Introduction
Traditional birth attendants (TBAs) have remained central to the care of mothers and newborns in most underserved populations, generation after generation. TBAs are often older women with long established roots in the community who are regarded as valued trusted partners, companions and care givers during pregnancy, child birth and the post-child birth experience. Even though they have great cultural importance, TBAs often are not medically trained, which hampers their ability to manage complications resulting in avoidable maternal and newborn deaths.
Nevertheless, as the world struggles to achieve the millennium development goal in reducing deaths related to maternal and newborns health systems are seeing the wisdom of using TBAs as a way of filling crucial service delivery gaps. TBAs, when well trained and even monitored can serve along with skilled professionals in providing a lot to maternal and newborn health. This paper discusses the manner in which TBAs can be incorporated into the contemporary health system through lessons learned by effective programs across the globe, as well as considerations on the regulatory issues and ways forward.
The Enduring Role of Traditional Birth Attendants
Historical and Cultural Relevance
TBAs have huge social capital within their societies. They go beyond the physical care services and provide emotional support, ritual activities and traditional medicines that are appreciated by many women. To pregnant mothers who must travel long distances to the clinics, those who lack the finances to reach clinics, or those in societies where giving birth in a facility is not a socially acceptable practice, TBAs are the sole available option.
Nevertheless, some traditional practices have involved harmful methods, which include nonsterile treatment of umbilical cords or delay in obtaining emergency care. This has been characterized as a dichotomy where there have been arguments about whether TBAs should be left out of the formal health strategies or whether they could be turned into important allies by training and integrating them.
Training and Skill Enhancement for TBAs
Building Competence and Confidence
Various nations have proved that training TBAs pays off. Topics covered in training programs are:
- Identification of risk factors in childbirth and pregnancy
- Clean and secure delivery practices
- Fundamental care in it such as warmth coverage and first-day breastfeeding
- On time health care referral to health facilities
- Family planning and nutrition counselling
In addition to the technical experience, training gives confidence to TBAs and makes them to work together, not against those skilled healthcare professionals.
Case Study: Bangladesh
A good example of TBA training account can be seen in Bangladesh. Several decades ago, the rates of maternal mortality belonged to the global top ones. TBAs were also trained on how to conduct a clean delivery, identify complications and make referrals through targeted programs.
Evolutions revealed:
- Higher antenatal care visits
- High ratings of facility deliveries
- Lowered neonatal and maternal deaths
TBAs also served as a force in aiding the communities in their education, safer practices and eliminating the myths that were harmful.
Supervision and Support Structures
Moving Beyond One Time Training
It is not sufficient to train TBAs. Unless supervised, skills are lost and they even go back to the conventional yet hazardous practices. Anything to do with integration requires continuous support:
- Standard refresher courses
- Supervising visits of health professionals
- Distribution of clean delivery provider kits and easy medicine equipment
- Emergency referral systems Clear Emerging referral systems
Case Study: Nepal
Nepal Safe Motherhood Programme involves incorporation of TBAs into a controlled network. TBAs receive:
- Periodic training updates
- Supports from health community volunteers
- Direct access to first line health facilities
This model keeps the TBAs informed, and they will be more comfortable to refer complex cases instead of making dangerous efforts at home births.
Formal Integration into Health Systems
Roles and Responsibilities
The countries, which have incorporated TBAs, successfully determine their functions within the expanded health system. Frequent actions include:
- Normal vender/delivery in low-risk pregnant women
- Training women about risk factors and good behaviour
- Promotion of visits to antenatal and postnatal care visits
- Monitoring of pregnancies in the society
- Working as a cultural translator between societies and institutionalized services
In other countries, TBAs are provided with an official status and small payment, which encourages them to work in a safer manner and be aligned with the national health targets.
Case Study: Nigeria
In Nigeria especially in the northern states where cultural requirement is very high on home impregnation, LBAs were not allowed to practice deliveries initially. Nevertheless, the problem of the high mortality was not eliminated since women still tried to use the services offered by TBAs in a clandestine manner.
Realising this fact the government switched to an integration strategy. TBAs now:
- Engage in the controlled deliveries with qualified attendants
- Encouragement of facility births
- Report obstetric emergencies cases
- Community health education
This combination model has resulted in enhanced skilled birth attendance and fall in rural maternal deaths in pilot areas.
- Regulatory Challenges and quality Assurance
- Balancing Tradition and Safety
- Generic solutions to resistance by professional medical associations
- Avoidance of excessive use of TBAs to handle dangerous births
Health authorities have to find a balance between cultural awareness and the necessity not to cause harm to both the mother and newborn.
Quality Monitoring Systems
The Role of Data
The incorporation of TBAs cannot be without remarkable monitoring mechanisms to assess their performance and results. Storing information can help:
- locate training gaps
- Tracking delivery outcomes and referrals
- Measure mother and baby healthy indicators
Other countries such as Ethiopia have managed to make use of community health data in which its TBAs are used to document births and any complications which helps in monitoring the process and making future policies.
The Complementary Role of TBAs and Skilled Professionals
Bridging Gaps in Underserved Areas
Talented individuals are not readily available in rural or underserved places. TBAs are one way of bounding a gaping hole, particularly in areas where women are discouraged to utilize the facility because of cultural or logistical reasons.
The integration however is not the replacement of the skilled care. TBAs must be:
- Having the status of first responders in the case of uncomplicated deliveries
- Evaluated the learner to diagnose cases that need referral
- Skilled in the recognition of cases that need referral
- An incorporated part of emergency transport plans
Case Study: Uganda
The maternal health plan in Uganda involves the TBAs in partnership with community health workers and skilled midwives. TBAs:
- Go for home visits
- Spot high pregnancy risks
- Follow women to health care facilities
This model embraces culture and enhances safe deliveries in the hands of skilled professionals.
Cultural and Social Considerations
Building Trust
TBAs usually play a role of intermediary between communities and the health system. They can change the norms within the community to safer practices as they approve health services.
This is exemplified by TBAs in Bangladesh, which have been able to fight against negative beliefs including shunning the use of colostrum among the newborns. TBAs promote facility deliveries in Africa and sentiments are not much in the conservative societies.
The Risk Marginalization
It is wrong to ban TBAs altogether. Women can still pursue ‘illicit services and rather early risks’ unexpectedly with no one checking. Incorporation and positive practices of engagement are critical in the incorporation of TBAs.
Innovations Supporting TBA integration
Technology as a Partner
Contemporary technology is assisting in the closing of the gap between TBAs and formal systems:
- With the mobile phones, emergencies are referred.
- Antenatal care is encouraged by SMS reminder.
- Apps play the role of guiding TBAs in delivery checklists.
- Monitoring is made better through digital record-keeping.
Example: mHealth in Ethiopia
Mobile applications are already applied in Ethiopia to make the births and emergency mob reporting by trained TBAs. This convergence makes it possible to act quickly and better outcomes among the mothers.
Sustaining Integration Efforts
Funding and Incentives
Sustainability is a difficulty. A lot of TBA programs exist on donor funding. In order to keep moving on:
- TBA training and support ought to be budgeted by governments.
- TBAs ought to be given small payments or reimbursements.
- Planning and monitoring Communities ought to engage in planning and monitoring.
Community Ownership
Communities can succeed with a sense of ownership. When local leaders are discussed and TBAs get involved in the planning, they become more trusting and sustainable.
Conclusion
Together with the engagement of traditional birth attendants in the formal health systems, it is one of the most workable solutions to ensuring improved maternal and newborn health outcomes in underserved regions. It is still facing problems, especially in the area of regulation, supervision, and sustainability, but the efficacy is evident.
TBAs add cultural competence, community confidence and closeness to groups of people that are often ignored by the formal services. When they are trained adequately and associated with competent people, they are the best when it comes to preventing mortality of newborn and the mother.
The incorporation of TBAs into their health systems is one way in which the countries in their effort to enshrine the principle of no one left behind can achieve that goal in a culturally competent, cost-effective, and effective way. The point is in cooperation, constant support and understanding of the long established place that TBAs have in protecting the mothers and their babies all over the world.
