Officially, traditional birth attendants (TBAs) in Uganda are not allowed to carry out deliveries. Instead, they are supposed to direct all expectant mothers to formal health facilities. The official line from the government of Uganda is that TBAs should not provide care for expectant mothers and newborns because their role has done little to reduce the rates of maternal and infant mortality in the country. They have been banned officially since 2010, but continue to work across Uganda.
Some of these TBAs, locally known as Bamulerwa, have been given an option of being incorporated into the less profitable Village Health Teams (VHT), which offer advice on basic healthcare to rural communities on topics ranging from detecting signs of complications or illness among pregnant women and babies, and encouraging women to deliver in health centres. However, there are still many deliveries that are carried out by TBAs independently, mostly in rural areas. TBAs seem to be the preference of rural mothers, with as many as 80% of pregnant women seeking the services of TBAs, according to estimates from ministry of health officials.
There are a few reasons that contribute to TBAs continued dominance in the health system and their overwhelming popularity among rural folk. Firstly, they are cheap and readily available in places without health facilities. Secondly, they are known within the communities, with some having quite a reputation of having delivered up to four generations of children in one family.
It should also be noted that TBAs earn their living through assisting mothers and delivering babies. The TBAs may therefore be prepared to take risks with expectant mothers’ health to protect their jobs of traditional birth attending, for example by not referring them to health centres.
Uganda has seemingly shifted from the idea of training TBAs to compliment the crippled antenatal care system in rural areas. The original focus of the World Health Organization was to train traditional birth attendants and integrate them into an improved health care system, for an achievable and effective intervention that reduces perinatal mortality. This was bound, it was presumed, to improve perinatal and maternal health in developing countries.
One can appreciate the impatience of the Ugandan government with TBAs, and their reasons for trying to do away with TBAs are in some ways valid. There are cases where the hygiene in TBA clinics are of a poor standard. Most of them only have makeshift and ragged facilities for carrying out their work. Furthermore, they cannot manage complications associated with labour. For example, where expectant mothers are HIV positive, prevention of parent to child transmission (PPTCT) interventions are totally out of reach of the TBAs abilities and scope.
The government does not seem to be ready to take such huge risks in allowing TBAs to manage expectant mothers who are HIV positive with compromised methods of PPTCT. Some health workers have also complained that, children born at TBA clinics miss out on the required routine vitamin supplements and immunization jabs. Such children are therefore at greater risk from commonly immunized diseases like measles, polio, TB, tetanus, and whooping cough.
It is apparent that efforts to incorporate the TBAs in the formal health sector need to be rethought. What happened to the efforts to train TBAs to better manage pregnancies and predict complications early enough? Will the TBAs accept a role whereby they merely referr mothers to the health facilities for delivery and forfeit all the money involved in their practice? Can the work of TBAs end at that, leaving them jobless? This may seem suicidal on their part.
On the other side of the argument, we cannot merely blame the TBAs for their continued role. There are challenges which have emerged in developing countries’ health systems, like the inability to supervise and pay health workers to do their part and ensure that TBAs do what they are supposed to do. Formal health centres also have their issues – they are far from communities, midwifes are absent or unavailable, and medical supplies continuously run out. Some mothers needs are not met in formal health settings, with demands a little as Maama Kits (kits which include items to aid clean delivery such as soap, gloves and plastic sheeting). Ultimately, it is the failure to manage some of these challenges that are keeping the TBAs in their jobs. That is why women find the services of TBAs cheaper, friendlier and nearer to them than the services provided by the formal health centres.
All in all, the focus on training TBAs to enable them extend the reach of primary healthcare, manage complications during deliveries and in new-borns, is not a bad idea. In rural settings characterized by high mortality and weak health systems, effectively trained TBAs can be more of an asset rather than a liability.
It is surprising and embarrassing that up to now we still have deliveries conducted with bare hands and without any training on emergency management of obstetric complications in Eastern Uganda.
A district like Bukwo is lagging far behind with only 19% of skilled birth attendants. Realization of MDG 4 & 5 remains a dream unless we all stand up to redirect the roles of traditional birth attendants in the community.