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In parts of the world where midwives and doctors are few and far between, traditional birth attendants (TBAs) play a critical though often controversial role in maternal healthcare. Though untrained, they function as medical leaders in their communities, sometimes delivering more babies than midwives. But as health experts reassess the functionality of untrained workers in the modern healthcare model, TBAs are at risk of being banned from assisting with births completely. Some African countries, such as Zambia and Sierra Leone, have already banned TBAs, although not without backlash. These bans have raised a very important and highly disputed question: are TBAs important or detrimental to the reduction of maternal mortality rates throughout the developing world?

TBAs, also known as traditional or community midwives, help pregnant mothers through delivery and the pre- and post-birth periods in areas where viable healthcare facilities are scarce or unreachable. They are typically older women who hold respect in their communities and often have children of their own. Unlike midwives and obstetricians, TBAs lack formal medical training and instead learn about the birthing process through oral tradition and delivery experience.

TBAs today work with mothers and their infants all over the world and are deeply rooted in the birthing cultures of many communities. TBAs are especially in demand in poor rural areas, where as few as 20 percent of births may be serviced by a skilled health worker. Much of their appeal comes from their accessibility, since TBAs offer their services at relatively low costs. TBAs are usually easier to reach than formal health professionals since they work within their communities, whereas bad roads, long distances and lack of transportation can deter women from seeking hospitalization. Women are especially unlikely to attempt the journey to a hospital if the care offered there is inadequate.

Some countries have attempted to make it easier for women to reach hospitals and receive inexpensive or free care, yet many women still seek out TBAs. This can most likely be attributed to the fear that is associated with clinics and hospitals, since many women are wary of facilities outside their communities, especially when surgery is involved. While there can be much trepidation and distrust surrounding doctors and hospitals, TBAs are well established and liked within their communities.

Mbarikit Eno of Nigeria was among the scores of pregnant women who feared hospitals when she was deciding where to deliver. “Two of my friends died in hospital during childbirth and I don’t want to die too,” Eno told the Global Health Next Generation Network in 2016. “Besides, those midwives in the hospital are very harsh; they shout at you and scold you as if you don’t know anything. They never use kind words on the woman despite the pain she experiences during labour. I know the traditional birth attendant that will deliver me. She is from within my community, she has delivered several women and they are all alive.”

Because there are both benefits and drawbacks to TBA-based care, health experts are divided on TBAs’ place in the modern healthcare model. TBA advocates claim that banning TBAs hurts mothers in disadvantaged communities, since TBAs are sometimes the only health workers available in these areas. This negative effect was demonstrated by a 2007 TBA ban in Malawi, which actually caused Malawi’s maternal mortality rate to rise. The country has since reversed the ban.

Experts also propose training and monitoring TBAs to ensure safe birthing practices. Organizations like the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have taken steps in this direction by increasing regulations on TBAs in recent years to integrate them into the modern healthcare model. These groups have implemented programs to improve TBA education and forge stronger links between health professionals and TBAs, among other measures.

On the other hand, many researchers argue that TBAs should be eliminated from today’s health system completely. Proponents of the TBA ban claim that TBAs are “untrainable” and too set in their ways to adapt to new healthcare methods. They also warn that TBAs cannot address the main causes of maternal death, such as eclampsia and hemorrhage, and that their often-characteristic illiteracy makes it difficult to keep records.

“It stands to reason that decisions must be made with an eye to the future and not just with a mind for the present,” said former Finnish obstetrician and gynecologist Kelsey A. Harrison in an article for the British Medical Journal. “Traditional birth attendants have no place in this future.”

As modern medicine progresses and new medical technologies enter the mainstream, health experts will need to further re-evaluate the role of more traditional workers in today’s healthcare model. While the best course of action currently remains unclear, banning TBAs and other unskilled workers is only a temporary fix for the low utilization of hospitals and clinics in developing areas. Until the underlying causes that send women to TBAs in the first place are addressed, women around the world will continue to turn to TBAs instead of trained health professionals.

Sabine Poux

Photo: Flickr


Public health midwives have been a part of Sri Lankan culture for nearly a century, but their role has recently evolved into a prominent one in the community. Midwives in Sri Lanka not only attend births, but now they also cover preventive health community services. Since approximately 72 percent of Sri Lankans live in rural areas, over 90 percent of public health midwives serve in rural communities, ensuring that typically neglected areas prone to high poverty rates still receive adequate health coverage.

Sri Lanka has committed itself to promoting gender equality. Absolute poverty rates, typically affecting females and children more than males, have been on the decline. As of 2013, 90 percent of Sri Lankan adult females are literate. One of the most impressive efforts to both alleviate poverty and promote the role of women in the community is the central role of midwives in Sri Lanka. The free provision of healthcare at all stages of life, coupled with the usage of traditional cultural practices, has allowed midwives to become respected, sought-after figures in communities. Midwives are viewed as trusted healthcare providers and provide medical guidance to both men and women. Midwives in Sri Lanka have also played a huge role in the high rate of attended births (98 percent) and the incredibly low maternal mortality rate (32 per 100,000 live births).

Improving maternal health has far-reaching effects due to the improvement of the quality of life for women. Access to education is improved. Girls now make up 50 percent of students in secondary education and have the opportunity to attend higher levels of education. Additionally, the focus on rural health by midwives in Sri Lanka is coupled with rural development efforts that have resulted in absolute poverty rates of less than 10 percent and improved access to safe drinking water and electricity.

New challenges are arising, such as a rise in noncommunicable diseases and low midwife recruitment numbers. However, adaptations are being made. Providing more educational opportunities for midwives, increasing their role in addressing public health issues like domestic violence, and offering more public sector employment incentives will be important moving forward. Midwives in Sri Lanka are not only an integral part of the healthcare system but also play an important part in promoting gender equality and opportunities for women.

Nicole Toomey

Photo: Flickr

Liberian MidwivesAlthough Liberia has been Ebola-free for over a year, the devastation the disease wreaked on the Liberian healthcare system persists. Liberian midwives are increasing in number, but they face many challenges.

Liberia was the center of an Ebola outbreak in 2014 that claimed the lives of roughly 180 healthcare workers. In the midst of the epidemic, maternal death rates rose, and they have been slow to decline.

Hannah Gibson, a trainee in a program designated to teach advanced obstetrics to midwives, recounted the panic that struck the Liberian healthcare system when patients suffering from Ebola first began to surface.

Many Liberian midwives abandoned their positions, leaving hospitals understaffed. Gibson and a few of her coworkers eventually quarantined themselves in their hospital, working around the clock to provide medical care for the women in the maternity unit.

Even before the Ebola outbreak, the number of obstetrician-gynecologists in Liberia was low. According to Liberian minister of health Bernice Dahn, today there may be fewer than five.

During the outbreak, Gibson became one of the first Liberian midwives to be trained by British NGO Maternal and Childhealth Advocacy International (MCAI). The NGO proposed teaching surgical procedures such as caesarean sections to midwives in order to bridge the gap in prenatal care in Liberia. The training empowers midwives to operate, resulting in more positive outcomes in semi-complicated childbirths.

Unfortunately, specialized midwifery like this is not accessible to all expecting mothers. There are currently only 400 trained midwives in the Liberian healthcare system, a number too small to meet the needs of over four million people, and the majority of midwives reside in urbanized sectors.

In Liberia, 44 percent of women give birth with no medical attendant because they live in rural areas where care is too far away to obtain. One in every 138 live births results in a mother’s death due to preventable complications requiring basic medical care.

The World Health Organization (WHO) is working with the Liberian Ministry of Health and Social Welfare to enhance Liberia’s six midwifery schools. But merely training midwives will not end the midwife crisis completely. Because midwifery in Liberia is a low-income profession with few opportunities to advance, retaining Liberian midwives is also a problem. Medical professionals trained in Liberia often take their credentials and move to countries that offer better salaries.

Fortunately, through a new Bachelor of Science midwifery program, midwives will be able to further their careers within the Liberian healthcare system, attending to peoples’ needs in understaffed locations. The Danish Midwives Association is giving program instructors current and advanced training in order to ensure the enterprise’s success.

Amy Whitman

Photo: Flickr

midwifery
During the 14-year civil war in Liberia, the health system became increasingly fragile, and a lack of roads and transportation made it difficult for pregnant women to receive necessary emergency care. This issue has created a strong need for strengthened midwifery in Liberia.

As a result, Liberia had one of the highest maternal mortality rates in the world according to a 2015 USAID article, but the country is now trying to change that through investment in midwifery programs.

Currently, 44 percent of Liberian women give birth without a skilled attendant, and nearly one out of 138 mothers die from preventable causes during childbirth. Such issues could be avoided with basic or strengthened midwifery in Liberia, according to the World Health Organization.

Bentoe Tehounge, a trained midwife in Liberia, told WHO, “We need midwives who can ensure a safe pregnancy even before a woman is pregnant. People who can provide advice on family planning, nutrition, physical activity and preventing mother-to-child transmission of HIV.”

There are six midwifery schools in the Liberia, half of which are in rural areas, and less than 200 midwives for over four million people. Most of these midwives work in urban areas. Strengthening these schools, especially the rural ones, will improve access to quality care for women around the country.

Retaining these midwives is one step towards Liberia’s investment in the profession. According to WHO, many health professionals were driven out of the country due to the civil war and the Ebola crisis, and now midwives lack “safe accommodation and transport, are overworked and paid poorly and have limited opportunities for career advancement.”

A new B.S. program addresses a portion of these concerns by providing further professional development. The program graduates 50 to 75 registered midwives per class, which is expected to staff more than 700 health facilities in the country. To develop better teaching methods, Liberia is working with the Danish Midwives Association to pair Liberian and Danish midwives in order to learn more advanced skills, like preventing and treating hemorrhages. It is hoped that this new alliance will result in strengthened midwifery in Liberia.

In the United States, this final element is comparable to the apprenticeships or clinicals that midwives do to obtain a license. Mary Anne Brown, a midwife serving the Great Falls and Helena areas of Montana, said that degree programs require that their students find and work directly with a midwife to gain clinical experience.

Past midwife training in Liberia tried to work within a culture of home birth in Liberia (USAID reported that 63 percent of Liberian women gave birth outside of a health facility) and with the knowledge of traditional midwives.

The goal was to shift the focus to encouraging birth preparedness, recognizing and referring complications and providing appropriate emergency care through what USAID called “home-based life-saving skills.” By utilizing storytelling, case histories, discussion, role-play and demonstrations, midwives, expectant parents and community leaders were able to educate themselves at community meetings.

One of the greatest achievements of the previous midwife training in Liberia was its ability to connect traditional midwives to both health facilities and certified midwives. Certified midwives perform their own visits to discuss problems the traditional midwives are having, replenish supplies and reinforce the training.

The current programs are a part of WHO’s efforts to provide clear guidelines, tools and an evidence base to lead to strengthened midwifery in Liberia and around the world in order to improve care for pregnant women and reduce both maternal and neonatal mortality rates.

Anastazia Vanisko

Photo: Public Domain Images

Midwives_in_Chiapas

Maternal mortality rates in Mexico have steadily decreased over the past fifteen years. The global maternal mortality rate has decreased by nearly 50 percent between 1990 and 2013. However, the work is far from over.

Ninety-nine percent of maternal deaths happen in underdeveloped countries according to the World Health Organization. Chiapas is the poorest state in Mexico with a poverty level at over 76 percent.

Maternal mortality rates can be significantly lowered with skilled care and supervision throughout the childbirth and traditional birth attendants are being trained to offer this care through workshops and programs in Chiapas.

Traditional midwives are extremely important in communities within Chiapas because of the negative connotation that comes with hospitals and the hesitation that women have toward giving birth in hospitals. Fifty-five or more out of every 100,000 women die in Chiapas during childbirth.

The traditional midwives are receiving training for problems that arise during obstetric emergencies. Understanding the protocol will allow them to act quickly in situations that may cost the mother’s life.

https://www.youtube.com/watch?v=jCuE8Y0d8sk

One such organization is the Global Pediatric Alliance. The alliance has started a training program for midwives in Chiapas. They have programs in four different municipalities in Chiapas. Los Altos de Chiapas is the first community and 88 percent of the population is poor. Fifty-six percent of the population lives in extreme poverty.

The plan is to train at least 120 Tzeltal and Tzotzil-speaking midwives between 2014 and 2017. An estimated 100,000 people will be impacted by the project. The second municipality is Las Margaritas, a highly marginalized area with extremely low Human Development Index rankings.

The isolated communities in the area particularly suffer from the lack of care adequate obstetric care. The program with GPA has already held five trainings for 29 traditional birth attendants in the area.

The training of midwives is changing the maternal mortality rates and the risks of home births in Chiapas.

Iona Brannon

Sources: Arizona State University, Global Pediatric Alliance, New York Times, Reuters, World Health Organization 1, World Health Organization 2
Photo: nyt

More Midwives Needed in NepalNepal’s maternal mortality rate (MMR), or the ratio of maternal deaths per 100,000 live births for reasons related to pregnancy or birth, has declined in Nepal over the last fifteen years. It is estimated that between 1996 and 2005, Nepal reduced its MMR from 539 deaths to 281. It was estimated in 2010 to be around 170.

These declines, similar to those seen in countries such as Bangladesh, Malaysia, and Thailand, are cause for hope. However, health care experts say the gains in Nepal are unsustainable if the country does not address its need for more health care professionals, especially midwives, to prevent women from dying in childbirth.

Declines in maternal mortality rate are attributable to a number of factors other than improved health care access or services. Nepal’s paradox is that even though the MMR is decreasing, access to skilled birth care is still very low. In general, improved health care positively correlates with reduced MMR, but sub-Saharan Africa and Asia have not demonstrated a strong correlation so far due to lack of skilled birth care.

Experts in maternal health do not have the data necessary to determine the exact causes of the decline, but there are multiple factors involved. The top reasons are the social empowerment of women, reduced fertility, and government health care programs. Nepalese women are now having fewer children on average, and have more access to contraception and family planning tools. Women’s life expectancies and literacy rates have increased as MMR has declined. Women are now also offered financial incentives to seek medical care during pregnancy and have more access to affordable, life-saving health care such as blood transfusions.

Nepal is on track to meet its Millennium Development Goal of reducing MMR by 75 percent, to 134 deaths per 100,000 live births. When it reaches that point, the country will require the help of more midwives and health care workers trained in birthing to further reduce maternal mortality. A 2012 UN study found that a midwife in attendance during birth can reduce up to 90 percent of maternal deaths.

– Kat Henrichs

Source: IRIN
Photo: Midwife Ramilla