By MELUSE KAPATAMOYO
For many years, Traditional Birth Attendants (TBA’s) were considered life savers, helping pregnant women, especially those living in rural areas, to deliver safely.
Statistics from the Ministry of Health indicate that Zambia functions on a limping health staff of 33, 000 as opposed to the required 60,000, therefore, TBA’s filled the gap in the healthcare system. Their role included paying expectant mothers periodical visits to educate them on the importance of delivering with a trained person and the importance of attending ante-natal.
However in December 2010 government made a shocking announcement putting an end to the main role that TBAs had been known for; they would no longer help pregnant women to deliver. Instead their new role would involve educating women on the benefits of delivering at health care facilities as opposed to home.
Under the new rules, traditional birth attendants are to give information to communities and women on the danger signs in pregnancy, the need to go for ante-natal, testing for HIV and all other reproductive issues that maybe necessary. They are also to escort the pregnant woman to health facilities to deliver.
At the time Ministry of Health spokesperson, Dr Kamoto Mbewe told the press that because TBA’s were unable to address complicated and life-threatening complications such as excessive bleeding which can occur during birth, they were contributing to high levels of maternal mortality rates in Zambia.
He said such complications needed the attention of qualified medical personnel. Unfortunately, because of women’s dependence on TBA’s due to long distances to health care centres and limited staff, they were shunning healthcare centres were they could receive comprehensive check-ups, treatments and care, during ante-natal, actual delivery and post-natal.
The World Health Organisation (WHO) estimates that out of every 100, 000 women who give birth, 591 die. And for each woman who dies, an estimated 100 survive child bearing but are afflicted by disease, disability or physical damage caused by pregnancy-related complications.
In addition, while ante-natal coverage in Zambia currently stands at 94 percent, only 47 percent of births are attended to by a trained midwife.
Government’s decision to halt the delivery of babies by TBA’s was highly criticised, more so in rural parts of Zambia where people have to walk long distances to get to health centres where they would have to wait in a long queue before being attended to. That is, if the health post was lucky enough to have trained medical staff.
Some people living in remote areas such as Mungule in Chibombo district, feel instead of saving lives as intended by government, realigning the duties of TBA’s from delivering to being mere escorts, has led to increased fatalities among pregnant women and their babies.
“Since the ban, the situation has become worse. Many women are dying. Some people live very far, and it’s worse during the rainy season. How do you expect a heavily pregnant woman to jump on a flooded river, most of these health centres do not have shelters so you can’t expect a woman to come weeks before delivery,” noted a former TBA who preferred anonymity.
As an alternative to discontinuing part of their services, she said they should have been offered additional training to help them cope with rare complications which sometimes occur during delivery.
She was trained back in 1996 by UNICEF and says she has delivered more than 300 babies in rural areas.
“A woman who has gone through labour knows the pain of labour, but when a mother delivers and hears that first cry from her baby, she is overwhelmed by joy. Unfortunately, there are now fewer women experiencing that joy. In our community, we are seeing more women and their babies die during delivery.”
Without the availability of trained birth attendants, pregnant women have been left with no choice but to rely on family members who have no training.
She described a recent incident where both mother and child died during labour. The neighbour who had been called upon to help with delivery accidentally pulled the umbilical cord too hard that it cut.
“Such an incident could have been avoided. We have been trained to handle such unexpected occurrences. If it was something we could not handle, we tried our best to get the woman to a health centre, or get a health staff to the woman,” the TBA explained.
It is because of such incidences that she has gone against governments regulations and helped women deliver. Some women gave birth on their way to the health centre while others simply lived too far to travel.
“If a woman comes to me for help, I cannot chase that person away because if I did their blood will be on my hands. I know what the law says but I can’t bear to see a woman in such pain and do nothing,” she said.
Despite these concerns, government says it will not rescind its decision. But, in emergency cases, such as when a pregnant woman is ready to deliver while being escorted to a health facility, the TBA can help with the birth.
“We understand that sometimes it’s difficult to find transport in time. Some people also find it difficult to tell when they are about to deliver. During those emergency cases, there is little anyone can do. The TBA can help deliver but it must be emphasized that we want all deliveries in a health facility,” explained, Dr Mbewe.
He said when TBA’s were introduced the idea was to help in the reduction of maternal mortality, but it was later discovered that they were unable to manage the five major causes that lead to death.
They are; hemorrhage (bleeding) during or after pregnancy, hypertensive disorders, unsafe abortion, infection and obstructed labour. Malaria in pregnancy, anaemia and HIV are other indirect causes that can lead to death.
“If you look at all these causes, if a woman is bleeding, the TBA will not be able to stop the bleeding. If she has an infection, again the TBA will not be able to manage the infection. It was with that realisation that we are now encouraging as many women as possible to deliver in the health facility.”
Another concern was that while in the past experts believed they could tell a woman whose pregnancy was at risk, recent data shows pregnancies considered to be at higher risk experienced recorded fewer deaths.
For example, a woman who had delivered at least five children would have been said to be at higher risk of bleeding after delivery, because of undergoing too many deliveries, the uterus may become flabby and not contract well after delivery.
At low risk were women who had never been pregnant before.
But overtime, results have shown that most of the deaths occurred in women between ages 20 and 29, women considered to be at low risk.
In a developing country like Zambia where access to emergency obstetric care is not readily available, for a woman who has delivered and starts to bleed, she only has two hours or less to seek medical attention. Those with obstructed labour can last upto 72 hours.
Dr Mbewe added, “If she is in hospital and is bleeding, the nurse will give the women a drug to stop the bleeding, if it’s a tear in the birth canal, we can suture, if the placenta has gotten stuck, we have trained the staff to conduct manual removal of the placenta. They can actually push in the hand and remove the placenta. Nurses are also trained on how to manage incomplete abortions e.g women who have had miscarriages or induced abortions. All these things can’t be done at community level.”
In 2010, government launched the Campaign on Accelerated Reduction of Maternal Mortality and formed Safe Motherhood Action Groups (SMAGs), where TBAs have now been incorporated.
A 2011 report on the Planned Parenthood Association of Zambia’s Global Poverty Action Fund “No woman Should Die While Giving Life,” a project funded by the UK Department for International Development (DFID), SMAGS are trained to assist women during their pregnancy.
They disseminate information to community members about pregnancy, childbirth and family planning, and work to challenge local awareness on maternal health, sensitise the community on the importance and benefits of seeking early ante-natal care, and educate people on the benefits of birth preparedness and transferring to a healthcare centre in advance to seek skilled and specialised care once in labour and during labour.
However, the overall objectives of the SMAG programme are; to strengthen community participation in maternal, newborn, child health. To improve community knowledge on safe motherhood and issues through health education, enhance the community’s utilization of reproductive health services, increase male involvement in safe motherhood activities and also strengthen partnerships between the community and health system.
Government is also up-scaling the training of midwives to meet the country’s demands.
“We have introduced direct entry into midwifery whereas before they had to train as a nurse and work before going for the midwifery course, they train for two years. We have also increased uptake of nurses and doubled in schools, all this in an effort to increase the workforce,” said Dr Mbewe.
In addition, in its 2013 budget, government has allocated K3.6 trillion, equivalent to 11.3 percent of the budget to health, and it intends to recruit not fewer than 2, 000 front line medical personnel.
The topic of whether or not, TBA’s contribute to the reduction of maternal and mortality remains a hot-button issue in many African countries.
In 2007, TBA’s were banned in Malawi, but reinstated later in 2010, with Malawian president Mbingu-wa-Mutharika admitting the Ministry of Health had made a ‘grave mistake.’
UNICEF Zambia recommends the involvement of traditional birth attendants to create demand for government-led maternal and child health and nutrition services, including encouraging pregnant women to go for ante-natal care.Chief of Communications, Patrick Slavin said “TBAs are part of UNICEF-supported Safe Motherhood Action Groups (SMAGs) in all 10 provinces of Zambia, an important approach to lower Zambia's unacceptably high maternal mortality rate. TBAs can also provide care for women when they are recovering following giving birth.”
He said UNICEF is also advocating for more mothers shelters in the country, which are urgently needed.PYM