Transforming traditional birth attendants

By reorientating TBAs, we are increasing their knowledge and skills through training, giving them a role in referring and accompanying women to nearby facilities, and providing pregnant women with a mix of the personal and professional care that they need and want.

The term ‘TBA’ refers to traditional, independent, community-based providers of care during pregnancy, childbirth and post-natal period .  TBAs generally use skills learned from relatives and friends and not based on any medical training.  Women’s reasons for using a TBA for home delivery, rather than going to a health facility, are varied.   Some say TBAs are familiar, known to them and from their own communities.  Others say TBAs are available and accessible at all times, whereas health facilities can be far away or closed at night.  Other pregnant women, particularly teenage mothers-to-be, say health facility workers are unfriendly or rough with them.  At a community meeting, one woman said:

“Sometimes when women go to a health facility, there is only one health worker and five women giving birth.  In contrast the TBA gives you warm water, nice food and 1-on-1 attention.”

From birth attendants to birth companions

Although TBAs have filled a gap in underserved areas, high maternal mortality rates mean the government of Kenya now actively discourages home births with unskilled providers.   So how can women be encouraged to access facility-based skilled delivery services?  The DFID-funded Maternal and Newborn Improvement (MANI) project in Bungoma County has been designed to increase community demand for and the supply of quality maternal and newborn health (MNH) services, including innovative approaches to link TBAs and their clients to the formal health system.

The MANI project is engaging and collaborating with TBAs, rather than marginalising them. MANI has reoriented 200 TBAs to become birth companions (BCs) who refer and accompany pregnant women to health facilities, and provide MNH support and education before and after birth. The BC training covers:

• the status of MNH in the local area – why mothers and babies will have better outcomes at health facilities with skilled providers
• MNH services available and how BCs can link women to these services
• how to promote household MNH practices such as good nutrition, supplementation and hygiene
• basic MNH skills such as: keeping the baby warm using Kangaroo baby care, instructing mothers to position and attach the baby on the breast, proper hand washing procedures and cord-cleaning
• basic communication, advocacy and networking skills

Birth companions in the community

Although BCs face a loss of income from home deliveries, they are mostly positive about the training they have received and their new role.  Since delivering babies at home is discouraged, TBAs’ services were in demand but they had to hide what they were doing.  Now, the MANI project has provided branded shirts and identification for BCs, bringing them and their work out in the open.  Thanks to meetings between MANI, BCs and health facilities, there is now an understanding and acceptance of the role of BCs by the formal health system.  MANI is also piloting a Village Savings and Loan (VSLA) model with BCs, a microfinance initiative developed 25 years ago by CARE and replicated across the world. With capacity-building from MANI, BCs will engage in group savings and loans, with a view to starting small business ventures to replace lost income from their work as TBAs.

Birth companion, Ruth Musuya:

“After MANI project training my work is now more in demand by the community and I am now known and appreciated. The identification tags and t-shirts make us look more professional.” 

Birth companion, Alice Khisa:

“What makes me happy with my work is that, now our job is simple and clear compared to back then where we used to deliver clients at home without any knowledge on MNH issues, which was directly putting mother and child’s life in danger.  The community now trusts us and have embraced our service.”   

Martha Wanjala, her client, describes their relationship:

“I met Mama Alice Khisa through my aunt who took me in when I was pregnant.  Mama Alice Khisa counselled me, examined me and… advised me to go for my check-ups at the antenatal clinic.  She also advised me on diet to keep my health well, since my aunt thought I was anaemic. After nine months under her care, we got used to each other and I used to visit her regularly. When I started labour she took me to the hospital. Nurses were good to me, encouraging me to be calm and that all will be well. I gave birth to a baby boy after spending 13 hours in the hospital. I really thank Mama Alice Khisa for her support.”

Remarkable referrals

BCs have embraced their role and the MANI project is tracking the number of referrals made by BCs each quarter.  In the first six months of 2016, BCs referred 1,738 women to health facilities to give birth.  BCs are proud of this result.

Here are some of their stories:

Ann Mulati, Tongaren sub-county:

What makes you happy about your work?

“I am happy when I handle a client [refers and/or accompanies a client, especially for skilled care delivery] and they come out successfully without a complication. I am now happy with my work because as a birth companion, I work without fear unlike in the past. Before we were trained by MANI project we used to hide in the villages and conduct home deliveries. With the identification badges and t-shirts, it makes us feel professional and even the health providers recognise and treat us well when we accompany our clients to facilities. In the community, people respect our work and they trust us when we do home visits because they know that it is work we are doing and not gossiping.”

Mary Juma Bisunu, Sirisia sub-county:

Tell us about a memorable client.

“I think of one of my clients, Lydia Sulwa.  I knew her many years back and I have referred her twice for skilled care deliveries where both were caesareans. We have been good family friends and I have become a mother to the family. The third pregnancy was scary to all of us since the doctors had indicated that all her deliveries will be through caesarean section. I encouraged her and started nurturing her, taking her to the clinic until she was due for delivery. When she started labour I took her to the nearby facility for onward referral but when they called the referral hospital they were informed that there was no bed space. I panicked because I knew my client could not push. She became weak and badly off. I decided just to take her to the referral hospital and when we got there they managed to get space and she delivered well again via caesarean. I took an extra step of standing with her as her guardian and signed the consent form for operation on her behalf. I am happy now because I saved her life and the baby’s life who is now three days old.”

CARE International is one of our partners on the MANI project. It leads all of MANI’s social and behavior change communications (SBCC) activities in Bungoma county at the community level. These approaches are integrated with other community strategy activities to progressively shift attitudes and beliefs, create local demand for MNH services, and foster accountability at all levels.