. Egypt to 3 months e.g. Sudan w3,4x. In some courses daily sessions are conducted e.g. Pakistan, while in others two or three sessions a week are given and the course is spread over a longer period. The duration of courses is determined by the content to be covered, background of the trainers and availability of the visiting instructors. Sometimes convenience of the TBAs is also a deciding factor particularly if daily commuting is necessary and long distances are involved. It is documented however that the duration of training is not always proportionate to the needs of the trainees and to the objectives to be achieved. 6.5. Incenti¨ es for the TBAs during training Travel expenses, daily subsistence allowance or a fixed amount as a stipend, TBA delivery kits, and certificate of attendance are the most commonly used incentives for the trainees. Financial incentives have at times attracted unsuitable candidates. It has been experimented to offer training without financial incentives to the trainees and provide only kits and certificates. Results were quite encouraging. This demonstrated the TBAs’ motivation either for more learning or for improved status or a bit of both w11x. 6.6. Curricula All core curricula focus on care of the pregnant woman, safe delivery and care of the mother and
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the newborn during puerperium w3,4,9,11x. The emphasis is on dealing with the normal, recognizing the expected or actual deviations from the normal and seeking timely professional help. Some curricula include teaching᎐learning experiences which prepare the TBA for certain additional functions for an extended role. The options are left to the individual countries. With this in view, WHO’s guidelines for TBA training w6x include sessions on various additional topics e.g. health education for nutrition, vaccination, family planning and prevention of HIVrSTD, and oral rehydration therapy etc. It is left up to the trainers to make the selection depending upon the roles assigned to the TBAs by the planners. Very few countries have been able to standardize the TBA training curriculum. Since no ideal curricula have been developed so far, the planners use their judgment in each program. Some curricula are highly structured e.g. Malawi, others need modification e.g. Uganda and many others w11x. The reasons for this variety are the differences in the expected role of the TBA after training as well as unclear perception of these roles. Therefore some curricula are over crowded with unnecessary topics or detail. Inadequate preparation of the trainers also perpetuates some of the weaknesses in the curricula. The trainer who lacks confidence treats the curriculum as if it were written in blood. 6.7. The trainers The trainers might be full time or part time. By and large staff of the local health and MCH centers are used as trainers. This includes nurses, nurse midwives, health visitors and other paramedical staff. Occasionally doctors may participate in some sessions e.g. Bolivia w3,4,9,11x. Training of TBAs is a function added to the normal duties of the trainers. If monetary incentives are involved, this additional responsibility is taken seriously by the trainers, otherwise it does not receive due attention. Where mobile training teams are used e.g. in Syria, India, Pakistan there are full time trainers w3,4,11x. The trainers may or may not be trained train-
ers. Some countries or regions give 1-day orientation to the trainers and some give up to a 2 week long course in training methods. Inadequate preparation of trainers has emerged as a point of concern during most evaluations of TBA training programs. Moreover, TBA trainers generally get only a one time opportunity of learning how to teach. They are then left on their own to function as trainers. Monitoring of training activities is a rare practice even though experiments have shown very good results e.g. Sindh Dai Training Program in Pakistan. TBA trainers have a very unique and difficult responsibility. They are trying to teach illiterate adults without enough preparation in teaching adults. Their pupils most of the time are older than them. They are teaching midwifery skills to those pupils who have more experience in delivering babies than the trainers. Because of her own orientation the trainers emphasize ‘learning’, even though in certain areas ‘unlearning’ is more important. This needs to be identified and emphasized e.g. TBA’s harmful advice to the pregnant women regarding nutrition w1x.
6.8. Teaching methodologies
Lectures, illustrated lectures, lecture-demonstration, role play, actual and simulated practical experience in ante and post natal care and explanation of safe delivery technique are the methods used for training TBAs. Demonstration by the trainers of actually delivering a baby in the home or home-life situation is not always possible for some justifiable reasons. Demonstrations and return demonstrations on models are depended upon. Where possible, use is made of films on various aspects of the maternity cycle. In some courses record keeping and referrals are taught with the help of pictorial cards. In some situations the TBAs spend a specified period in a hospital’s maternity unit. With a few exceptions inadequate supervised practice in safe delivery is a gap in teaching as well as evaluating the actual amount of learning and unlearning as a result of training.
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6.9. E¨ aluation of the outcome of training By and large the evaluation consists of verbal assessment of the pieces of information gathered by TBAs during the training period. Where possible the TBA demonstrates the examination of a pregnant woman, hand washing technique, recording information on pictorial records of mothers and infants and health education to the mothers about nutrition, advantages of ante natal care and family planning etc. Presence of the trainer at the time of delivery for teaching safe delivery technique and for observation of learning outcome is very rare. This has, however been possible in those courses where trainers and transport were available 24 h and TBA could call upon the trainer to be present when a mother was ready to be delivered. This could be in a home or in a birthing station. Another method used by some examinersrtrainersrsupervisors, was to seek out mothers in the community who were delivered by the same TBA before and after training. The mother was asked to describe the differences in the TBA’s practice and behavior as a result of training. Though not the ideal method of evaluation, still it provides some very useful information not only about the effectiveness of training but also about the reaction of the mother and the family to the new or modified behavior of the TBA w11x. 6.10. Registration, certification and licensing of TBAs after training Some countries maintain registers of all practising TBAs, and some keep a record of only trained TBAs. The untrained TBA is either recognized by the government with or without an inventory or just accepted without any legal status e.g. Burma, Morocco. As mentioned earlier some countries have banned the TBA by law but the law could not be enforced so they are ignored and they continue to practice. The registration mechanism where it exists is quite varied. The registering bodies range from local governments to Ministry of Health w3x. In most cases a certificate of having completed the training, once awarded is the license to practice. No documented information
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was available as to the renewal of these licenses with the exception of Malaysia where renewal is obligatory. 7. Utilization of trained TBAs As mentioned earlier almost all the developing countries are training TBAs. A lot of effort is going into meeting the targets of trained TBAs. Yet very few countries have preplanned and organized systems to utilize the trained TBA effectively. This requires thorough planning for supporting the TBA in her work, active community participation, regular follow up and supervision. Not many countries have given a serious thought to the support needed by the TBAs to function effectively, on the top of the list being access to emergency obstetric care. 7.1. Expectations from a trained TBA Upon the completion of training, the TBA returns to her place of residence. She is left to function as an independent private practitioner yet is expected to meet the demands made on her time and make certain voluntary contributions, e.g. she is supposed to provide ante-natal care, screen the pregnant woman for high-risk conditions and refer them to a health center. She is to conduct deliveries as taught and seek immediate help when there is a suspected or actual complication. Whether this help is accessible is not given due consideration when she is taught with emphasis not to wait too long and refer the woman. Refer how, and refer where are issues which are not discussed in any detail during her training. She is expected to maintain and submit certain records and keep in regular contact with the nearest healthrMCH center. She is supposed to attend monthly meetings, to report on her activities and discuss her problems. She travels in her own time and with her own money and often receives a cold welcome from the health personnel at the health facility. Moreover her expected role is not restricted during the maternity cycle, she is assigned some additional tasks also. These extend her role beyond her original parameters.
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7.2. Extended role of the TBA after training Realizing her free access to most homes in the community where the TBA lives andror works, planners started assigning her roles in addition to her midwifery functions. These include health education for nutrition, family planning, prevention of STD HIVrAIDS, oral rehydration, encouraging breast feeding and immunization of pregnant women, infants and children. In some programs she distributes iron and folic acid supplements, packets of ORS and certain contraceptives. She is also expected to participate in immunization activities. While there are examples of trained TBAs functioning in some of these areas by and large it is felt that it is not justifiable to expect the average TBA to carry this load w3,11x. To fulfil her expected role in the maternity cycle and her extended role, there are hardly any vocational, human, psychological or financial incentives for her to meet the expectations of the planners. 7.3. Assumed roles of TBAs TBAs are well known for helping women to get rid of unwanted pregnancies. In addition they treat gynecological complaints, infertility and minor ailments of pregnancy. They provide traditional methods for spacing pregnancies. They perform female circumcision and provide sex guidance to the bride to be. In some cultures the TBA functions as a match maker also. She is present at rituals connected with pregnancy and child birth w4x. In some of the middle eastern countries she certifies virginity by rupturing the hymen of the bride and collecting the blood on a white piece of cloth. This blood stained cloth is then circulated in the community. 7.4. Incenti¨ es after training Incentives differ from country to country and sometimes within the country. Some incentives are promised to the TBA in her post training period. These include replenishment and or replacement of items in the TBA delivery kit, reimbursement of travel cost for attending monthly
meetings in the health facility, and technical support of the health personnel. These, however, seldom get implemented. Referral fees for motivating and referring client for tubal ligation are normally implemented, where such a system exits e.g. Bangladesh, India, and Pakistan. 8. Supervision of trained TBAs Every TBA training projectrprogram has a section on supervision but most supervisory mechanisms are not thought through to analyze the constraints of regular supervision. Trained manpower and available means of transport are the two most important requirements for TBAs’ supervision. Almost all the evaluation and study reports reviewed pointed out unanimously the problem of weak supervision. This results in the TBA slipping back into her old ways. This was substantiated by the examination of the UNICEF supplied delivery kits of the TBAs. The majority of the kits had either been used very little or not used at all w11x. 9. Impact of TBA training 9.1. On the TBA Immediate post training evaluations have always been encouraging. The retention levels of newly learned knowledge and skills are fairly high but these tend to decrease without continuous reinforcement in the form of regular and supportive supervision and periodic refresher courses. 9.2. On maternal mortality ratio (MMR) It is almost impossible to make a categorical statement about the impact of TBA training on MMR. There are however, indicators which point to the fact that training of TBAs produces positive results. Tetanus neonatorum is falling, more mothers are brought to the health facilities before it is too late etc. It must be acknowledged that it is not the impact of training only. Where TBA training has shown positive results in project areas e.g. Brazil, Philippines w7x, Bangladesh, these
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were due to a combination of factors i.e. TBA training, follow up and supportive supervision and accessibility of means of communication and transport.
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being conducted by a trainee TBA. Follow up of the TBAs after training to maintain regular contact with them, and periodic refresher training is necessary if learning is to be sustained and unlearning made permanent.
10. Some of the myths surrounding TBA training 10.1. ‘TBA are illiterate therefore it is difficult to make them understand scientific facts’ TBAs might be illiterate but they are not incapable of learning. Experiences from all over the developing world have proved that they are trainable. The problem by and large lies with planning and conducting of training. If the curricula are tailored to the needs of the TBAs, if training is conducted at the level of TBAs’ understanding and if teaching learning experiences are planned carefully, the TBAs learn, perhaps somewhat slowly, but they learn. These four ‘ifs’ are the challenge of the curriculum designers and of the trainers. 10.2. ‘TBA training is easy. Any health professional can train TBAs’ This erroneous belief is based on extremely limited knowledge of the multifarious factors involved in proper TBA training. It is a specialized activity for which trainers have to be specially prepared. The trainers who have been dependent upon the written word for teaching learning activities have to learn approaches to help the illiterate learner to acquire new knowledge and develop new skills. Not only learning but a lot of ‘unlearning’ of misinformation and harmful and undesirable practices of TBAs has to be ensured. The learner in most cases is much older than the trainer and has a lot more experience in delivering babies than the trainers. Special sensitivities are needed to develop desirable rapport. Specific training materials and methods are needed to train illiterate adult learners. To ensure that learning has taken place, supervised practice in safe delivery is needed of the skills taught. If the training is to be done properly the trainer and the transport have to be available 24 h. Only then the trainer can observe a delivery
10.3. ‘Maternal mortality can be reduced by training TBAs’ Training of TBAs is only one of the interventions necessary to make child birth safe. Unless it is combined with other essential elements of safe motherhood, MMR cannot be brought down. These elements are, regular supervision of and back up support to trained TBAs around the clock. Unless emergency obstetric care is available to the community the TBA is helpless when a killer strikes. No country has been able to reduce its MMR by TBA training alone. The supervision of and support to the trained TBA combined with training completes the triangle of ingredients required to make an impact on MMR. 10.4. Use of contraception by the couple goes against the interest of the TBAs, therefore they will not participate in family planning programs Many countries e.g. seven in the Middle East and North Africa region of IPPF have used the TBAs to provide family planning information to women and refer them to the source of service. Some countries have used them for providing condoms and re-supply of oral contraceptives. In a country like Pakistan, Pathfinder International funded two projects in two totally different areas using TBAs. Both were very successful ŽProject Reports.. 11. The challenge Grudgingly, the health policy makers, planners and implementers in the third world have accepted or should accept the existence of TBA as a reality which cannot be obliterated for some time to come. All those having a moral, human, religious, political, official, professional, personal interest in lowering maternal mortality are faced with the following challenge.
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I.T. Kamal r International Journal of Gynecology & Obstetrics 63 Suppl. 1 (1998) S43᎐S52
Improve the TBA curricula and preparation of the trainers to teach the TBA effectively. The objective should be that the learning be sustained and the unlearning made permanent. Supervise the TBA to ensure continuity and reinforcement of learning. Ensure accessibility of emergency obstetric care. Get the community to realize that the TBA has been trained to serve them better. Therefore she should be compensated through reasonable fees for her service. She must be supported in her decision to transfer the woman in danger to a facility equipped to deal with that life threatening condition. The biggest challenge of all is to simultaneous include in the national health plans a replacement strategy. This should aim at providing the communities with a better trained alternative which is acceptable, accessible and affordable. When such an alternative becomes widely available and proves its worth the communities will gradually develop a taste for safety and quality. This will automatically eliminate the TBA as has already started to happen in countries which have met the challenge.
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