Introduction
Maternal Health is indeed a problem of paramount public health concern all over the world, especially in the areas where there is no or minimal healthcare infrastructure. Policymakers and international health body have highlighted institutional delivery that is attended by skilled personnel as the safest pathway to minimize maternal and infant mortality in decades. The same good intentioned emphasis has however, on some occasions, sidelined the service by the traditional birth attendants (TBAs) who until now have remained the most common way through which maternal care is offered to the millions of women globally.
However, the story is changing. Grassroots-driven movements are demonstrating that not only is it a mistake to sidelined TBAs, it is possible to use a combination of local training, peer-to-peer networks and education, as well as support structures to help TBAs transform maternal health outcomes, in a sustainable, culture-sensitive way. These models of communities to communities fight against the idea that TBAs cannot be reconciled with safe and modern health methods. Instead, they show that substantive change may and should develop in the grassroots.
This paper examines the best examples of community-led maternal care initiatives to have absorbed TBAs into the contemporary health care system, and how the policy makers can learn significant lessons based on these projects.
The Enduring Role of Traditional Birth Attendants
Cultural and Social Anchors
TBAs are more than birth attendants in most rural societies. They are community turn to and trusted health advisors and cultural brokers. They are not limited in the areas of physical help during the course of Labor:
- Emotional support of pregnant women
- Teaching communities about postpartum care
- Nutrition and breast feeding support of the mothers
- Holding the traditional practices related to safe deliveries
Clinical professionals are not easily able to take over these roles because they might not be familiar with the culture or be trusted by the community.
Challenges of Exclusionary Polices
Efforts to prohibit or limit practice of TBAs have tended to lead to unintended results:
- Women are still quiet women secretly seeking TBAs instead of using formal healthcare.
- TBAs work without being supervised and this augment risks that come with unsafe procedures.
- Communities and formal health providers have a greater suspicion of each other.
Blanket prohibition fails to appreciate the ground realities in rural healthcare services delivery where TBAs are the most readily available alternative to most women.
Grassroots Solutions: Transforming TBAs into Community Health Allies
New grassroots programs all over the world are also thinking out of the box in terms of the role of TBAs, noting that that cultural knowledge and modern medical practice can mix and make their miracles as well.
Bangladesh: Community Based Training and Empowerment
Bangladesh, TBAs have been main providers of maternal care for so long. Community-led programs have considered their influence and have resorted to a collaborative model that entails:
- Largescale practice of clean delivery methods and the identification of emergencies.
- Contact with competent health professionals.
- TBAs to be incorporated in health campaigns that encouraged respectively, facility deliveries and antenatal care.
The findings are impressive: territories involved in such projects have indicated:
- More referrals to the health facilities of the cases classified as high-risk.
- Reduced cases of maternal deaths.
- Enhanced baby health conditions.
Instead of eliminating traditional practices, by evidencing safety precautions, the Bangladesh approach originally improves them.
Nigeria: The Lagos State Model
Another good illustration is presented by Nigeria. Firstly, the traditional birth attendants in Lagos State were prohibited in delivering babies because of the maternal mortality. Nevertheless, policymakers soon came to note that the exclusion was not enough to make the women stop relying on TBAs. In its place a new model arose:
- TBAs registration and licensing.
- Structural learning and training practical programs paying attention towards safe referrals and practices.
- Creation of networks linking TBAs and local health facility.
Since implementation Lagos State has recorded:
- Increased facility based deliveries.
- These were dramatic decreases in the obstetric emergencies treated exclusively by the TBAs.
- Increased level of confidence in formal health services.
This is a partnership method that proves the effectiveness of regulation and respect to the traditions of the community.
Nepal: Integrating TBAs into Community Health Systems
Nepal has made a prologue in relating TBAs into its community health worker system. The government instead of abolishing TBAs concentrated on:
- Training TBAs in the essential obstetrics care.
- Including TBAs in the community health committee.
- Use of TBAs in provision of outreach on issues like family planning and antenatal care.
Outcomes in Nepal are, among others:
- Enhanced maternal health alerts
- More delivery of high-risk pregnancies to facilities.
- Greater ties between the health services and the communities.
Such community-based initiatives demonstrate that TBAs can become effective mediators between the old rituals and the healthcare facilities.
Building Effective Grassroots Training Programs
Core Components of Successful TBA Training
The initiative of maternal care by the communities always focuses on a certain aspect in their training:
- Clean Delivery Techniques
- Sterilised and hand hygiene tool usage
- Cutting of the cord safely and newborn resuscitation basics
- Recognition of Danger Signs
- The determination of such symptoms as excessive bleeding, blood pressure, and too long labor.
- Emergency Referrals
- Well defined procedures to be followed in transferring cases at risks to medical facilities.
- Creation of emergency transport systems.
- Health Education and Counselling
- Empowering antenatal support visits
- Provision of postpartum support and breast feeding advice.
There are also programs where culturally respectful practices are incorporated so that TBAs are able to be trusted within the community and yet use modern ways of practice.
Peer Based Education Models
The education that is based on peers is another important invention with respect to grassroots initiatives. In models like these:
- New practitioners are mentored by the experienced TBAs.
- The frequent group meetings develop therapeutic places to express the problems and acquire new knowledge.
- Teamwork in solving problems enhances a sense of responsibility and a culture of enhancement.
These peer networks have been found to be effective in keeping up high standards of care, cutting on unsafe practices and enhancing solidary within the community.
Community Support Networks: The Social Backbone
Engaging Community Leaders
Those programs which have succeeded in changing TBAs usually manage to win the endorsement of local leaders, such as:
- Rural community elders
- Religious authorities
- Females advocacy groups
Engaging influential voices:
- Supports proper training programs
- Motivates the populace into new health practices.
- Minimizes the opposition to facility based support
Family and Male Partner Involvement
In the past, men have been left out in maternal health discourse. Effective grassroots efforts are turning more and more to the involvement of male partners, informing them about:
- Birth preparedness
- Danger signs during pregnant stage
- Facility-Based Deliveries support.
In Tanzania and Uganda programmes, the delays to seek care are lower when family members, particularly the male partners are involved in maternal health planning.
Evidence Based Results from Community Led Maternal Care
The overall effect of grass-roots initiated programs is huge. All over the world:
- The rate of maternal mortality has reduced significantly.
- The TBAs have emerged as supporters of safe delivery.
- There is more confidence within the communities in formal health systems.
In Bangladesh, mortality rate of mothers reduced dramatically in regions where trained TBAs were active. The same tendencies can be seen in Nigeria and Nepal, and support the assumption that TBA competencies may be measured by the positive aspects of its empowerment.
Overcoming Challenges
Resistance to Change
At the beginning, it happens that some TBAs are unwilling to embrace the modern ways as they fear that:
- Losings of status in their communities.
- Mis-trust of official health leaders.
- Stability to income.
The most appropriate programs deal with these fears by:
- Respected dialogue
- Appreciation of the TBAs in communities.
- Partnership under clear incentives
Sustainability and Funding
A lot of grassroots programs rely on donor funding, which is a matter of concern with regard to sustainability. To leave a long-term effect, governments should:
- Align TBAs training inside national health revenue budget
- Build cost-sharing systems with the local communities.
- Integrate all program with wider health systems strengthening initiatives
Policy Lessons for the Future
Integration, Not Exclusion
The Community-led maternal care programs have important lessons policymakers around the world can learn:
- TBAs do not obstruct safer maternal care, they are the connector.
- Community participation is enhanced through respect of culture.
- Low-cost training has important public health payoffs.
Banklet restrictions on TBAs usually lessen healthcare disparities. Instead, aligning policies:
- Enhance Maternal and New-born health outcomes.
- Highs facilities deliveries
- Establish decision-making trusted relationships between communities and the health systems.
Scaling Successful Models
Governments, as well as the NGOs, are advised to prioritize:
- Recording effective grass-root strategies.
- Adjusting program trainings to localised contexts.
- Technological investments, such as mobilized health tools, in supporting TBAs.
Various promises to mobile applications have shown in:
- Directing TBAs on methods of safe delivery.
- Monitoring patient information and referrals
- Offering real time emergency service.
Those innovations can amplify success stories from the grassroots level to the national level.
Conclusion
Maternal care programs initiated by grassroots comprise an important revelation: the socially acceptable and culturally aligned sustainable changes in maternal health have to take into consideration the local community dynamics, the cultural traditions, sustainable practicalities following its ground. These initiatives help to achieve a paradigm shift in international TBAs training them with modern knowledge, getting them involved in formal health systems, and utilizing community support networks to achieve such a transformation.
These successes hold a lot of lessons to the policymakers. Governments would do better to examine and adopt community led maternal care that combine tradition and safety with healthier mothers, safer childbirths, and healthier communities.
The evidence is clear, wherever it has been measured communities are putting their own teams on the ground in Bangladesh, in Nigeria and in Nepal, to drive maternal health improvements top down.
