L.I. LARTSONETAL.

Perspectives in Primary Care The Trained Traditional Birth Attendant: a Study of Her Role in two Cultures by L. I. Lartson*, MD, MSc, O. A. Sodipe*, MB, BS, MSc, G. J. Ebrahim*, FRCP, DCH, and R. Abel**, MD * Tropical Child Health Unit, Institute of Child Health, London ** Rural Unit for Health and Social Affairs, Vellore, India Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021

Summary The training of the traditional birth attendants in the national programme in Liberia and in the innova- tive health programme of RUHSA in south India has been evaluated. There has been an improvement in coverage with and immunization with tetanus toxoid associated with a fall in the incidence of low and neonatal tetanus. The need for repeated refresher courses, for effective back-up in case of emergencies, and for close supervision to prevent risk-taking is stressed. Even though the per- formance of the trained traditional birth attendants (TTBA) improved with regard to the assessment of and the identification of risk factors, the TTBA tended to handle complicated births, retained , and prolonged labour by themselves. Whatever the reasons, it stresses the need for the super- visory back-up services to work closely with the TTBA.

Introduction maternal and perinatal mortality rates remain high and have not altered much during the last decade. As It is estimated that between 60 and 80 per cent of a rough estimate, 500 000 women die of causes related births in the developing world are attended by tradi- to pregnancy each year—most of them preventable.6 tional birth attendants (TBA).1 Understandably, In a study of maternal mortality in Bangladesh, the there has been a desire to improve the quality of care rate was 7.7 per 1000 live births with 80 per cent of they provide and to upgrade their skills. In a world deaths being due to direct obstetric causes, and wide survey conducted under the auspices of the eclampsia was the most common cause.7 World Health Organization (WHO) 24 out of the 64 In all traditional societies, child bearing is firmly countries (38 per cent) surveyed were reported to have rooted in the cultural milieu and is surrounded with a existing training programmes for the TBA in 1972.2 variety of mystical beliefs and magico-religious prac- Since then case studies in utilization and training of tices.8 Hence, an indigenous practitioner like the TBA the TBA from seven countries have been published,3 from within the same culture is preferred to the skilled and the characteristics of the TBA as well as their professional. Upgrading of the TBA's skills and common practices during pregnancy, at the time of improving her knowledge through training will be a delivery, and in the postnatal period have been de- rational approach. Moreover, expansion of coverage scribed.4 Such studies have provided a momentum for with maternity care through trained professionals change so that the training and utilization of the TBA would mean expanding health services 3-4-fold which constitute a significant part of the national health no country can afford. On the other hand, 'articula- strategies of many countries. tion' of trained TBAs to the formal health service is Coverage with skilled care at delivery is low in most an achievable goal. Hence, a number of countries developing countries and varies from 29 per cent in have adopted such a strategy and developed curricula for the training of TBAs, and the Sudan is one such tropical Africa (Africa average 34 per cent) and 20 per 9 cent in southern Asia (Asia average 49 per cent) to 51 example. per cent in middle America (Latin America average The training of TBAs has to be related to specific 64 per cent).5 The number of pregnant women who problems. Since low birth weight and neonatal receive antenatal care is also low, varying from 5 to 48 tetanus are the two most common causes of neonatal per cent in countries where fewer than half the preg- mortality, their prevention must be stressed. Improve- nant women receive prenatal care to a range of 50-98 ment of maternal nutrition and motivation for immu- per cent in countries where more than half the preg- nization of the pregnant woman with tetanus toxoid nant women receive such care.5 Not surprisingly, are emphasized in most training programmes. Preven-

Journal of Tropical Pediatrics Vol. 33 February 1987 © Oxford University Press 1987 29 L. I. LARTSON ET AL.

tion of anaemia and the referral of high-risk preg- deliveries performed by TTBAs than UTTBAs. The nancies for more skilled care are the other skills women delivered recently by the two study groups taught to the TBA. Emergencies are likely to arise were traced and were also interviewed using a struc- unexpectedly and their early anticipation for prompt tured questionnaire so designed as to obtain addi- referral as well as simple relevant skills for handling tional evidence for testing the above hypotheses. In them must form part of the training.10 all, 100 mothers were interviewed, of whom 52 had In all traditional birth systems the relationship been delivered by TTBAs and 48 by UTTBAs. between the birth attendant and the 'client', is of a personalized nature. The TBA is treated more like an RUHSA programme, India elder who joins with the rest of the family in assisting The RUHSA programme is characteristic of the di- the woman in labour.11 She is rewarded in cash or lemma in all developing countries in that despite a kind, or both, according to the ability of the family. rising output of skilled professionals who largely Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021 There are no fixed charges. This relationship is differ- enter the private sector, the vast majority of the popu- ent from the professional-client relationship of the lation have little access to modern medical care on or obstetrician. Because of the relationship account of poverty. In the population served by the and the system of reward, the services of the TBA are RUHSA programme 77 per cent are below the more accessible to the disadvantaged groups. Is the poverty line, and hence the need of a maternity service relationship likely to change after training? which is affordable. A national programme of train- The evaluation of training and of the performance ing the TBAs operates in the area in addition to of the trained TBA is necessary to assess the success RUHSA's own programme. The full content of or otherwise of the strategy of extending coverage RUHSA's training is given in Appendix 2. The study with maternity care through modernization of the was carried out in three villages constituting the main traditional systems. We report here on the perform- headquarters village, an intermediate village with a ance of the trained TBA in two cultural settings. One health facility, and a remote village with no health is a national programme in Liberia and our report is facilities. Comparable villages were selected from a part of the process of evaluation currently in progress neighbouring area outside RUHSA's boundary. The 11 in that country. The second is a relatively small-scale method of selection has been described previously. project as part of the RUHSA (Rural Unit for Health An interview based on a structured questionnaire was and Social Affairs) programme of the Christian Medi- conducted with all the TBAs in the six villages to cal College, Vellore.12 assess the size of their clientele, their knowledge and practices concerning prenatal, intrapartum, and post- natal care. Similar interviews were conducted with Methods and Materials mothers who had been delivered by the TBAs. In all Liberia 38 TBAs were interviewed, 28 being from the study The study was part of the national evaluation of the villages, 12 of whom were untrained. Out of the 10 in training of TBAs, and was carried out in four counties the comparison villages, 7 were untrained. In all 223 avoiding the areas where the national evaluation mothers were interviewed, 113 of whom were from teams were operating. Each of the four counties has a the study villages. training programme based on a curriculum formu- lated by the Ministry of Health and Social Welfare (see Appendix 1). Twelve towns were identified in Results which trained and untrained traditional Liberia—national programme were practising. From amongst the trained TBAs who General characteristics of the traditional birth atten- had been identified by their supervisors, 26 were dants. There were no significant differences between selected for the study by the lottery method (TTBA). the TTBAs and the UTTBAs as regards age, literacy Untrained TBAs had to be identified with the help of rate, general education, years of experience, and the community leaders as being the only way since induction into the art of assisting with deliveries. The they are not registered with the board. A only difference was whether they had attended the group of 24 untrained TBAs (UTTBA) were selected training programme or not. In general, the traditional for the study by the lottery method. In both the birth attendants were between 35 and 55 years old, groups the birth attendants were operating from a were largely illiterate, had been in practice for more distance of 8 km radius from a health centre or district than 10 years, and had acquired their skills through hospital and 40 km radius from a regional hospital. A apprenticeship to a relative (mother, grandmother, or structured questionnaire was administered to the aunt).13 Many of the birth attendants were also lead- selected birth attendants, so designed as to test the ing members of the Sande secret society.13 hypotheses that (i) TTBAs are more knowledgeable History-taking for identifying high-risk preg- than UTTBAs. (ii) TTBAs perform better and pro- nancies and assessment of pregnancy was better with vide more informed and skilled care than UTTBAs, TTBAs (Table 1). and (iii) maternal and perinatal mortality is lower in Clean handling of the cord stump is important

30 Journal of Tropical Pediatrics Vol. 33 February 1987 L. 1. LARTSON ET AL.

TABLE 1 Prenatal care (Liberia)

TTBA UTTBA (n = 26) (n = 24) Significance No. (%) No. (%) value of P

History-taking Inquiry into parity 25(96) 11 (46) 0.0003 Eliciting history of previous problems in labour 24 (92) 8(33) 0.0001 Inquiring into medical problems 9(35) 2 (8) 0.0018

Establishing duration of pregnancy 13(50) 4(17) 0.0017 Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021

Assessment Checking foetal lie 19(73) 0 0.0001 Checking foetal heart sounds 12(46) 0 0.0005 Checking 19(73) 1 (4) 0.0001 Checking for anaemia 18(69) 3(13) 0.0003 Referral for checking blood pressure 6(23) 1 (4) 0.0302 Examination of urine 15(58) 4(17) 0.0088

Dietary advice 20(77) 4(17) 0.0001

Knowledge of risk factors History of difficult labour 22(85) 16(67) N.S. Oedema of feet and headache 20(77) 8(33) 0.0019 Female circumcision 5(19) 2 (8) N.S. Anaemia 18(64) 3(13) 0.0003

TABLE 2 Dressing used on the cord stump (Liberia)

Sap of Ever- Dust Ground unripe lasting from Red herbs paw paw leaf floor Clay Alcohol palm oil No. (%) No. (%)• No. (%) No. (%) No. (%) No. (%) No. (%)

TTBA (n = 26) 1(4) 0 8(31) 0 0 17(65) 0 UTTBA (n = 24) 1(4) 2(8) 13(54) 1(4) 1(4) 5(21) 1(4)

because of the dangers of tetanus and sepsis, and also TABLE 3 because of the practices which exist in all traditional Distribution of the birth attendants by obstetrical prob- societies. In all, 22 birth attendants used alcohol for lems managed (Liberia) cleansing the cord. Of these 17 (27 per cent) were TTBAs and five UTTBAs (P = <0.001). The various TTBA UTTBA types of dressings used on the cord stump are shown (« = 26) (n = 24) in Table 2. No. (%) No. (%) A number of problems had to be handled by the TTBA as an emergency situation. These were patients Breech delivery 13(50) 18(75) /><0.68 who had a complication diagnosed and who were ad- Retained placenta 18(69) 15(63) NS Twin delivery 3(12) 7(29) NS vised hospital delivery, but declined. In some the Prolapse of cord 2 (8) 3(13) NS complication was not diagnosed early enough. Both the TTBA and the UTTBA handled an equal number of complicated deliveries (Table 3). Although the training programme had listed many of these compli- out of the 100 interviewed. Among these mothers, 52 cations as high-risk requiring referral to were delivered by the TTBA and 48 by the UTTBA. hospital, both the groups erred equally, even though In general, mothers under the care of the TTBA the TTBA had easy access to the health system. received better prenatal care (71 per cent for TTBA Antenatal care had been received by 92 mothers and 27 per cent for UTTBA) and dietary advice in

Journal of Tropical Pediatrics Vol. 33 February 1987 31 L. I. LARTSON ET AL.

TABLE 4 TABLE 5 Perinatal outcome (Liberia) Prenatal care (RUHSA programme]1

TTBA UTTBA TTBA UTTBA No. (%) No. (%) («=19) (n=19)

No. of mothers delivered 52 48 Importance of antenatal care 19 12 Stillbirths 8(15) 9(19) First consultation in pregnancy 12 1 Low birth weight 7(13) 14(29) First consultation in labour 7 18 Early neonatal deaths 2 (4) 5(10) Late neonatal deaths 2 (4) 3 (6) Assessment

Neonatal tetanus 4 (8) 4 (8) Checking fundal height 9 2 Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021 Incidence of septic cord 4 (8) 5(10) Inquiry into 'kick count' . 14 3 I Checking for anaemia 15 1

Dietary advice 12 9 at-risk and there was no significant difference in the referral rates between the two groups of birth atten- dants. Immunization with the tetanus toxoid in preg- ive fundal pressure during is a common nancy is becoming increasingly common in Liberia, practice amongst the traditional birth attendants in partly on account of greater awareness and largely south India, and the training stresses the danger of due to the Expanded Programme of Immunization. such a practice. Significantly more (/><0.05) TTBA In the study, 53 mothers had been fully immunized gave up this practice after training. against tetanus. There was no significant difference in Immunization with the tetanus toxoid and preven- the immunization rate amongst the clients of TTBA tion of anaemia through the issue of iron and folic and UTTBA. acid form the main thrust of the RUHSA programme Thus, the TTBA performed better with regard to in maternity care. These services are routinely pro- history-taking, dietary advice, assessment of preg- vided in the antenatal clinics, and the TTBA is the nancy, knowledge of risk factors, and handling of the main motivator for her clients to attend the clinics. cord compared to the UTTBA. There were no signifi- There was in general better attendance in the study cant differences with regard to provision of antenatal than in comparison villages (50 and 25 per cent, care, tetanus immunization, and handling of compli- respectively). More surprisingly, in the study area cated deliveries. Table 4 compares the mortality and mothers delivered by TTBA reached a higher level of morbidity rates in the newborns of mothers delivered antenatal attendance than those delivered by doctors by the two groups of birth attendants. and midwives in the comparison villages. With regard to obstetrical emergencies, the TTBA RUHSA Programme in the RUHSA area had good back-up and support. General characteristics of the trained birth atten- For example, they were trained to refer all primi- dants. The majority were over the age of 50 years, gravida to a health facility for delivery, and all their though the trend is for the younger ones to be selected clients could be assessed at the antenatal clinic by a for training. They were mostly agricultural labourers professional midwife for the presence or otherwise of and either semi- or illiterate. Several (42 per cent) had a complication or risk factor. The traditional birth acquired their skills by being apprenticed to a relative attendants look upon bleeding after delivery as (usually mother or grandmother) and had been in normal and some would even encourage flow of'bad' practice for 15 years or more.'4 blood in the postnatal period. The TTBA considered Prenatal assessment of pregnancy and care with the postpartum blood loss as potentially dangerous and objective of identifying the high-risk pregnancy was referred patients to nearby health facilities. Similarly, more common with the TTBA (Table 5). Clean hand- retention of placenta was also considered to be a ling and aseptic procedures during delivery are neces- situation requiring urgent referral. On the other hand, sary for avoidance of sepsis. The majority (84 per despite the instruction not to allow labour to be pro- cent) of TTBA used hot water, boiling, or antiseptics longed for more than 2 days, most TTBAs did so and for sterilizing instruments compared to 47 per cent also conducted the deliveries themselves. UTTBA who were unaware of such requirements. All During the past 10 years there has been a 50 per the TTBA and the majority of the UTTBA used soap cent reduction in neonatal mortality and 25 per cent and water to wash their hands before attending to the in infant mortality in the RUHSA area. In the present woman in labour. Surprisingly, more than half the study, the mothers were asked to recall the perinatal TTBA said they carried out vaginal examinations on outcome during the past 5 years if they had been their clients to assess progress of labour, thereby delivered of a child and the birth attendant who increasing the risk of infection. Application of excess- delivered them. The results are shown in Table 7.

32 Journal of Tropical Pediatrics Vol. 33 February 1987 L. I. LARTSONETAL.

TABLE 6 provement in nutrient intake, regular administration Application to the cord stump of iron and folic acid to prevent anaemia and immuni- zation with tetanus toxoid are of proven benefit. Cord Study Comparison handling techniques and applications on the cord villages villages stump appear to be difficult to change. Some of the No. (%) No. (%) TTBAs in Liberia and in the RUHSA programme continued with the traditional routines despite their Nothing 25 (23) 40 (36) training. The improvement in the incidence of neo- Talcum powder 29(26) 21(19) natal tetanus is therefore largely due to immunization Mercurochrome 34(31) 25(23) of the mother with the tetanus toxoid, which was also Others (herbs, hot ashes, dyes) 22 (20) 24 (22) the experience in Bangladesh.1 s Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021 Total 110 110 The effect of all training wanes over a period of time unless supported with texts and class notes. In the case of the semi-literate or illiterates, such texts need to be copiously and well illustrated and easily understood. A number of training programmes, as in- deed also in Liberia and the RUHSA programme, TABLE 7 have developed local texts which are largely mimeo- Perinatal outcome by birth attendant (RUHSA) graphed. The need for printed texts on durable paper is obvious. Still- Neonatal Postnatal birth death death References UTTBA 4 TTBA 1 Doctor/Nurse 9 1. World Health Organization. Traditional Birth Atten- dants. WHO Offset Publication No. 44. Geneva: WHO, 1979. Total 14 2. Verderese M, Turnbull LM. The traditional birth atten- dant in maternal and child health and . A guide to her training and utilization. WHO Offset Discussion Publication No. 18. Geneva: WHO, 1975. 3. Mangay-Maglacas A, Pizurki H. The traditional birth The above results demonstrate that training alone is attendant in seven countries: case studies in utilization not enough. Practices and routines which are deeply and training. Public Health Papers No. 75. Geneva: rooted in the local culture cannot be changed by a few WHO, 1981. weeks of lectures and demonstrations, especially 4. Cosminsky S. Traditional midwifery and contraception. when the participants are leading members of the In Bannerman RH, Burton J, Wen-Chieh C (eds) Tradi- tional medicine and health care coverage. A reader for local cultural institutions like the Sande society as in health administrators and practitioners. Geneva: WHO, Liberia. Refresher courses and informal on-going 1983, 142-62. training through professional back-up and continuing 5. World Health Organization. Coverage of Maternity supervision is necessary. Despite their training and a Care. A tabulation of available information. Geneva: system of supervisors, TTBAs in Liberia were hand- WHO, 1985, FHE/85.1 (mimeo.). ling breech and twin deliveries as well as retained pla- 6. World Health Organization. Maternal mortality rates. centa and prolapse of the cord even though referral A tabulation of available information. Geneva: WHO, was possible. Similarly, in the RUHSA programme, 1985, FHE/85.2 (mimeo.). the TTBA handled deliveries which were prolonged. 7. Chen LC, Gesche MC, Ahmed S, el al. Maternal mor- Repeated evaluations like the present one are neces- tality in rural Bangladesh. Stud Family Plan 1974; 5: sary to identify the reasons for reluctance to refer and 334-41. 8. Ebrahim GJ. Cross-cultural aspects of pregnancy and work out ways of overcoming it. In the RUHSA pro- breast feeding. Proc Nutr Soc 1980; 39: 13-15. gramme, the delivery of all primigravida in a health 9. Bella H, Ebrahim GJ. The village midwives of the facility and selection of high-risk pregnancies for Sudan: an enquiry into the availability and quality of skilled obstetric care does help to filter out a large maternity care. J Trop Ped 1984; 30: 115-18. proportion of likely obstetrical problems. Such an 10. Leedam E. Traditional birth attendants. Int J Gynae- 'articulation' of traditional midwifery care with the col Obstet 1985; 23: 249-74. national health services must be encouraged. 11. Newman LF. Midwives and modernisation. Med Anth- ropoll981;5:l-12. Reduction in the incidence of neonatal tetanus and 12. Scheer P, Pinto A, Tuga S, Ebrahim GJ, Abel R, low birht weight has been achieved in the two study Mukherjee D. Does health intervention ameliorate the programmes. The most effective contribution made effects of poverty-related diseases?—1. Experience in by the training of traditional birth attendants will rural south India. J Trop Ped 1985; 31: 219-22. appear to be in the area of prenatal care, where im- 13. Lartson LI. An evaluation of the knowledge, perform-

Journal of Tropical Pediatrics Vol. 33 February 1987 33 L. l.LARTSONETAL.

ance and effectiveness of traditional midwives in Conduct home visits; do case finding; give health Liberia. University of London: MSc dissertation, 1985, education. 38-42. Manage minor disorders. 14. Sodipa OA. The trained traditional birth attendants: Make proper referrals. how effective are they in providing basic maternity care? University of London: MSc dissertation, 1985, 24-8. 2. Intrapartum 15. Rahman S. The effect of traditional birth attendants and Distinguish between true and false labour. tetanus toxoid in reduction of neonatal mortality. Prepare patient, equipment, and area for delivery. JTropPed 1982; 28: 163-5. Observe contractions; know normal duration of labour. Observe for signs of full dilatations; estimate time Appendix 1 of delivery. Training of the traditional birth attendants in Liberia Coach patient to 'push' appropriately. Downloaded from https://academic.oup.com/tropej/article/33/1/29/1672468 by guest on 29 September 2021 Purpose Manage delivery and inspect the placenta; recog- 1. To teach all those women who are already nize complications and make referrals. attending deliveries and all those who are interested in Give immediate care to the baby and the mother. Traditional Midwifery (as agreed upon by the mid- Manage haemorrhage in emergency. wives of each town): 3. Newborn and children (a) the principles of clean delivery; Give proper cord care; identify abnormalities and (b) the anticipation and diagnosis of obstetric danger signals in the newborn and make refer- complications for which they need to refer the mother rals. to a clinic or hospital; Transfer low birth weight babies in the proper way. (c) basic preventive measures in the care of obstet- Teach mothers proper breast-feeding techniques. ric patients (e.g. maintaining the bladder empty, Manage common ailments like fever, diarrhoea, proper pushing techniques, etc.); etc., in newborns and older children, and make (d) basic emergency measures; appropriate referrals. (e) principles of child spacing; 4. Family planning (f) nutrition, , and prevention of com- Teach child spacing; encourage modern methods of municable diseases. child spacing. 2. To give recognition and credibility to the Tradi- Identify families who need child spacing advice and tional Midwives' ability in order that the community refer. will use their skills and knowledge to their best advan- Identify families with problems of . tage.

General goals of the training Every trained traditional birth attendant should: Appendix 2 1. know how to conduct a clean delivery to prevent Course content—training of traditional birth atten- tetanus and other infections in the newborn as well as dants in RUHSA the mother; 2. have the knowledge and skills necessary to anti- 1. Anatomy of the female pelvis and of the repro- cipate problems and therefore avoid situations which ductive organs. Menstruation, fertilization and she will be unable to handle; growth of the foetus. , concep- 3. be able to cope with emergencies and protect the tion, and methods of contraception. mothers and babies from further harm until they can 2. Definition of sepsis and aseptic precautions and be got into hospital for more skilled care; methods. Sterilization of instruments and cord tie, 4. know the importance of child spacing, as well as etc. the methods and where and how they are available; 3. Preventable diseases; causes of illness; deaths 5. Understand (a) the value of common local foods, among mothers and new born infants. and how best to use them, (b) the best methods of 4. Care during pregnancy. Immunization against caring for babies and children, and (c) the basic prin- tetanus. ciples of prevention of communicable diseases. 5. Unrecognized complications of pregnancy. The need for referral in the case of the elderly primi- Tasks to be performed by trained traditional midwives gravida, the grand multigravida, and multiple preg- I. Antenatal care nancy. Identify anaemia; pre-eclampsia. 6. Awareness of accidents arising from ill-advised Estimate gestation; recognize previous caesarean interventions. section scar. 7. Early recognition of abnormalities in pregnancy Identify presentation; recognize normal foetal and timely referral for medical advice and care. heart; recognize multiple pregnancy. 8. Preparation for normal delivery and its super- Recognize high-risk mothers; recognize danger sig- vision with minimal interference during normal nals in pregnancy. labour.

34 Journal of Tropical Pediatrics Vol. 33 February 1987