Although government has banned traditional birth attendants, health centres must improve to effectively drive them out of business Hearing a faint voice through her hut’s wedges calling “mama, mama” late in the night, Maritina Abweso thought she was dreaming. But a few seconds later, there was a bang on her door.
“Mama, mama, come quickly the baby is coming,” Abweso recalls her son shouting outside her grass-thatched mud-and-wattle hut.
She jumped off her bed half asleep, leaped to one corner of the hut and picked a few medicinal herbs, a tin of cooking oil and a jerry can of water. She then hurried across the courtyard to the nearby hut where her daughter-in-law, Christine Amayo lay on her back, screaming in pain.
“Mama, what is happening?” Amayo asked Abweso, who is a well-known traditional birth attendant in her village of Abarilela in Katine sub-county, Soroti district. Amayo was only seven months pregnant but had gone into labour.
“I didn’t know what to do,” Abweso tells The Observer. “She was too early, but her membranes had ruptured. I massaged her stomach and realised the baby was near. I gave her some herbs, washed my hands and then told her to push.”
But the baby did not come out.
“I had delivered all her other babies; I didn’t know why this one was not coming, so I rushed her to Soroti hospital,” Abweso narrates.
At Soroti hospital, 30 kilometres away, Abweso explained what had gone on at home but did not tell them about the herbs.
“When she delivered, the baby was dead. I had seen the doctor giving her an injection; I suspect it killed the baby because why would he inject her? For me I just give herbs and the baby is always fine,” Abweso says, obviously ignorant of the emergency medical attention Amayo needed to save her life.
This kind of ignorance among traditional birth attendants (TBAs) seems to justify the government’s decision to phase out their activities by 2015. The ministry of Health says that TBAs assuming the role of midwives has not helped to reduce maternal mortality rates in Uganda, which stand at 435 per100,000 live births. In fact, the minister, Stephen Malinga says TBAs contribute to the death of many mothers.
TBAs like Abweso are members of the community with no formal training in maternal health, but who have acquired maternity skills through apprenticeship. In rural communities like Katine, in Soroti, more than half of all deliveries are handled by TBAs or simply neighbours.
But the World Health Organisation says this must stop.
“TBAs will give promotional messages by encouraging antenatal care, immunisation and postnatal care; they should be referring women for routine delivery to reduce chances of complications,” says Dr Olive Sentumbwe, the WHO Family Health and Population advisor in Kampala. “WHO cannot recommend routine delivery in the hands of unskilled persons.”

Which skills?

Experienced TBAs like Tereza Asao would feel insulted by the notion that they lack skills. Apparently in her 70s, the frail-looking Asao emerges from her hut and sits next to Michael Achol, a young man she says she helped deliver 27 years ago. She can’t remember exactly when she started delivering women, but wherever she looks, she sees men, women, boys and girls that she helped to bring to this world. After delivering all her 13 children by herself, Asao thought she had enough experience to deliver any mother. Her mother had taught her what herbs to use.
“Even when a baby dies in the womb, I massage the womb and when the baby doesn’t move I know it is dead. I then give the mother some herbs and tell her to push.”
Because TBAs are often community members known to the mothers, they are seen as friendlier and more accessible than an impersonal midwife several kilometres away. They carry their own herbs, sometimes offering improvised sheets to wrap the baby in. Asao says she knows how to cut the cord – sometimes using a sharp type of grass – and tie it.
TBAs’ methods, though not hygienic and capable of causing infections, are cheap. For delivering a woman, Asao or Abweso would only expect a chicken, a kilo of sugar, soap, or some other token.
At the hospital, on the other hand, a poor woman would have to look presentable in shoes and clean clothes, clean baby clothes, and she may anger the midwives if she doesn’t measure up.
She is often required to buy gloves and cotton wool, a razor blade, a book, not to mention paying for transport.
In the end, she spends about Shs 20,000, money that is difficult to get in poor communities. For these and other reasons, 58% of deliveries in Uganda are not handled by trained personnel. Worldwide, 34% of deliveries have no skilled attendant, according to WHO. This means 45 million births occur without skilled health personnel each year.

Problem with TBAs

As Abweso’s example shows, TBAs remain active in the communities, sometimes bringing life, sometimes losing it. NGOs such as the African Medical and Research Foundations have been training TBAs like those in Katine to refer women to health centres, but this sometimes fails.
“Some complications like obstructed labour and severe bleeding are unpredictable and this is where TBAs fail,” says Dr Jennifer Wanyana, the commissioner Reproductive Health in the ministry of Health.
“They hang onto the mother because they don’t want to miss the sugar and soap or chicken.”
Also, some mothers who always deliver with TBAs do not seek antenatal services. They miss out on crucial medical tests, vaccines and helpful medicines.
The 2006 demographic and health survey showed that 94% of women in Uganda received antenatal care from a skilled provider, with 50% getting tetanus immunisation, 52% blood pressure monitoring, and 28% HIV counselling and testing.
While TBAs can indeed deliver a woman safely, they don’t offer post-partum care yet the first two days after delivery are critical for a woman’s life since many complications and deaths occur then.
The 2006 demographic and health survey showed that 84% of women who deliver at home did not receive post partum care.
Esther Mududa, a midwife at Tiriri health centre IV, a kilometre from Abarilela village, says she often handles complications of women who have delivered – bleeding, retained placentas or third degree tears, which need further referral.
“Many end up with severe asphyxia (seizures), vaginal fistula and some even lose their babies. Then I am in trouble with the ministry of Health because that death is audited on me and not the TBA,” Mududa says. She sees about 10 mothers with complications every week, who often come with TBAs.
“When TBAs come with a mother, they want to stay in the labour ward. Sometimes when you go out to get equipment, you find her telling the mother to push. Sometimes we even fight with them and they tell you, ‘are you the one who is going to pay me?’” Mududa says.

Entrenched

Now 27 and a father himself, Michael Achol says he values Tereza Asao as the woman who helped bring him into this word. But he would not let her or any other TBA touch his wife because he believes she is safer delivering at Tiriri health centre.
Asao herself says she would not try to deliver a woman when the government has stopped her activities and the health centre is so near.  
Francis Alibu, the Tiriri health centre statistician, says the number of women who deliver at the health centre has gone up from 462 between 2006 and 2007 to 547 in 2008 – 2009. Over the same period, the hospital’s records show that women delivered by TBAs reduced from 327 to 52.
But changed attitudes are not necessarily widespread. In other areas like Kaabong, 90% of deliveries are handled by TBAs.
Commissioner Jennifer Wanyana admits that it will take time to erase the function of TBAs from the community. She says that countries party to the agreement of phasing out TBAs agreed that they should first make health centres more attractive, with quality maternity services.
This means having a skilled midwife at the smallest health centre, a functional referral system, as well as a maternity ward and functional theatre at every health centre IV.
For now, Tiriri HC IV has a theatre but it does not work because there is no medical doctor, water or electricity. The health centre, which serves seven sub-counties, has one ambulance but patients must fuel it before they use it.
Today, for every Ugandan midwife, there are nearly 17,000 mothers, much higher than the WHO-recommended ratio of one midwife per 400 mothers.
As the figures at Tiriri suggest, things are slowly improving. But with such figures, there will still be many Ugandan mothers opting for the TBAs, and Maritina Abweso can expect more bangs at her door.

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