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Tuesday, July 5, 2011

Traditional birth attendants outlawed in Uganda but practice persists

By Esther Nakkazi
June 13th 2011

Throughout the African continent,  many public officials believe their most powerful tool for improving health outcomes for mothers and infants is to ban or severely limit the influence of so-called Traditional Birth Attendants, and steer women to public health facilities.

However, many observers note that this strategy is complicated at best, and too often fraught with danger. For example, in Uganda, the government banned Traditional Birth Attendants (TBAs) in 2009 because they had deviated from their major role of identifying and referring women pregnant mothers to health centres.

But they are still the providers of choice of many women in Uganda’s rural areas. This is because the country’s health system problems include health workers who are rude and insensitive to the needs of poor, uneducated clientele, substandard care given to pregnant women, or lack transport to government sanctioned health centres.

So with the demand for their services still high, some organisations are training TBAs to work more closely with the official health care system by doing more referrals. This is a complicated proposition, because while many TBA’s are dedicated and professional, they may not possess the nuanced ability to know when it’s time to stop depending on their own skill and call on mainstream health professionals. In many cases, they may wait too long to admit they cannot handle a complicated delivery, resulting in death or serious injuries to baby and mother.

“They can give them herbs to stop vomiting and for bathing to bring down temperatures. But we encourage them to refer all mothers to health facilities for antenatal, delivery and postnatal services,” said Primrose Kyeyune, a technical advisor to Traditional and Modern Health practitioners Together against Aids and other Diseases (THETA) in Uganda.

Across the globe, experts readily acknowledge that many traditional birth attendants are often skilled enough in normal labor and birth. The problem arises when TBA’s lack the back up resources to transfer women enduring obstructed labor, or who need caesarian sections to nearby health facilities.

On average, sixteen women die of pregnancy-related problems everyday in Uganda, most of them due to emergency complications like excessive bleeding at delivery or during 42 hours after giving birth. Two thirds of maternal deaths occur during that window of time.

At least 22 percent of women die due to infections developed during pregnancy, labour, and even after birth.

Dr Sentumbwe-Mugisa, a reproductive health expert, says women develop severe infections and die because the birth canal, the abdomen, or sometimes the blood becomes infected, a condition called septicemia. Other women get infections after abortions.

But Uganda also has many survivors of obstetric fistula; women who survived obstructed labour, often lasting for days, but rarely with a live child at the end of it. Officials believe most of these cases may involve a TBA who did not seek outside help.

Why Demand remains high

Ms. Bernadette Nabatanzi, a former TBA, says most women choose TBAs because they are confidants and counselors.

Nabatanzi a 70-year old reproductive health and counseling expert says she learned the skill from her grandmother, who was also a traditional birth attendant.

“I remember very well when women used to give birth to premature babies, and we placed them in underground holes we had dug in the house.

“My grandmothers’ house had eight holes in different locations, which were padded with dry sorghum leaves and old cloths for the baby’s mattress.

“When a premature was born, we would wrap them in a clean cloth and place them in those holes, only to be removed to breastfeed. After about two weeks, the child would be grown enough to go with the mother.”

Indeed, stories like these help explain the complicated clash between tradition and modernity when it comes to providing appropriate health care for pregnant women and babies. For example, many rural Ugandan women about to deliver go to a nearby banana plantation, hold on to a plantain and push the baby. Banana leaves are spread below to act as a bed for the delivery and the TBA stands by, to administer herbs.

In communities where these practices are common, it takes more than just a government decree to convince women they need to choose public health facilities over the kind, trusted older women they’ve known all their lives.

“I give my clients a lot of time to express themselves and talk about anything. They do not pay consultation fees, there are no long lines,” says Nabatanzi, who has delivered hundreds of babies but now only refers pregnant women to health facilities.

Nabantanzi says she now only gives herbs for bathing and to stop vomiting. But she adds that she is a mainstay in her village- ‘Always available, reliable and people trust me.’

Ends-

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