The role and effectiveness of traditional birth attendants in Somalia

\ PERGAMON

EVALUATION and PROGRAM PLANNING Evaluation and Programming Planning 10 "0887# 242Ð250

The role and e}ectiveness of traditional birth attendants in Somalia Noreen Prendiville UNICEF Somalia\ PO Box 33034\ Nairobi\ Kenya

Abstract In Somalia\ many organisations have supported Traditional Birth Attendant "TBA# training as a strategy to reduce maternal mortality and morbidity[ An evaluation was undertaken to assess the e}ectiveness of this intervention and its potential as a component of a national strategy for safe motherhood in Somalia[ The study examined the TBA|s actual in~uence in improving a woman|s chances of surviving life!threatening complications of pregnancy and delivery[ The results of the study showed that despite a high standard in TBA training\ when dealing with complications such as prolonged labour\ haemorrhage or infection\ families prefer traditional practices[ Families are unlikely to value the opinion of the TBA in making a decision to refer a woman for emergency obstetric care[ The report concludes that TBA programmes which exist in isolation of other interventions are unlikely to have any signi_cant e}ect on maternal mortality although clean deliveries and ante!natal care pectised by trained TBAs may reduce maternal morbidity and perinatal mortality and morbidity[ Þ 0887 Elsevier Science Ltd[ All rights reserved[

0[ Introduction

1[ Background

While Somalia remains without a central government\ responsibility for the provision of health services lies with the private sector and with local and international organ! isations[ The Health and Nutrition Co!ordination Com! mittee has been formed by organisations operating in Somalia to improve co!ordination of their activities and policies[ Many member organisations have been involved in the training of traditional birth attendants as a means of reducing the maternal mortality rate in Somalia[ The time and resources invested in this activity\ the absence of an evaluation by any organisation in recent years and the availability of new research reports from other coun! tries prompted debate on the usefulness of this inter! vention[ In 0886\ it was proposed that a full review be undertaken[ UNICEF Somalia\ a member of the com! mittee and an active supporter of TBA training in the past\ volunteered to undertake the evaluation with fund! ing provided by USAID[ The aims and objectives of the evaluation were to de_ne the current role of TBAs in Somalia\ to review and evaluate the training of TBAs in recent years\ to evaluate the role of TBAs in supporting Safe Motherhood Initiat! ive in Somalia and to make recommendations on future support of TBAs in Somalia[

Somalia has been without a central government since 0880[ Throughout the country\ with the exception of the North West\ {Somaliland|\ faction leaders exercise their authority through armed militias[ Regular outbreaks of insecurity threaten the sustainability of projects and dis! courage investment by donors in material resources[ The resulting lack of infrastructure and services cause hard! ship and su}ering along with the ever decreasing funding capacity of donors and international organisations[ Viol! ent attacks and threats against both expatriate and local UN and non!governmental organisation sta} members continue[ Intimidation and extortion are a constant con! straint in the planning of meaningful programme inter! ventions[ Somalia has a population of approximately seven million and is estimated to have one of the highest maternal mortality ratios in the world at 0599 per 099\999 live births[ Most of the health services in Somalia have been devastated[ International organisations\ private sec! tor and traditional practitioners have attempted to pro! vide basic services but the specialised services required for maternal health are weak and the related policy and planning has been neglected[ Training of midwives and doctors ceased when hostilities broke out and has not resumed\ while substantial numbers of quali_ed health personnel left the country\ died or assumed other occu! pations[ Today\ as in the past\ services in Somalia have con!

 Corresponding author[ Tel] ¦143 147 1244^ fax] ¦143 147 1244^ e!mail] hertzÝarcc[or[ke S9038Ð6078:87:,08[99 Þ 0887 Elsevier Science Ltd[ All rights reserved PII] S 9 0 3 8 Ð 6 0 7 8 " 8 7 # 9 9 9 1 5 Ð 2

243

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

centrated in urban areas[ However\ UNICEF planning _gures estimate that approximately 59) of the popu! lation are nomadic or live in rural areas[ In Somalia\ the status of women is low and their health is not a priority[ Almost every woman has been subjected to Female Genital Mutilation "FGM# "UNICEF\ 0887#0[ FGM is known to increase mortality and morbidity of young girls and women due to infection and haemorrhage at the time of the procedure and during the second stage of labour[ "WHO:UNICEF:UNFPA\ 0886#[ Women su}er from severe anaemia\ chronic infection\ painful injuries and the misery of _stulae\ having little access to appropriate health services and afraid to complain for fear of being rejected by their husbands[ Stillbirth and death in the perinatal period are common occurrences in Somalia[ In response to these problems\ many organisations have undertaken training of TBAs[ However\ some of these organisations question the e}ectiveness of this training in reducing maternal and neonatal mortality and morbidity[

2[ Evaluation methodology and data collection Little data is available on maternal mortality in Somalia\ and available mortality estimates are obtained through modelling[ In the current situation\ it was con! cluded that data collection should focus instead on pro! cess rather than outcome indicators "Maine et al[\ 0886#[ Choice of methodology was based on the desire to collect qualitative data within the restrictions imposed by a ~uctuating and unreliable security situation "which ruled out the possibility of using a sampling frame based on random selection#[ Data collection in Somalia was opportunistic and undertaken in the areas that were accessible and considered secure during the evaluation period[ Security conditions vary widely among the four zones and even the zone considered the most secure "the North West# had presented survey teams with serious security problems[ "UNICEF\ 0885#[ The ~ooding of vast areas of the Southern and Central Zones also restricted movement during this evaluation[ Semi!structured interviews "using pre!tested ques! tionnaires#\ discussion and observation helped to over! come some of the constraints presented by the cultural and personal characteristics of many Somalis who are cautious about sharing information on issues of a per!

0 The di}erent types of female genital mutilation are] Type I\ excision of the prepuce\ with or without excision of part or all of the clitoris^ Type II\ excision of the clitoris with partial or total excision of the labia minora^ Type III\ excision of part or all of the external genitalia and stitching of the vaginal opening "in_bulation or Pharaonic#^ Type IV\ any pricking\ burning\ stretching or scarring of the genitalia[ "WHO:U! NICEF:UNFPA\ 0886#[

sonal nature[ This methodology broadened the scope of the study and provided greater understanding of the reality[ Visits were made to all four zones of Somalia between November 0886 and January 0887[ Interviews were con! ducted as follows] , Locations visited , TBAs\ trained and untrained interviewed alone and in groups , Mothers who had delivered within the past one year , Health professionals*doctors\ midwives\ nurses , Focus group discussions with people having an interest in the issue*usually conducted at the site of the other interviews\ consisting mostly of women[ "Men were invited but usually saw the issue as a woman|s problem#[ , Organisation co!ordinators and project leaders in Somalia and Nairobi

15 30 21 11

07 35

Background research was conducted on other countries| experience[ The realities of the referral system were exam! ined[ Data was analysed with the aim of identifying com! mon issues throughout the country although some signi_cant di}erences emerged within the country[ The evaluation is presented with many anecdotes and examples[ This is done to bring the reader closer to the reality of a situation in which enormous hardship has caused the people to develop diverse means of coping which fall outside the experiences of other countries and will stimulate imaginative thinking in the development of programme strategies[

3[ Literature review In the past ten years\ much progress has been made in understanding the problem of maternal mortality[ It is now generally agreed that programme interventions should form part of an integrated approach within a broader strategy for the reduction of maternal mortality "WHO\ 0883#[ The majority of maternal deaths can in general be attributed to _ve main causes] obstructed labour\ haem! orrhage\ eclampsia\ induced abortion and infection[ Most pregnancy related complications cannot be predicted or prevented and cannot be managed at community level but require the services of quali_ed health personnel and facilities which are equipped to manage emergencies "Maine et al[\ 0886#[ Access to emergency obstetric care\ therefore\ becomes the crucial element in programmes aimed at reducing maternal mortality[ Challenges in this strategy are best described in the {Three Delays Model|[ The delays are in "0# deciding to seek care\ "1# reaching treatment facility and "2# receiving adequate treatment at

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

the facility[ The TBA|s role in in~uencing these issues is examined in this study[ Recent studies suggest that while the trained birth attendant can be e}ective in such areas as reducing the incidence of neo!natal tetanus\ they are not e}ective in preventing maternal deaths in the absence of a functional referral system "Maine\ 0880^ Tinker et al[\ 0882^ UNICEF\ undated^ UNICEF\ 0886^ UNFPA\ 0886#[ Because of lack of precise de_nition and di.culties in measurement\ maternal morbidity is often under! estimated but 04) of women are likely to experience some complication during pregnancy or delivery "Graham and Murray\ 0886#[ Serious complications\ without the appropriate treatment cause women acute or chronic su}ering[ Infant morbidity directly related to complications occurring during pregnancy and delivery is well documented and includes anaemia\ low birth weight\ birth injuries including cerebral palsy\ asphyxia and infec! tion\ "Tinker et al[\ 0882#[ In the late 0879s\ a review of a UNICEF:SCF sup! ported primary health care programmes was undertaken in Northwest Somalia[ It examined the e}ectiveness of conventional TBA training programmes and concluded that the lack of referral facilities\ the fact that TBAs traditionally have no role in the ante!natal period and the shortage of quali_ed midwives available for training and supervision of TBAs made the expectations unreal! istic "Bentley 0875#[ During a meeting of UNICEF\ UNFPA and WHO representatives in New York in 0886 "UNICEF\ 0886b# it was agreed that {TBA training in isolation cannot be used as a single approach to improving maternal and child health|[ Training of TBAs should be part of a larger plan to improve services provided by health professionals and referral centres as well as to strengthen the linkages between the TBAs and the health system[ At the recent Safe Motherhood tenth anniversary meeting in Sri Lanka\ more than two hundred experts on maternal health representing international agencies\ research institutes\ governments and NGOs met and dis! cussed future programme options "Donnay\ 0886#[ The meeting|s conclusions highlighted the fact that Safe Motherhood is a matter of women|s empowerment and social justice[ It also emphasised the need for pro! fessionalisation of delivery care and the importance of process indicators for monitoring progress of all aspects of programme implementation[

4[ Support to TBAs in Somalia by UN and non! governmental organisations Support to traditional birth attendants in recent years has largely consisted of training\ often but not always accompanied by the provision of basic kits and the replenishment of supplies[ A small number of organ!

244

isations have followed the training with regular super! vision[ An overview of the numerous projects demonstrates a recent history of vertical projects and short!term support to TBAs[ In general\ training of TBAs is done because {there is no one else to deliver the services| and because {the health services are otherwise not func! tioning|[ Thus TBAs are trained within a non!functional referral system and often remain with no possibility of longer!term supervision or support[ Insecurity\ uncer! tainty about funding and the general absence of a sup! portive infrastructure have contributed to this scenario\ with organisations tending to favour quick {doable| pro! jects[ In comparison to most other interventions\ TBA training courses are easy\ they are considered to be quick\ straightforward\ relatively inexpensive\ in!keeping with the {community based approach| of primary health care and their e}ectiveness is taken for granted[ Investment in human resources is considered to have greater potential for sustainability than investment in material resources\ which are liable to be looted or which the responsible organisation may have to abandon if security deterio! rates[

4[0[ Training The focus of TBA training in Somalia is generally reported to be on "0# enabling the TBA to undertake a clean and safe delivery and "1# the early detection and referral of complications during pregnancy and labour[ Basic TBA training is intensive\ covering anatomy and physiology\ antenatal care\ normal and complicated preg! nancy\ labour and puerperium and management of the newborn[ Many organisations have added on a number of broader primary health care and reproductive health subjects including management of diarrhoea\ promotion of immunisation\ general health education and pro! motion of child spacing[ In general\ the content and meth! odology appears to be of a high standard[ TBA training generally lasts two weeks\ although some organisations o}er follow!up and refreshers over a period[ Some TBAs have received one training whereas a signi_cant number "in easily accessible {secure| areas# have attended numerous courses[ Most organisations in Somalia continue strongly theoretical training\ although various learning methods such as discussion and role!play are used[ Practical train! ing is usually done through examination of antenatal women[ A few organisations favour a community!based approach[ The process of selection of women for training is usually undertaken through village committees that sometimes but not always include women[ Poor co!ordination among organisations has led to much time\ e}ort and _nance being invested in the pro! duction of numerous TBA training manuals and curric!

245

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

ula[ Cost!e}ectiveness analysis was not attempted during this study[1

thousands of Somalis have experienced in recent years# and the in~uence of aid and development organisations have created exceptions to the general rule[

4[1[ Other support 5[0[ Role of the Traditional Birth Attendant While most organisations stated that follow!up of TBAs after training was part of their plan\ some stated that no further direct contact with the TBAs was planned[ On the whole\ supervision and follow!up has fallen short of the hopes of the organisations[ The issues of insecurity and budget _gure large among the reasons for lack of follow!up[ TBA reporting procedures vary considerably through! out the country but consisted of either oral reporting through the Community Health Workers "CHWs# or the use of pictorial forms[ In the past\ TBAs received kits during their training courses[ Most of the kits distributed by UN and NGOs have been supplied by UNICEF although a few organisations have made their own[ Kits contain basic equipment and supplies that should be renewed every two months[ Single delivery packs for mothers have been increasing in popularity in recent years in a number of neighbouring countries\ but not in Somalia[ The pack contains cord tie\ razor blade\ soap and other items\ which will facilitate one clean delivery[ During the evaluation\ all women including those in isolated areas and nomadic settle! ments\ stated that they would make a special e}ort to go to the Maternal and Child Health Centre "MCH# for such packs if they could be guaranteed "0# that the MCH would be open\ "1# that the midwife would be present and "2# that the supplies would be available[ 5[ Characteristics and role of Traditional Birth Attendants in Somalia In Somalia\ TBAs vary in age\ background\ standing in the community and standard of practices[ All TBAs are female[ In a previous study in Somalia in 0875 "Bentley\ 0875#\ it was suggested that TBAs could be categorised according the size of the settlement in which they lived\ those in settled villages conducting up to 19 deliveries per month\ those in smaller centres seeing only one or two deliveries per month and in pastoralist com! munities\ each grandmother acting as a TBA helping in around _ve deliveries each year[ This description con! tinues to be relevant to!day although displacement of populations\ life in refugee camps "which hundreds of

1 Recent research in other countries has shown that cost e}ectiveness of conventional TBA training in the absence of other interventions is extremely low "Maine\ 0880#[ It is estimated that the cost per maternal death prevented is approximately ,06\149\ which is three to four times higher than upgrading and managing health facilitates to manage emergencies[

According to mothers and TBAs\ a TBA was usually chosen because the TBA was well known\ well experi! enced and had assisted the family previously[ Few mothers chose a TBA because she was trained and many were unaware of her training status[ Contact in the antenatal period\ if it happened at all\ was likely to be social in nature or if the woman was particularly ill[ The distance to the nearest health facility and the availability of resources to the family were the determining factors in whether and when women seek professional assistance for problems[ Traditionally\ TBAs are called when labour is well established[ TBAs will ensure that the mother has the necessary supplies or she will bring a razor blade\ some rags and sometimes gloves[ On the issue of cord care\ some signi_cant di}erences were noted between the north and the south of the coun! try\ which appeared to be associated with di}erences in the prevalence of neo!natal tetanus[ In the north\ all TBAs reported using a clean razor blade to cut the umbili! cal cord[ The need to keep the cord exposed\ clean and dry is explained to newly delivered mothers with particular emphasis on never allowing breast!milk or the child|s own urine to wet the cord[ According to the TBAs\ cords should always be separated by the third day after delivery[ Antiseptics or antibiotic powders might be used[ In the southern parts of Somalia\ cord care di}ered[ Trained TBAs used new razor blades[ Untrained TBAs used any sharp instrument[ Some untrained TBAs applied {mal! mal|\ a local plant extract\ talcum powder or ash[ All TBAs stated that even if they applied antiseptic to the cord or o}ered advice on cord care\ the mother|s family was likely to apply malmal when they left the house[ Some of the untrained TBAs use a knife or nail or other metal that has been heated in the _re to {seal| the cord after the delivery[ According to quali_ed health personnel interviewed during the evaluation\ neonatal tetanus appears to be extremely rare in the north whereas in the south\ cases are common[ Descriptions of hand!washing procedures by TBAs suggested that more thorough hand washing is done after the delivery than before[ Trained TBAs had a greater awareness of the need for handwashing before delivery[ Clean areas for delivery were more likely in homes where women have prepared for delivery[ Women from deprived homes\ with little domestic support\ those unsure of their expected date of delivery and rural women are less likely to be prepared with clean supplies[ During pregnancy\ many women in Northern Somalia

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

will make a special trip to the nearest urban centre to make some preparation for the birth of the child[ Usu! ally she will take a goat or sheep and sell it[ The preg! nant woman will ensure that a new razor blade is purchased along with Ergometrine tablets and vitamin supplements[ Other items include soap and clothing for the new baby and some special scents for the baby|s clothes[ Many women now include a plastic feeding bottle in the purchases[ Post!natally\ all TBAs remain with a woman until the placenta has been delivered[ Thereafter\ visits are more likely if the TBA lives near the woman or if she is a relative[ This factor appears to have a stronger in~uence than whether the TBA has been trained or not[ Concerning infant feeding\ tradition rules over train! ing[ The majority of TBAs encourage breast!feeding after delivery of the placenta when the mother has bathed[ Many of the trained TBAs were aware of the bene_ts to mother and child of early sucking but the practice was not generally accepted by mothers[ All mothers gave the newborn sugar and water[ All TBAs were aware of the dangers of arti_cial feeding using bottles stating that it was better for mothers to use a cup instead[ Most TBAs felt that new mothers did not usually take their advice and they regretted the increasing use of bottles over cups[ Bottles are seen as a status symbol and fresh milk\ imported ordinary and baby milk powders are used[ Mid! wives and birth attendants in some hospitals have clearly tried to deter bottle!feeding but appear to have little success as evidenced by the observable {hiding| of bottles by mothers during visits by the researcher[ Trained TBAs were likely to refer women and children for immunisation[ However\ they were usually located in places where immunisation services were available and women were already more likely to be using these services[ In general\ TBAs said that they would not o}er advice on child!spacing as they feared the anger of the husband if they {interfered| in what was seen as a private matter between a woman and her husband[ If asked\ most TBAs would recommend breast!feeding to delay another pregnancy[ A number of women expressed an interest in having fewer children but most said that they would not like to in~uence their fertility in any way because their husbands saw children as a sign of hope for the future and wished to replenish numbers depleted during the war[ Most of the TBAs interviewed claimed to have no involvement in the practice of female genital mutilation[ This was generally considered a speciality of women from a particular sub!clan[ Some TBAs claimed to perform {only Sunna type|[ Those who assisted with or performed FGM used a variety of substances to promote healing similar to those used for aftercare of episiotomy i[e[\ malmal\ eggs and sugar[ In Somalia\ it appears that abor! tion is carried out by quali_ed health professionals such as midwives\ nurses and doctors[ In general\ it seems that TBAs are not involved[

246

The issue of remuneration is sensitive[ TBAs feel it is natural that they should assist another women in her hour of need[ TBAs in rural areas are likely to be rewarded for their assistance by sharing in the general celebration after the birth[ Most families give a small gift according to their means[ 5[1[ Management of complications of labour and delivery In the management of post partum haemorrhage\ the use of ergometrine both oral and injection by all TBAs is common\ if locally available\ along with a range of traditional practices[ Most trained TBAs also know about nipple stimulation although it was not among the primary methods described[ In detecting hypertensive disorders of pregnancy\ all TBAs would refer a woman with swelling of the feet\ hands and face although many claimed never to have seen the condition[ Many of the TBAs would advise the woman to rest and to restrict salt in her diet[ De_nition of prolonged and obstructed labour was vague[ Most TBAs would become worried after twenty! four hours[ Many untrained TBAs would rely on observ! ing the mother|s condition[ TBAs described a range of traditional practices\ which would be tried before referral was attempted[ All TBAs would attempt delivery of a retained placenta without considering referral[ Techniques includes manual removal of the placenta and cord traction without control on the uterus[ Many traditional methods involved man! oeuvring of the mother|s position or tying the end of the cord to a heavy object and encouraging the woman to walk around[ Herbs might also be used[ Two trained TBAs mentioned nipple stimulation[ All TBAs state that because of circumcision\ the open! ing of the perineum in a primagravida will not be adequate to allow the baby to be born and so episiotomy is performed[ The procedure may involve the following] , Premature episiotomy early in the second stage\ before the head has crowned "causing excessive bleeding\ infec! tion and unnecessary pain and injury to the mother# , Episiotomy with inappropriate\ unclean or blunt instru! ments , Extensive or multiple episiotomy , Allowing uncontrolled lacerations[ Practices relating to the aftercare of episiotomy are varied[ Some TBAs will attempt to suture the wound[ Others allow healing to occur naturally and in some parts of the country\ traditional remedies are applied to the perineum[ All TBAs report that they could recognise a post!partum infection and would use a traditional rem! edy as a _rst line of treatment before recommending other measures[ If these did not work\ antibiotics were purchased[

247

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

5[2[ Referral of complicated cases Overall\ trained TBAs had a good knowledge and rec! ognition of complications[ All TBAs described di.culties in referring women[ Frequently\ the families question the need for referral and press the TBA to {do her best| for the women[ Many TBAs take pride in their ability to manage di.cult deliveries and are reluctant to suggest that they cannot cope with a problem[ Thus\ a "trained# TBA who encourages referral might be seen as less skilled than others who attempt to deal with the problem using traditional methods[ In September 0886\ a nomadic woman living in an isolated settlement close to the Ethiopian border experienced a problem in labour[ After twenty four hours of labour\ the family became worried and began to discuss sending the woman to hospital[ Because the hospital was a long distance\ the family prayed and gave some traditional medicine to the women to assist the delivery[ There was no progress and so prep! arations were made to send the woman to Berbera[ One day after the problem was recognised the journey began[ A camel was used to carry the woman to the nearest rural settlement\ "camels are used for human transport in extreme cases only#\ then the family waited for a passing truck which dropped them at a village after which a series of cargo trucks and small vehicles brought the woman and her family from village to village until they arrived in Berbera Hospital[ The jour! ney had taken six days[ On arrival at the hospital\ the woman had been in labour for eight days and her condition was critical[ The woman was seen immedi! ately on arrival at Berbera Hospital and resuscitation was commenced[ She died half an hour later[ Lack of con_dence in the referral hospital\ fear of the expenses involved in transfer and medical care and an association between hospitals and bad outcomes for mothers tend to delay a family|s decision to refer woman and in some cases will prevent it altogether[ Families know that referral once decided upon can be a lengthy\ complicated and expensive procedure[ Thus the opinion of the TBA is but one small element in the decision making process[ Further delays in having life!saving treatment are experienced in some hospitals[ Women can sometimes wait for days for treatment while the family search for drugs\ supplies and money[ Also signi_cant is the appar! ent lack of the {feeling of urgency| with which health professionals may greet a woman with serious com! plications when she enters a hospital[ In August 0886\ in Hospital X\ a woman was admitted with a diagnosis of prolonged labour[ She was exam! ined\ the labour was diagnosed as obstructed and the obstetrician decided that mother and baby could be

saved if caesarean section was performed[ The obste! trician demanded ,299 for the procedure and refused to undertake the procedure without having the full amount[ The family departed\ to raise the money[ Two days later\ some midwife tutors visited the ward in order to plan teaching sessions\ examined the woman and realised that her uterus had ruptured[ The woman had been unattended and her labour had remained unmonitored for the two days on the ward[ The woman was _nally taken to theatre where she died[ The obste! trician demanded the full fee\ despite pleas from the family to allow them some of the money for the burial of the mother and her baby[ Traditionally\ TBAs have no formal link with the health services\ though during training\ this link is pro! moted[ Some trained TBAs are linked to a Health Post or an MCH through which she will channel reports and receive supplies[ 6[ Discussion 6[0[ Is the training of TBAs in Somalia effective in reduc! ing maternal mortality levels< In Somalia\ training of TBAs has been done because {there is no one else| and because {nothing else works in the health services|[2 Many well!trained TBAs return to work in isolation in unsupportive communities and in the absence of functioning referral systems[ Training of TBAs will enable them to detect complications but can do little to prevent death when the referral process is not treated with urgency by the family\ community or hospital sta}[ In the presence of a supportive environ! ment\ and with the back up of a functional health facility\ TBAs can in~uence maternal and neo!natal mortality and morbidity in performing a clean and safe delivery\ eliminating harmful practices and promoting immu! nisation[ Despite good training\ in many situations\ tra! dition rules over training and the knowledge or wishes of the trained TBA are outweighed by the wishes and practices of the mother and her family[ Even if trained\ a TBA remains primarily a neighbour or a friend and her opinions on any issue are unlikely to outweigh those of others within a group[ The role of the TBA can be analysed within the context of her contribution to the four principle elements of Safe Motherhood] "0# Family Planning\ "1# Antenatal Care\ "2# Clean:Safe Delivery\ "3# Essential Obstetric Care[ Most of the TBAs interviewed knew little about mod! ern methods of family planning[ Some felt that they could get into trouble in the community if the men thought

2 Most health services have collapsed due to the war and lack of central government[

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

they were encouraging women to limit the size of their families[ Others considered that this issue was a private one between the husband and wife and that they had no role in discussing it[ Almost all TBAs did\ however\ mention that by encouraging the mother to breast feed\ she could delay her next pregnancy[ Although most TBAs know about the relationship between breast!feeding and child spacing\ few understand that this refers to women practising exclusive breastfeeding\ which is rare in Somalia[ The fact that most TBAs perceive themselves as a family friend rather than a trained practitioner is signi_cant in this issue[ The role of the TBA in the promotion of family plan! ning and child spacing are heavily dependent on her links with the facility that provides these services[ As a _rst step\ it is probably more realistic to expect that the TBA can relay the information to women in the community about the availability of particular services[ A community approach\ with a focus on education of men is important[ As it stands\ it could be concluded that TBAs could have very little impact in improving access to family planning services[ Traditionally\ TBAs in Somalia do not play a strong role in the antenatal period[ Trained TBAs with supplies of iron or those with a solid link to a particular clinic or organisation are more likely to visit and examine women during pregnancy[ Where TBAs are linked to an ante! natal clinic that is run by a quali_ed midwife\ she is in a position to play a role in encouraging women to attend the clinic for full assessment\ iron supplements and teta! nus toxoid vaccination[ While improvement of antenatal care alone will have little impact on maternal mortality\ it is a valuable element of a more comprehensive programme[ Well!trained TBAs are capable of detecting high!risk cases and in the presence of an informed and supportive community as well as a functioning referral system\ their role in this area can be e}ective[ Every woman should experience a clean and safe deliv! ery[ While TBAs are personally responsible for ensuring a clean delivery\ achieving this will be di.cult without the support of the woman and her family[ Responsibility for preparing the essential items for delivery and pro! viding the TBA with a clean environment is essentially the responsibility of the woman and her female relatives[ Maintaining the hygiene of the cord after the delivery will also depend on the knowledge and beliefs of the newly delivered mother and her family[ Thus\ an e}ort to ensure clean delivery for all women has to target all women and all TBAs[ Information and education at com! munity level accompanied by support with some essential supplies\ such as the clean delivery pack\ will promote the demand for a higher standard of care[ Community information targeted at all women will also open the way to reducing other harmful practices during delivery[ One of the most damaging practices\ that of multiple\ extensive\ premature and badly performed episiotomies

248

may have to have a two sided approach] some level of training and eduction to minimise the current su}ering\ and a continued e}ort to promote debate on the issue of female genital mutilation[ Clean and safe practices at delivery also have a direct impact on perinatal mortality[ This involves avoidance of di.cult manoeuvring\ a well!managed second stage\ some knowledge of resuscitation technique and good cord care by the TBA and the mother[ The most easily monitored of these\ good cord care\ is equally dependent on the TBA\ the mother and her female relatives[ Without the support of an educated and informed community\ the TBA has little in~uence on changing harmful practices[ During pregnancy and labour\ a well!trained TBA can recognise complications that require professional assist! ance[ Throughout this study\ obstacles to ensuring that this act of recognition results in the mother having the appropriate treatment in time to save her life have been described[ At present in Somalia\ the role of the TBA is extremely limited in improving access of women to emergency obstetric care[ However\ within a supportive community and with the back!up of an e.cient referral system\ her knowledge and experience could be valuable[ Trained TBAs are most e}ective in towns where they are linked to an MCH and have the back!up of a well!sup! plied and functional emergency obstetric unit[ Unfor! tunately\ with a population that is mostly rural\ the vast majority of women remain without access to this kind of service[ In conclusion\ it appears that while TBAs may have an impact on maternal morbidity through improved delivery practices\ it is highly unlikely that training as it exists at the moment\ undertaken in isolation from other activi! ties\ will be e}ective in reducing the current high level of maternal mortality in Somalia[ Training of TBAs has\ however\ proved to be e}ective in reduction of peri!natal morbidity and mortality due to sepsis and neo!natal teta! nus in other countries[ If training is combined with com! munity education and Tetanus Toxoid immunisation\ it most likely will also be e}ective in Somalia[ Improving a woman|s access to emergency obstetric care has to start with community level education and involves issues such as the status of women in Somali society[ It is only when society acknowledges the import! ance of women and their health that real progress can be made in improving their care[ 6[1[ Which interventions are most likely to be effective in reducing maternal mortality in Somalia< E}ective interventions for the reduction of maternal mortality in Somalia will be those which acknowledge the principle causes of maternal death and seek means to address these at community level\ at hospital level and to build a link between the two[ In the last section and throughout the document\ reference has been made to

259

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

the many factors that directly and indirectly in~uence a woman|s access to emergency obstetric care[ Any mean! ingful intervention to reduce maternal mortality in Som! alia will have to address some or all of these factors[ The {Three Delays Model| can be used as a guide in planning programme interventions[ E}ective interventions will have to acknowledge that approximately 59) of the population of Somalia are nomadic and:or living in remote rural areas[ In principle\ community information and education will have to aim towards prioritising the health of a pregnant woman and recognising that she needs special care[ Solutions to transport and communications di.! culties need to be addressed at community and district level[ Services for women at emergency facilities will have to be upgraded[ The use of programme goals and process indicators will enable planners to examine what is really achievable in each area and will allow them to measure even small steps in the progress towards more ambitious targets[

7[ Conclusions and recommendations The status of women in Somalia is low and their health is not a priority[ The extremely high maternal mortality ratio is masked and not seen by the public as a serious problem since {only| one or two women die for every hundred births[ De_nitions of morbidity vary\ but as approximately 04) of all women experience some com! plication during pregnancy and labour\ maternal mor! bidity levels\ using any indicators must be very high in Somalia[ Thus\ thousands of Somali women experience the pain and misery of injuries and chronic infections\ which rarely receive the appropriate treatment[ The improved status of women and a raised public awareness of their special needs during pregnancy and labour has to be a goal of any programme attempting to have an impact on maternal health in Somalia[ Three critical programming principles with regard to reducing Maternal Mortality levels emerge from this study[ First\ any programme that aims to address maternal mortality in Somalia has to recognise that the TBA cannot function well without a supportive and informed community[ All community members and all TBAs\ therefore\ need to be informed about the special needs of pregnant women and the importance for mother and baby of an early referral when a complication is recognised[ All women and TBAs need to be educated on such issues as the basic elements of a clean and safe delivery\ on the after!care of the infant|s cord and on the importance to mother and child of exclusive breast! feeding[ An educated community will also demand good standard antenatal services\ whether from a trained and equipped TBA or from an MCH centre[ This process should commence with a study of the existing knowledge\

attitudes and practices in the community\ build on the positive aspects and promote behaviour change in a sen! sitive and culturally appropriate manner[ Organisations who undertake to educate and inform communities and TBAs should be meticulous in checking the facts of their essential messages[ Some of the very common mistakes are "0# promoting breastfeeding as an option for child!spacing and "1# denouncing bottle!feed! ing*and then promoting the use of clean cups[ The mess! age needs to be {exclusive breastfeeding from birth|\ i[e[\ no water\ no sugar\ no cups[ To support e}orts in enabling women to have a clean delivery\ it is recommended that organisations should consider the promotion of individual packs containing the necessary supplies for one clean delivery[ These Single Delivery Packs should be provided directly to the preg! nant woman during an antenatal visit to an MCH as part of an e}ort to improve uptake of other important services like iron supplementation\ tetanus toxoid vaccination and antenatal physical examination[ Furthermore\ its introduction will be an essential element of a campaign to raise awareness of the need for a clean delivery[ As the e}ectiveness of this activity has not yet been well evaluated in their countries\ monitoring and evaluation tools need to be set in place before the commencement of any project[ The second critical programming principle to reduce MMR must be the upgrading of referral facilities and examination of what is a realistic expectation for an emer! gency obstetric service in each geographic area[ Where hospitals are inaccessible\ MCH centres can be upgraded\ with supplies and training to provide all services except caesarean section[ The programme that attempts to address maternal mortality has to rebuild the con_dence of the communities in the referral facilities[ Finally\ clear programme objectives with appropriate monitoring and evaluation tools are essential elements of programme planning[ For situations\ such as that of Somalia\ where maternal death rates remain very di.cult to measure directly\ process indicators and output indi! cators are now acceptable methods of monitoring impact in programmes designed to reduce maternal mortality[ Many organisations have described the objective of TBA training to be the reduction of maternal and neo! natal mortality and morbidity\ in the absence of a proven link between the two[ It is suggested that before new e}orts are commenced\ organisations should develop new perceptions of Safe Motherhood\ and set very speci_c objectives for what they hope to achieve[ Objectives should then be translated into activities and backed up with supplies where necessary[ Objectives and indicators "process or outcome# have to be based on sound scienti_c background and will usually involve more than one level of intervention[ Although the situation in Somalia is unique\ the _n! dings in this study are consistent with those in a number

N[ Prendiville:Evaluation and Program Planning 10 "0887# 242Ð250

of other recent studies in other countries[ The report concludes that TBA support programmes\ which exist as isolated activities\ as the majority do in Somalia today\ are unlikely to have any e}ect on maternal mortality[ There is a possibility that clean deliveries and antenatal care practised by trained TBAs may reduce maternal morbidity\ perinatal mortality and perinatal morbidity[

Acknowledgements Throughout this study\ I have been aware that I was treading on what is {sacred ground| for many[ Few pro! gramme interventions are as popular and as loved as TBA training[ The reasons for this are many\ and the technical ones are well described in this report[ But the other reason for the popularity must be the sheer pleasure of working with one of the most wonderful groups of women in the world[ Women who make such great per! sonal e}ort to assist other women during childbirth with little material gain are special[ During the past few months\ I had the pleasure of meeting many of these special women and I thank them for their patience and their insights into their lives and work[ I would also like to thank the many health pro! fessionals and organisation representatives throughout Somalia and in Nairobi who gave time for interviews and provided valuable information[ I am very grateful for the support and advice of Dr Pirkko Heinonen\ Project O.cer\ Health + Nutrition\ UNICEF Somalia\ Marianne Lindner\ Project O.cer\ Monitoring + Evaluation\ UNICEF Somalia^ Dr Eras! mus Morah and Dr Romanus Mkerenga\ UNICEF Har! geisa\ Daphne Kilroe!Wagsta}e\ American Refugee Committee\ John Spring\ UNICEF Somalia and my other colleagues in UNICEF[ Throughout the country\ many other women\ mothers and grandmothers helped me to understand a little about their lives in conversations which were usually cheerful and optimistic but which often told of great su}ering and

250

hardship[ I sincerely hope that this study will contribute towards making their lives better[ References Bentley\ C[ "0875#[ Primary health care in Northwest Somalia[ In Implementing Primary Health Care[ Stree~and P[\ Chabot Jarls "Eds#[ Centre for Studies and Evaluation:UNICEF[ "Undated# Making Car! ing Hands Safe[ Impact Evaluation of TBA Training Programme in Punbjab[ Lahore\ Pakistan[ Donnay\ F[ Colombo Highlights[ "0886#[ Team Report[ UNICEF[ New York[ Graham\ W[ J[ + Murray\ S[ F[ "0886#[ A Question of Survival< Review of Safe Motherhood[ Ministry of Health\ Kenya[ Maine\ D[\ Akalin\ M[ S[ S[\ Ward\ V[ M[ + Kamara\ A[ "0886#[ The Design and Evaluation of Maternal Mortality Programmes[ Centre for Population and Family Health\ School of Public Health\ Col! umbia University\ New York[ Maine\ D[ "0880#[ Safe Motherhood Programmes] Options and Issues[ Centre for Population and Family Health\ School of Public Health\ Columbia University\ New York[ Tinker\ A[ + Koblinsky\ M[ A[ "0882#[ Making Motherhood Safe[ World Bank Discussion Papers 191[ The World Bank[ Washington\ D[C[ UNFPA[ "0886#[ Support to Traditional Birth Attendant\ Evaluation Report[ UNFPA\ New York[ UNICEF[ "0885#[ Multiple Indicator Cluster Survey[ North West Zone "Somaliland#[ UNICEF\ Nairobi[ UNICEF[ "0886a#[ Report on the Consultation on Attendance at Birth[ New York\ June 8Ð09\ 0886[ UNICEF\ New York[ UNICEF[ "0886b#[ The Summary Report of the third round of super! visory visits of Trained TBAs in Luang Phabang and Xieng Nguen Districts of Luang Phabang Province[ UNICEF Somalia[ "0887#[ Children and Women in Somalia[ A Situ! ation Analysis[ UNICEF[ WHO[ "0883#[ Mother!Baby Package] Implementing safe motherhood in countries[ World Health Organisation\ Geneva[ WHO:UNICEF:UNFPA[ "0886#[ Female Genital Mutilation\ WHO\ Geneva[

Disclaimer The views expressed by Noreen Prendiville in this paper are solely her responsibility[