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Traditional birth attendants and maternal mortality in Ghana
0277-9536193 S6.00+ 0.00 Copyright 0 1993Pergamon Press Ltd
Ser. Sri. Med. Vol. 36, No. 1I, PP. 1503-1507, 1993 Printedin Great Britain.All rightsreserved
TRADITIONAL
BIRTH ATTENDANTS AND MATERNAL MORTALITY IN GHANA
CAROL A. EADES’, CHRISTOPHER BRACES, LAWRENCE OSEI~
and
KATHERINE D. LAGUARDIA~
‘Department of Obstetrics, Gynecology and Reproductive Sciences, and 2Department of Family Medicine, University of California San Francisco, San Francisco, CA 94122, U.S.A., 3Department of Community Health, University of Ghana Medical School, Accra, Ghana and 4Department of Obstetrics and Gynecology, Cornell University Medical College, New York, NY, U.S.A. Abstract-Maternal mortality is high in most African countries, particularly in rural areas where access to formal health care is limited. The sociopolitical and economic environment complicates the medical factors directly responsible for this high rate. Since the 1970s many African countries have addressed this problem by training traditional birth attendants (TBAs) in health promotion and in the basics of safe delivery and referral. The Danfa Rural Health Project in Ghana has trained and supervised TBAs since 1973. It is located relatively close to the health services of the capital city of Accra, providing an ideal environment for the practice of trained TBAs. Thirty-seven trained TBAs currently practice in the area. Most provide patient education and encourage women to go to the health center for preventive services. However, many report routinely performing the high risk deliveries that they have been taught to refer to higher level care and that when they do refer, their patients may not go. Reasons for referral refusal frequently cited by TBAs include financial limitation or lack of transportation and the patients fear of disrespectful or painful treatment from medical personnel. In the rural environment, the trained TBA’s greatest contribution to lower maternal mortality rates may lie in the area of health promotion rather than disease intervention. Key words-maternal
mortality,
traditional
birth attendant,
INTRODUCTION
It is estimated that worldwide, 500,000 women die each year from causes related to pregnancy and childbirth. Ninty-nine percent of these deaths occur in developing countries, with 150,000 occurring in Africa. In Africa as a whole, 640 women die for each 100,000 live births [l]. In rural Africa, where an estimated 70-90% of the population live, this rate may be much higher. In a rural area of The Gambia, where the 200 km trip to the nearest hospital included crossing a river on an unreliable ferry, maternal mortality was 2360 per 100,000 live births [2]. For each maternal death, an estimated 15 women suffer permanent disability. Incontinence, uterine prolapse and infertility are common [3]. Such disability leads to physical incapacitation and social ostracism 141. With an average fertility of 6.2 births per woman, exposure to the risks of pregnancy is frequent [5]. In rural areas, where economic and educational opportunities for women are limited, it is not uncommon for them to bear 8 live infants and have several other pregnancies. The reasons for this high fertility rate are complex. An interview with mothers in Burkina Faso revealed that women believed that their main role in life is to bear children and that their status and prestige are gained through high fertility [6]. However, in many countries in sub-Sarahan Africa, a large percentage of married women do not desire another child, yet few use effective contraceptives [7]. Repeated exposure to the risks of pregnancy gives an African woman a lifetime risk of death due to
rural health
care
pregnancy of 1 in 15, while the risk to a woman in the industrialized world ranges from 1 in 4000 to 1 in 10,000 [8]. The leading direct causes of maternal death in the developing world include hemorrhage, infection, toxemia, obstructed labor and illicit abortion [9]. These medical factors, however, need to be analyzed in their social, political and economic context in order to fully understand the scope of the problem. Thaddues and Maine have described the way in which this context contributes to maternal mortality by delaying adequate treatment once an obstetric complication commences [lo]. A woman may die because she and/or her family delay the decision to seek medical care for a complication. This may be influenced by the status of women, illness characteristics, distance, cost, previous experience with the health care system and perceived quality of care. A second level of delay occurs when the decision to seek care has been made but availability and cost of transportation, travel time, condition of roads or distance delay reaching the facility. Finally, a woman may reach the facility but be delayed in receiving adequate care once she is there because of lack of competent personnel, supplies, and equipment. Although delay in receiving emergency treatment for obstetric complications may immediately precede a maternal death, additional factors also play a role. Fathalla’s “road to death” vividly exemplifies a maternal death in which many other factors contributed [ll]. As in Thaddeus and Maine’s model, a woman dies of postpartum hemorrhage because she does not
1503
1504
CAROL
A.
receive
adequate or timely medical treatment. Other social and economic factors, however, may have contributed to the development of postpartum hemorrhage in the first place. The hemorrhage may have been caused by having many children. The mother may have wanted to limit her family size but had no access to effective contraceptives. Finally, her lack of knowledge about or access to family planning and medical services may have been due to the fact that she was illiterate and lived in a poor, rural area with few roads. The West African country of Ghana has been expanding its system of primary health care since 1980. Rural maternal and child health programs, coordinated locally by community health nurses and nurse-midwives, play a central role. An integral component of these services has been the training of traditional birth attendants, and the country is currently expanding TBA training nationwide [12]. The TBA is defined as “a person (usually a woman) who assists the mother at childbirth and who initially acquired her skills delivering babies by herself or by working with other TBAs” [13]. The main tasks assigned to trained TBAs are: (1) to encourage women to seek prenatal care; (2) to recognize women at high risk of complications and refer them for medical attention and/or delivery in a health facility; (3) to encourage women to use family planning after delivery and (4) to assist in normal, uncomplicated births and facilitate a clean, safe and culturally appropriate delivery [14]. By performing these tasks, TBAs theoretically can decrease maternal mortality by promoting healthy practices among pregnant women, improving screening and referral for high risk pregnancies, expediting emergency care for obstetrical complications, performing uncomplicated deliveries safely and decreasing fertility. The Danfa Comprehensive Rural Health Project, located 29 km north of Accra, has had a TBA training program since 1973. This study was undertaken to evaluate the potential of trained rural TBAs working in an area of relatively abundant health resources to reduce maternal mortality. THE
STUDY
AREA
After initial registration in 1973 of 263 untrained TBAs in the entire study area, a survey of pretraining knowledge, attitudes and practices was administered to 82 TBAs who lived in a defined area. The results have been published elsewhere [IS]. A training manual was designed based on the findings [ Between and 60 were in subsection the area, Area [17]. prohas relatively since and additional were between and Initial has supported periodic courses supervisory in TBA’s every or The health who develop pro-
EADES et al.
has and these since inception. Danfa Area located km of in Greater Region, the of coastal and rain Area has villages populations from to The are subsistence A community-based of women childbearing in village Area in 2 TBAs indicated 93% the in previous had attended a [18]. facilities the include Danfa Post, rotating clinics a hospital general outpatient The facilities Accra 6 7 180 clinics 68 homes. passenger operon major between Danfa and during hours. trip include walk several to main for living the remote In area relatively health ties, emphasis been on the to and complications mediately. protocol referral been lished is to TBAs training reinforced supervision. vehicle the centre made to patients local is available. TBA advised refer to the to hospital health if to if doubt, give of at to nurse physician to a of referral indicating nature the In maternal is to 500&1500 100,000 births infant greater 100 per live [l2]. total rate 6.3 per and annual of population is with birth death of and per population Five of women modern [5]. percent births attended a 24% an family and are [191. SURVEY
METHODS
A questionnaire based on the original survey was field tested in the Eastern Region of Ghana. Symptomatic descriptions rather than strict diagnostic criteria were used to identify maternal complications. For example, postpartum hemorrhage was defined as excessively heavy bleeding after delivery of the baby. Four Danfa Health Post employees fluent in the local vernacular were trained to administer the questionnaire with efforts to standardize translation. Most TBAs were given at least 24 hr notice before administration of the questionnaire at the TBA’s place of residence. Questionnaires were administered by a
Traditional
birth attendants
and maternal
translator with one investigator recording and clarifying answers as necessary. On average, administration took 45 min. The TBAs interviewed were located in 20 villages. Of 86 TBAs trained in Area 1, 37 are currently in active practice in the area, defined by Danfa staff as performing a minimum of 1 delivery per year. The questionnaire was administered to 35 of the 37 active TBAs. Two TBAs were out of the area and were unavailable for interview. No other selection criteria were used.
mortality
Table I. Routine
in Ghana handling
1505
of high risk deliveries
Routinely performed
by TBAs
Routinely referred
Total
High risk category
N
%
N
%
N
%
Primipara Physical deformity/ short stature History of obstetric complications Previous cesaerean section Twin gestation Antepartum complications Malpresentation
8 6
23 17
27 29
77 83
35 35
100 100
5
14
30
86
35
loo
5
I4
30
86
35
100
I3 3 9
37 9 26
22 32 26
63 91 74
35 35 35
100 100 100
RESULTS
Most TBAs were elderly married women with no formal education (Fig. 1). The female TBAs had an average of 6 children and the males 9. Attending births was a part-time activity for most, their primary income coming from farming and trading. Twentyfour held either traditional, political or church leadership positions in their communities. These TBAs performed an average of 7 deliveries in the year prior to interview and had been in practice an average of 21 years. Most charged the equivalent of three dollars and a small gift of food for their services. Eighteen had originally learned their skills from a parent, and 16 had mentored one of their own children. Only four TBAs limited their practice to birth attendance. Twenty-five treated infertility and menstrual problems, 15 practiced general herbal medicine and 12 considered themselves spiritual healers. All reported attending the pregnant woman in the months before delivery. Frequency of visits ranged from daily to monthly, with the first visit at anywhere from 3 to 8 months of pregnancy. Most stated that on the first visit they took a simple obstetrical history, examined the patient and gave nutritional advice. All reported referring the pregnant woman to the health post for routine antenatal care, with 14 doing so on the first visit. Thirty routinely gave the pregnant and laboring woman herbal treatment to prevent problems, stimulate fetal growth and hasten labor. Twenty-five had
soap and a scrub brush in their midwifery kits for handwashing before delivery. All but two reported always using a new blade to cut the umbilical cord and dressing the cord with mercurichrome provided in the midwifery kit. Thirty-two reported contact with the new mother and baby in the weeks following delivery, and all reported referring patients to the child welfare clinic. All offered advice on breastfeeding, most recommending it until the child was 1 or 2 years old. All but one reported referring patients to the health center for family planning services. One TBA did not refer because of her belief that husbands do not approve of family planning. Although most TBAs reported appropriate referral of high risk patients for delivery at the hospital or health center, many reported routinely performing such deliveries themselves (Table 1). Malpresentation and twin deliveries were commonly performed in the village. When confronted with an obstetrical emergency, many reported immediate referral, particularly for seizure (Table 2). For antepartum bleeding, postpartum hemorrhage or obstructed labor, many described an attempt at management with herbal treatment before referral, and some did not consider referral necessary at all. Ten TBAs reported that when they referred their patients to the health post or hospital the patient always went (Fig. 2). Many, however, reported that their patients do not go to the hospital or health post when referred. When asked why, TBAs reported that financial limitation or lack of transportation and the expectation of disrespectful or painful treatment from hospital personnel were major barriers to higher-level care. DISCUSSION
Fig. 1. Demographic
characteristics
of TBAs.
In many parts of Africa, traditional birth attendants have provided obstetrical care for centuries and are very well respected and highly influential members of their communities [20,21]. In 1974, TBAs performed an estimated 70-90% of deliveries in African countries [22]. Recent data based on nationally representative samples indicates a more modest role, ranging from 30% of deliveries in Mali to 6%
CAROLA. EADES et al.
1506
Table 2. Management Antepartum bleeding
of complications
Postpartum hemorrhage
Peripartum seizure
Obstructed labor
Manaaement
N
%
N
%
N
%
N
%
Refer directly Attempt management then refer Herbal treatment only Does not know
I6 I2
46 34
12 I8
34 52
26 4
74 II
20 II
57 32
6 I
I7 3
5 0
I4 0
2 3
6 9
4 0
II 0
I-i&II
3s
100
3s
loo
3s
loo
3s
loo
in Zimbabwe [19]. The proportion of births attended by TBAs is greater in rural than urban areas, and in isolated rural areas, TBAs and herbalists may be the only accessible health-care providers. Even when the services of a midwife or physician are available, many women prefer the services of a TBA. Ekarem et al. found that reasons given for preference for a TBA had little to do with scarcity of hospitals and maternity clinics. The patients’ perception of the TBA’s experience, kindness, skill and interest in the welfare of the baby attracted the clientele [23]. Williams and Yumkella found that 85% of mothers preferred TBAs because they were easily accessible, friendly and kind during delivery, and less expensive than a hospital delivery [24]. Sargent found that clients and TBAs share similar beliefs, values and ideas about the cause of illness. The TBA’s duties included traditional healing activities, which patients found valuable [25]. These additional services and a perceived sociocultural similarity may explain many women’s preference for a TBA even when modern facilities are accessible. The combination of availability and acceptability of TBAs in rural areas increases their potential to improve the health status of women and children in their communities. This potential has long been recognized, and from the early 1970s the World Health Organization has actively encouraged countries to establish TBA training programs and utilize them as extensions of their maternal and child health services. Between 1972 and 1982 the number of countries with some form of TBA training increased to 52 from 24, many of them in Africa [22]. Studies assessing the impact of TBA training on maternal and/or infant
Fig. 2. Reasons for referral refusal
mortality are few and inconclusive, however. In the Farafenni area of The Gambia, the maternal mortality rate fell to half the preintervention level 3 years after the introduction of a primary health-care program that included TBA training. The authors acknowledge that improved transportation also may have contributed to this decrease [2]. Evaluation of TBA records in Andhra Pradesh, India, however. showed no decrease in death rates [26]. This type of analysis is difficult, at best, because of the lack of transport and personnel to collect community-based data, the relative rarity of maternal deaths and the cultural belief that maternal death is a disgrace to the family and should not be discussed [27,28]. The Danfa TBAs are in a good position to play an important role in all phases of prevention of maternal mortality. The preventive services of the rural health post are available in the immediate area at rotating satellite clinics. The more sophisticated services of Accra are close and relatively accessible. One of the TBA’s greatest strengths lies in primary prevention. They enthusiastically refer their patients for antenatal care and encourage the use of contraceptives and family planning. At higher levels of prevention, however, their impact on maternal mortality is lower. Many are performing deliveries that they have been taught to refer to higher-level care, and many are attempting management of complications with herbal remedies before referring or are not referring at all. In spite ofmany years in practice, they perform few deliveries per year, and because the incidence of most complications is low, their personal experiences with complicated pregnancies are limited. In traditional apprenticeship systems knowledge acquisition is cxperiential, acquired by ‘going around’ with an expcrienced midwife. With little or no formal education. training sessions for TBAs may be an ineffective surrogate for experience [29]. This relative lack of experience may make it difficult for them to perceive their limits when confronted with a complicated pregnancy or an obstetrical emergency that requires higher-level care than they can provide. These TBAs report, however, that even when a patient is referred, she may not go. The tinding that cost for
Traditional
birth attendants
and maternal
mortality
in Ghana
1507
fear of anticipated treatment is a barrier to care. TBAs reported that patients feared painful and disrespectful treatment from hospital personnel [25]. Families may be less willing to accept the financial burden of hospitalization when they feel poorly treated by medical personnel. In the developing world, where many causes of maternal mortality are preventable, trained TBAs play an important role in health promotion in their communities. When prevention fails, many maternal deaths may be avoided with surgical intervention, blood transfusion and antibiotics, which TBAs are clearly unable to provide. As the point of first contact with the health-care sector for many women with life threatening complications, however, the TBA is essential in facilitating timely and appropriate care. This study, like most in this area, is limited by its very nature. Although some TBAs reported practices inconsistant with their training, assessment of behaviors by a survey questionnaire is fraught with recall bias, presumably toward the perceived correct response. In future research, studies including a direct participant observer of TBAs at work would better clarify their most appropriate role in reducing maternal mortality and morbidity. Acknowledgements-This study was funded by the AMSA International Health Fellowship. The authors would like to thank the staff at the Danfa Clinic for their invaluable assistance as well as the faculty and staff of the Departments of Community Health at the University of Ghana Medical School, Accra and the University of Science and Technology, Kumasi.
REFERENCES
1. World Health Stutistics Annual. WHO, Geneva, 1988. 2. Greenwood A. M., Bradley A. K., Byass P., Greenwood B. M., Snow R. W., Bennett S. and Hatib-N’Jie A. B. Evaluation of a primary health care programme in The Gambia: the impact of trained traditional birth attendants on the outcome of pregnancy. J. crop. Med. Hygiene 93, 58866, 1990. the tragedy of maternal deaths: a report 3. Preventing on the International Safe Motherhood Conference. Nairobi, Kenya, 1987. 4. Harrison K. A. Obstetric fistula: one social calamity too many (Commentary). Br. J. Obstet. Gyn. 90, 385-386, 1983. Refer5. 1990 World Popularion Data Sheet. Population ence Bureau Inc, Washington DC, 1996. 6. van de Walle F. and Ouaidou N. Status and fertility among urban women in Burkina Faso. Inr. Fam. Plan. Perspect. 11, 6064, 1985. 7. Kent M. and Larson A. Family size
8.
of TBAs in the South Eastern State of Nigeria. Inst. of Pop. and Manpower, Series 3, 1975. Williams B. and Yumkella F. An evaluation of the training of TBAs in Sierra Leone and their performance after training. In The Potenrial of the TEA. WHO Offset Pub. 95, Geneva, 1986. Sargent C. Obstetrical choices among urban women in Be&. Sot. Sci. Med. 20, 287-292, i985. Swaminathan M., Naidu A. and Krishna T. An evaluation of Dai training in Ananda Pradesh. In The Potential of the TBA. WHO Offset Pub. 95. Geneva. 1986. Boerma J. T. Levels of maternal mortality in developing countries. Stud. Fam. Plan. 18, 213-221. 1987. Lewis J., Janowitz B. and Potts M. Methodological issues in collecting data from traditional birth attendants. Int. J. Gvn. Obstet. 23, 291-303, 1985. Jordan B. Cosmopolital obstetrics: some insights from the training of traditional midwives. Sot. Sci. Med. 28, 925-944, 1989. Lasker J. N., Choosing among therapies. Illness behavior in the Ivorv Coast. Sot. Sci. Med. 15. 157-168. 1981. Mwabu G. M. Health care decisions at the household level: results of a rural health survey in Kenya. Sot. Sci. Med. 22, 315-319, 1986.
Ser. Sri. Med. Vol. 36, No. 1I, PP. 1503-1507, 1993 Printedin Great Britain.All rightsreserved
TRADITIONAL
BIRTH ATTENDANTS AND MATERNAL MORTALITY IN GHANA
CAROL A. EADES’, CHRISTOPHER BRACES, LAWRENCE OSEI~
and
KATHERINE D. LAGUARDIA~
‘Department of Obstetrics, Gynecology and Reproductive Sciences, and 2Department of Family Medicine, University of California San Francisco, San Francisco, CA 94122, U.S.A., 3Department of Community Health, University of Ghana Medical School, Accra, Ghana and 4Department of Obstetrics and Gynecology, Cornell University Medical College, New York, NY, U.S.A. Abstract-Maternal mortality is high in most African countries, particularly in rural areas where access to formal health care is limited. The sociopolitical and economic environment complicates the medical factors directly responsible for this high rate. Since the 1970s many African countries have addressed this problem by training traditional birth attendants (TBAs) in health promotion and in the basics of safe delivery and referral. The Danfa Rural Health Project in Ghana has trained and supervised TBAs since 1973. It is located relatively close to the health services of the capital city of Accra, providing an ideal environment for the practice of trained TBAs. Thirty-seven trained TBAs currently practice in the area. Most provide patient education and encourage women to go to the health center for preventive services. However, many report routinely performing the high risk deliveries that they have been taught to refer to higher level care and that when they do refer, their patients may not go. Reasons for referral refusal frequently cited by TBAs include financial limitation or lack of transportation and the patients fear of disrespectful or painful treatment from medical personnel. In the rural environment, the trained TBA’s greatest contribution to lower maternal mortality rates may lie in the area of health promotion rather than disease intervention. Key words-maternal
mortality,
traditional
birth attendant,
INTRODUCTION
It is estimated that worldwide, 500,000 women die each year from causes related to pregnancy and childbirth. Ninty-nine percent of these deaths occur in developing countries, with 150,000 occurring in Africa. In Africa as a whole, 640 women die for each 100,000 live births [l]. In rural Africa, where an estimated 70-90% of the population live, this rate may be much higher. In a rural area of The Gambia, where the 200 km trip to the nearest hospital included crossing a river on an unreliable ferry, maternal mortality was 2360 per 100,000 live births [2]. For each maternal death, an estimated 15 women suffer permanent disability. Incontinence, uterine prolapse and infertility are common [3]. Such disability leads to physical incapacitation and social ostracism 141. With an average fertility of 6.2 births per woman, exposure to the risks of pregnancy is frequent [5]. In rural areas, where economic and educational opportunities for women are limited, it is not uncommon for them to bear 8 live infants and have several other pregnancies. The reasons for this high fertility rate are complex. An interview with mothers in Burkina Faso revealed that women believed that their main role in life is to bear children and that their status and prestige are gained through high fertility [6]. However, in many countries in sub-Sarahan Africa, a large percentage of married women do not desire another child, yet few use effective contraceptives [7]. Repeated exposure to the risks of pregnancy gives an African woman a lifetime risk of death due to
rural health
care
pregnancy of 1 in 15, while the risk to a woman in the industrialized world ranges from 1 in 4000 to 1 in 10,000 [8]. The leading direct causes of maternal death in the developing world include hemorrhage, infection, toxemia, obstructed labor and illicit abortion [9]. These medical factors, however, need to be analyzed in their social, political and economic context in order to fully understand the scope of the problem. Thaddues and Maine have described the way in which this context contributes to maternal mortality by delaying adequate treatment once an obstetric complication commences [lo]. A woman may die because she and/or her family delay the decision to seek medical care for a complication. This may be influenced by the status of women, illness characteristics, distance, cost, previous experience with the health care system and perceived quality of care. A second level of delay occurs when the decision to seek care has been made but availability and cost of transportation, travel time, condition of roads or distance delay reaching the facility. Finally, a woman may reach the facility but be delayed in receiving adequate care once she is there because of lack of competent personnel, supplies, and equipment. Although delay in receiving emergency treatment for obstetric complications may immediately precede a maternal death, additional factors also play a role. Fathalla’s “road to death” vividly exemplifies a maternal death in which many other factors contributed [ll]. As in Thaddeus and Maine’s model, a woman dies of postpartum hemorrhage because she does not
1503
1504
CAROL
A.
receive
adequate or timely medical treatment. Other social and economic factors, however, may have contributed to the development of postpartum hemorrhage in the first place. The hemorrhage may have been caused by having many children. The mother may have wanted to limit her family size but had no access to effective contraceptives. Finally, her lack of knowledge about or access to family planning and medical services may have been due to the fact that she was illiterate and lived in a poor, rural area with few roads. The West African country of Ghana has been expanding its system of primary health care since 1980. Rural maternal and child health programs, coordinated locally by community health nurses and nurse-midwives, play a central role. An integral component of these services has been the training of traditional birth attendants, and the country is currently expanding TBA training nationwide [12]. The TBA is defined as “a person (usually a woman) who assists the mother at childbirth and who initially acquired her skills delivering babies by herself or by working with other TBAs” [13]. The main tasks assigned to trained TBAs are: (1) to encourage women to seek prenatal care; (2) to recognize women at high risk of complications and refer them for medical attention and/or delivery in a health facility; (3) to encourage women to use family planning after delivery and (4) to assist in normal, uncomplicated births and facilitate a clean, safe and culturally appropriate delivery [14]. By performing these tasks, TBAs theoretically can decrease maternal mortality by promoting healthy practices among pregnant women, improving screening and referral for high risk pregnancies, expediting emergency care for obstetrical complications, performing uncomplicated deliveries safely and decreasing fertility. The Danfa Comprehensive Rural Health Project, located 29 km north of Accra, has had a TBA training program since 1973. This study was undertaken to evaluate the potential of trained rural TBAs working in an area of relatively abundant health resources to reduce maternal mortality. THE
STUDY
AREA
After initial registration in 1973 of 263 untrained TBAs in the entire study area, a survey of pretraining knowledge, attitudes and practices was administered to 82 TBAs who lived in a defined area. The results have been published elsewhere [IS]. A training manual was designed based on the findings [ Between and 60 were in subsection the area, Area [17]. prohas relatively since and additional were between and Initial has supported periodic courses supervisory in TBA’s every or The health who develop pro-
EADES et al.
has and these since inception. Danfa Area located km of in Greater Region, the of coastal and rain Area has villages populations from to The are subsistence A community-based of women childbearing in village Area in 2 TBAs indicated 93% the in previous had attended a [18]. facilities the include Danfa Post, rotating clinics a hospital general outpatient The facilities Accra 6 7 180 clinics 68 homes. passenger operon major between Danfa and during hours. trip include walk several to main for living the remote In area relatively health ties, emphasis been on the to and complications mediately. protocol referral been lished is to TBAs training reinforced supervision. vehicle the centre made to patients local is available. TBA advised refer to the to hospital health if to if doubt, give of at to nurse physician to a of referral indicating nature the In maternal is to 500&1500 100,000 births infant greater 100 per live [l2]. total rate 6.3 per and annual of population is with birth death of and per population Five of women modern [5]. percent births attended a 24% an family and are [191. SURVEY
METHODS
A questionnaire based on the original survey was field tested in the Eastern Region of Ghana. Symptomatic descriptions rather than strict diagnostic criteria were used to identify maternal complications. For example, postpartum hemorrhage was defined as excessively heavy bleeding after delivery of the baby. Four Danfa Health Post employees fluent in the local vernacular were trained to administer the questionnaire with efforts to standardize translation. Most TBAs were given at least 24 hr notice before administration of the questionnaire at the TBA’s place of residence. Questionnaires were administered by a
Traditional
birth attendants
and maternal
translator with one investigator recording and clarifying answers as necessary. On average, administration took 45 min. The TBAs interviewed were located in 20 villages. Of 86 TBAs trained in Area 1, 37 are currently in active practice in the area, defined by Danfa staff as performing a minimum of 1 delivery per year. The questionnaire was administered to 35 of the 37 active TBAs. Two TBAs were out of the area and were unavailable for interview. No other selection criteria were used.
mortality
Table I. Routine
in Ghana handling
1505
of high risk deliveries
Routinely performed
by TBAs
Routinely referred
Total
High risk category
N
%
N
%
N
%
Primipara Physical deformity/ short stature History of obstetric complications Previous cesaerean section Twin gestation Antepartum complications Malpresentation
8 6
23 17
27 29
77 83
35 35
100 100
5
14
30
86
35
loo
5
I4
30
86
35
100
I3 3 9
37 9 26
22 32 26
63 91 74
35 35 35
100 100 100
RESULTS
Most TBAs were elderly married women with no formal education (Fig. 1). The female TBAs had an average of 6 children and the males 9. Attending births was a part-time activity for most, their primary income coming from farming and trading. Twentyfour held either traditional, political or church leadership positions in their communities. These TBAs performed an average of 7 deliveries in the year prior to interview and had been in practice an average of 21 years. Most charged the equivalent of three dollars and a small gift of food for their services. Eighteen had originally learned their skills from a parent, and 16 had mentored one of their own children. Only four TBAs limited their practice to birth attendance. Twenty-five treated infertility and menstrual problems, 15 practiced general herbal medicine and 12 considered themselves spiritual healers. All reported attending the pregnant woman in the months before delivery. Frequency of visits ranged from daily to monthly, with the first visit at anywhere from 3 to 8 months of pregnancy. Most stated that on the first visit they took a simple obstetrical history, examined the patient and gave nutritional advice. All reported referring the pregnant woman to the health post for routine antenatal care, with 14 doing so on the first visit. Thirty routinely gave the pregnant and laboring woman herbal treatment to prevent problems, stimulate fetal growth and hasten labor. Twenty-five had
soap and a scrub brush in their midwifery kits for handwashing before delivery. All but two reported always using a new blade to cut the umbilical cord and dressing the cord with mercurichrome provided in the midwifery kit. Thirty-two reported contact with the new mother and baby in the weeks following delivery, and all reported referring patients to the child welfare clinic. All offered advice on breastfeeding, most recommending it until the child was 1 or 2 years old. All but one reported referring patients to the health center for family planning services. One TBA did not refer because of her belief that husbands do not approve of family planning. Although most TBAs reported appropriate referral of high risk patients for delivery at the hospital or health center, many reported routinely performing such deliveries themselves (Table 1). Malpresentation and twin deliveries were commonly performed in the village. When confronted with an obstetrical emergency, many reported immediate referral, particularly for seizure (Table 2). For antepartum bleeding, postpartum hemorrhage or obstructed labor, many described an attempt at management with herbal treatment before referral, and some did not consider referral necessary at all. Ten TBAs reported that when they referred their patients to the health post or hospital the patient always went (Fig. 2). Many, however, reported that their patients do not go to the hospital or health post when referred. When asked why, TBAs reported that financial limitation or lack of transportation and the expectation of disrespectful or painful treatment from hospital personnel were major barriers to higher-level care. DISCUSSION
Fig. 1. Demographic
characteristics
of TBAs.
In many parts of Africa, traditional birth attendants have provided obstetrical care for centuries and are very well respected and highly influential members of their communities [20,21]. In 1974, TBAs performed an estimated 70-90% of deliveries in African countries [22]. Recent data based on nationally representative samples indicates a more modest role, ranging from 30% of deliveries in Mali to 6%
CAROLA. EADES et al.
1506
Table 2. Management Antepartum bleeding
of complications
Postpartum hemorrhage
Peripartum seizure
Obstructed labor
Manaaement
N
%
N
%
N
%
N
%
Refer directly Attempt management then refer Herbal treatment only Does not know
I6 I2
46 34
12 I8
34 52
26 4
74 II
20 II
57 32
6 I
I7 3
5 0
I4 0
2 3
6 9
4 0
II 0
I-i&II
3s
100
3s
loo
3s
loo
3s
loo
in Zimbabwe [19]. The proportion of births attended by TBAs is greater in rural than urban areas, and in isolated rural areas, TBAs and herbalists may be the only accessible health-care providers. Even when the services of a midwife or physician are available, many women prefer the services of a TBA. Ekarem et al. found that reasons given for preference for a TBA had little to do with scarcity of hospitals and maternity clinics. The patients’ perception of the TBA’s experience, kindness, skill and interest in the welfare of the baby attracted the clientele [23]. Williams and Yumkella found that 85% of mothers preferred TBAs because they were easily accessible, friendly and kind during delivery, and less expensive than a hospital delivery [24]. Sargent found that clients and TBAs share similar beliefs, values and ideas about the cause of illness. The TBA’s duties included traditional healing activities, which patients found valuable [25]. These additional services and a perceived sociocultural similarity may explain many women’s preference for a TBA even when modern facilities are accessible. The combination of availability and acceptability of TBAs in rural areas increases their potential to improve the health status of women and children in their communities. This potential has long been recognized, and from the early 1970s the World Health Organization has actively encouraged countries to establish TBA training programs and utilize them as extensions of their maternal and child health services. Between 1972 and 1982 the number of countries with some form of TBA training increased to 52 from 24, many of them in Africa [22]. Studies assessing the impact of TBA training on maternal and/or infant
Fig. 2. Reasons for referral refusal
mortality are few and inconclusive, however. In the Farafenni area of The Gambia, the maternal mortality rate fell to half the preintervention level 3 years after the introduction of a primary health-care program that included TBA training. The authors acknowledge that improved transportation also may have contributed to this decrease [2]. Evaluation of TBA records in Andhra Pradesh, India, however. showed no decrease in death rates [26]. This type of analysis is difficult, at best, because of the lack of transport and personnel to collect community-based data, the relative rarity of maternal deaths and the cultural belief that maternal death is a disgrace to the family and should not be discussed [27,28]. The Danfa TBAs are in a good position to play an important role in all phases of prevention of maternal mortality. The preventive services of the rural health post are available in the immediate area at rotating satellite clinics. The more sophisticated services of Accra are close and relatively accessible. One of the TBA’s greatest strengths lies in primary prevention. They enthusiastically refer their patients for antenatal care and encourage the use of contraceptives and family planning. At higher levels of prevention, however, their impact on maternal mortality is lower. Many are performing deliveries that they have been taught to refer to higher-level care, and many are attempting management of complications with herbal remedies before referring or are not referring at all. In spite ofmany years in practice, they perform few deliveries per year, and because the incidence of most complications is low, their personal experiences with complicated pregnancies are limited. In traditional apprenticeship systems knowledge acquisition is cxperiential, acquired by ‘going around’ with an expcrienced midwife. With little or no formal education. training sessions for TBAs may be an ineffective surrogate for experience [29]. This relative lack of experience may make it difficult for them to perceive their limits when confronted with a complicated pregnancy or an obstetrical emergency that requires higher-level care than they can provide. These TBAs report, however, that even when a patient is referred, she may not go. The tinding that cost for
Traditional
birth attendants
and maternal
mortality
in Ghana
1507
fear of anticipated treatment is a barrier to care. TBAs reported that patients feared painful and disrespectful treatment from hospital personnel [25]. Families may be less willing to accept the financial burden of hospitalization when they feel poorly treated by medical personnel. In the developing world, where many causes of maternal mortality are preventable, trained TBAs play an important role in health promotion in their communities. When prevention fails, many maternal deaths may be avoided with surgical intervention, blood transfusion and antibiotics, which TBAs are clearly unable to provide. As the point of first contact with the health-care sector for many women with life threatening complications, however, the TBA is essential in facilitating timely and appropriate care. This study, like most in this area, is limited by its very nature. Although some TBAs reported practices inconsistant with their training, assessment of behaviors by a survey questionnaire is fraught with recall bias, presumably toward the perceived correct response. In future research, studies including a direct participant observer of TBAs at work would better clarify their most appropriate role in reducing maternal mortality and morbidity. Acknowledgements-This study was funded by the AMSA International Health Fellowship. The authors would like to thank the staff at the Danfa Clinic for their invaluable assistance as well as the faculty and staff of the Departments of Community Health at the University of Ghana Medical School, Accra and the University of Science and Technology, Kumasi.
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of TBAs in the South Eastern State of Nigeria. Inst. of Pop. and Manpower, Series 3, 1975. Williams B. and Yumkella F. An evaluation of the training of TBAs in Sierra Leone and their performance after training. In The Potenrial of the TEA. WHO Offset Pub. 95, Geneva, 1986. Sargent C. Obstetrical choices among urban women in Be&. Sot. Sci. Med. 20, 287-292, i985. Swaminathan M., Naidu A. and Krishna T. An evaluation of Dai training in Ananda Pradesh. In The Potential of the TBA. WHO Offset Pub. 95. Geneva. 1986. Boerma J. T. Levels of maternal mortality in developing countries. Stud. Fam. Plan. 18, 213-221. 1987. Lewis J., Janowitz B. and Potts M. Methodological issues in collecting data from traditional birth attendants. Int. J. Gvn. Obstet. 23, 291-303, 1985. Jordan B. Cosmopolital obstetrics: some insights from the training of traditional midwives. Sot. Sci. Med. 28, 925-944, 1989. Lasker J. N., Choosing among therapies. Illness behavior in the Ivorv Coast. Sot. Sci. Med. 15. 157-168. 1981. Mwabu G. M. Health care decisions at the household level: results of a rural health survey in Kenya. Sot. Sci. Med. 22, 315-319, 1986.