Understanding links between Traditional and Skilled Birth Attendants

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By Pamela Onyo, Anglican Overseas Aid

AACES TBA

The Road Less Travelled (TRLT) is a project supported within the Australia Africa Community Engagement Strategy (AACES). AACES is a partnership comprising the Australia government with ten Australian NGOs and their partners working across eleven African countries. Each year AACES releases an annual report and this year the Kenya partners decided that the theme should be the outcomes of research conducted under the auspices of TRLT.

The research sought to enable better understanding of the current care seeking behaviour of childbearing women in pastoralist communities of Laikipia and Samburu Counties. The two-year study has been conducted by TRLT partners Nossal Institute for Global Health at the University of Melbourne and the Mother’s Union of the Anglican Church Mt Kenya Diocese, in collaboration with Amref Health Africa. It has been funded through the Australian Development Research Awards.

What is the issue?
Kenya has an unacceptably high numbers of mothers and babies dying at the time of birth. This is particularly and especially true for the semi-nomadic pastoralist communities who are living in remote parts of the country where many women deliver their babies at home attended by a traditional birth attendant (TBA). These TBAs are generally highly respected and trusted members of their communities who have a personal relationship with the women they are caring for. However, they are not trained nor equipped to manage complications of pregnancy and childbirth, which occur in about 15% of cases, and contribute to the preventable deaths of mothers and babies.

The government of Kenya wants all women to deliver their babies attended by skilled birth attendants (SBAs) in health facilities such as dispensaries and hospitals and has put a target of 90% skilled birth deliveries by 2015. SBAs are doctors and nurses who are trained and equipped to respond in the event of complications. However, for a range of reasons, women from pastoralist communities are often reluctant or unable to attend these services.

Launching the AACES Annual Report
With the research now complete the findings were disseminated to local stakeholders from Laikipia and Samburu County’s, and also at the national launch of the Australian Africa Community Engagement Scheme (AACES) annual report. Over 200 people attended the national annual report launch including government representatives, community members, and NGO CEO’s.

The report was launched by the Australian High Commissioner, HE John Feakes, while the Archbishop of the Anglican Church of Kenya, HE Eliud Wabukala, was invited to deliver an address on the research report where he said: “If we are to reduce the incidence of maternal and neonatal mortality then we need to understand what the factors are that attracts or inhibits a woman from seeking professional support when giving birth … The report provides illuminating information on the situation for pregnant women in Laikipia and Samburu. This information gives a detailed picture about what it is like for a pregnant woman, the difficulties and challenges that she faces in bringing new life into the world.”

The Research Findings
The main findings from the study are that:

  • The pastoralist women knew about the free delivery care provided by the government, but for many, the distance to the health facility was too far to walk, and transport costs were a problem.
  • Both women and men acknowledged that delivery with an SBA in a health facility is more hygienic and safer because they can manage complications if they occur.
  • The women said that they were frightened of some medical procedures in hospitals, were concerned that their modesty would not be protected, found hospitals to be very cold places, and did not want to be separated from their families during the delivery period. Additionally, SBAs have a reputation for being unfriendly to pastoralist women. Some women thought that having a baby in a health facility was a sign of weakness.
  • According to pastoralist women, TBAs provide comfort and care in a warm and familiar place, and are locally available and affordable.
  • TBAs remain with the women for days to weeks after delivery to care for them and to take responsibility for household duties so they can rest.
  • The role of TBAs includes helping to mediate between the husband and wife, giving dietary advice (sometimes not very good advice), receiving the baby, massaging the woman, promoting breastfeeding, and if necessary, referring and accompanying the woman to the health facility.
  • TBAs are able to recognise the important complications of delivery, but refer rather late in the event of an obstructed labour. They do not really know how to manage a baby that is having difficulty breathing.
  • Actively including TBAs in programmes designed to improve better utilisation of SBAs in pastoralist communities will help to increase the number of SBA deliveries, and reduce the number of TBA deliveries, some of which are unhygienic and unsafe.

Conclusion and Way Forward

  • There is potential complementarity in the perceived strengths of SBAs and TBAs. TBAs are highly acceptable and accessible to women, and are valued for their supportive role and emotional and socio-cultural sensitivity, but are not trained or able to diagnose or manage most obstetric and neonatal risks and complications. SBAs are skilled in diagnosis and management of these risks and complications, but are not seen as very accessible, or acceptable, in their service delivery. This complementarily, and the strong support from all stakeholders for greater integration of the work of TBAs and SBAs, will lead to further consideration of potential models for collaboration and cross-learning.
  • When combined with results from the quantitative arm of the study, they informed options for collaborative models of care involving both TBAs and SBAs for more effective, efficient and contextually appropriate care, which will be developed in partnership with participants and other stakeholders. These models will consider the potential for collaboration across all stages of pregnancy, labour and delivery, and the neonatal period.

As a result of the research the TRLT project and research partners, in conjunction with the Ministry of Health, are investigating the possibility of piloting a ‘pastoralist friendly health facility’.

A pastoralist health facility would support shared care by traditional birth attendants (who are preferred by women to be their service providers) with skilled birth attendants (who are the providers with the skills to save maternal and newborn lives). Such a facility would be structured specifically to suit the requirements of pastoralist women and ameliorate the issues that inhibit them for attending. For example, it may have a traditional house with fireplace on clinic grounds where a woman may weight prior to going into labour, and her close friends and family can be in attendance. A TBA may accompany the expect mother and comfort her during the birthing process, while clinic staff are especially trained to respect the woman’s modesty and accommodate her cultural requirements. The clinic would build close links to the community so that they feel ownership and responsibility for it. The objective is to significantly increase the number of women who attend ante- and post- natal care, and deliver in a safe environment, therefore reducing maternal and neo-natal mortality.

You can watch a video on the AACES 2013-14 Annual Report at: https://www.youtube.com/watch?feature=player_embedded&v=UQJePZcIaKI

You can access the AACES 2013-14 Annual Report at: http://dfat.gov.au/about-us/publications/Pages/aaces-annual-report-2013-14.aspx

You can download a booklet where TBAs and SBAs who took part in the research tell their stories:Walking together book viewing version

Below is a video about TBAs and SBAs, and how they are working together to benefit communities.

Credits for the photo are: From Left – Mary, AACES program beneficiary, John Feakes, Australia’s High Commissioner designate to Kenya (left), Anna Dorney from DFAT, Eliud Wabukala, Kenyan Anglican Archbishop, and Patrick Amoth, Ministry of Health. Photo by Douglas Waudo, ACBF.

Video: Eliminating barriers to skilled birth attendance

Following on from our previous post, here is the second clip featuring our team in action at the Global Maternal Health Conference (GMHC) last month. Valerie Browning of the Afar Pastoralist Development Association (APDA), our Ethiopian partner, led a panel discussion around a topic very close to her heart, “Eliminating barriers to skilled birth attendance.”

This two-part video from the Maternal Health Task Force gives insight into some of the incredible work being done and different strategies being adopted in Ethiopia, Burkina Faso, India and Bangladesh, in an effort to improve skilled birth attendance. (You can view Valerie’s presentation on APDA’s work from the beginning of the second video).

Eliminating barriers 1 from Maternal Health Task Force on Vimeo.

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