Amref Health Africa’s Position on the Role and Services of Traditional Birth Attendants

According to the World Health Organisation (WHO), a traditional birth attendant (TBA) is “a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or by working with other TBAs”. In addition to attending deliveries, TBAs help with initiating breastfeeding; providing health education on sexually transmitted illnesses (STIs), reproductive health and nutrition; visiting mothers during and shortly following delivery to check for and educate them on the associated danger signs; and accompanying referrals to the health facilities for complicated deliveries.

Throughout history, traditional birth attendants have been the main health care providers for women during childbirth in Africa. They attend to the majority of deliveries in the rural areas of developing countries.

TBAs are highly respected in African communities. They perform cultural rituals and provide essential social support to women during childbirth. Their clients trust them and share their secrets with them. Without modern training on how to attend to pregnant women, however, TBAs are unable to recognise and respond appropriately to complications of pregnancy. For this reason, deliveries attended by untrained TBAs are risky for women and their babies, leading to poor health outcomes and even death.

Training TBAs has been a key strategy for improving maternal and child health care in many African countries. Although such training has not contributed directly to reduction in maternal mortality, it does appear to improve their effectiveness in other areas such as the reduction of neonatal tetanus, increasing the provision and use of antenatal care, and increasing referrals in case of complications. Therefore, TBAs can be considered an important part of the informal community health care system.
Despite intensive training of TBAs, recent studies have concluded that the impact of training TBAs could also be counter-productive, as it would hold back the training of the necessary numbers of mid-level health care providers. This led WHO and UNICEF to recommend the use of skilled birth attendants for child delivery rather than TBAs. However, TBAs would be the ideal group to use to increase awareness on family planning practices and fight female genital mutilation.

Amref Health Africa’s Position

Amref Health Africa agrees with WHO and UNICEF that TBAs cannot be substitutes for skilled providers, but strongly believes that they can contribute to the survival of mothers and newborns by facilitating access to needed information, clinical services and support. In other words, TBAs, like other community health workers, can effectively convey vital information to families and communities in culturally appropriate ways that will help them to recognise danger signs during pregnancy and know where to go for help (referral).
Amref Health Africa believes that TBAs meet vital community needs in supporting women throughout pregnancy, childbirth and the post-partum periods.

Amref Health Africa advocates for TBAs to work closely with health planners, health professionals and other members of the formal health system as a strong link between the community and the health services. TBAs should be included in community education and mobilisation efforts.

Different ways in which TBAs can work with health care teams include:

• Partnering with skilled providers (every TBA should be attached to a specific health facility so that she can benefit from the supervision of a skilled health provider).
• Acting as community educators or change agents for health-seeking behaviour on reproductive health, including family planning and child health.
• Identifying pregnant women in the community and encouraging them to visit health facility for antenatal care, as well as making early referrals for obstetric problems.
• Distributing iron folate supplements to pregnant women in the community.
• Sensitising the community to fight harmful practices such as FGM.
• Helping skilled health workers to build good relations with the community.

While Amref Health Africa always operates within national health system guidelines and laws, the organisation believes that TBAs are useful and reliable partners in maternal, neonatal and child health programmes. This belief is based on years of experience in remote and hard-to-reach areas, where health facilities are few and far between and numbers of skilled health providers severely limited. Until they are replaced by sufficient skilled birth attendants, TBAs remain the only option for many women. Therefore, Amref Health Africa advocates for their training, supervision and support in assisting deliveries.