The decision by the government to ban traditional birth attendants from delivering women may not succeed if the current feelings on the ground are anything to go by.

While the government has directed retired midwives to be the ones to deliver women, some of the women in rural areas remain suspicious of these trained personnel.

Like her, many other women share her views, saying the treatment they are subjected to by midwives in hospitals is the reason why they are hesitant to consult them now, instead preferring traditional birth attendants.

Gladys Okalo, a retired midwife, says some women even believe that what a TBA cannot do is impossible to the midwives as well.

“Some women consider the only difference between a TBA and retired midwife is that one has been working within an institution and the other one in the villages,” she adds.

Such thinking is compounded by some TBAs who are moving around the villages spreading propaganda about retired midwives and asking women to seek other alternatives.

Dr Solomon Orero, a gynaecologist and obstetrician who has done a lot of research around safe motherhood, agrees these are real challenges the government needs to confront. To him, the midwives policy is likely to run into problems because of the past perception and experiences women harbour about these trained professionals.

“Unless the retried midwives change their attitudes and how they handle the women, then we may see them diverting back to TBAs.”

The fears some women still harbour about retried midwives are well captured by statistics. While 88 per cent of the women sort antenatal care from trained health providers, only 40 percent went back to deliver under their care, according to the 2003 Kenya Demographic Health Survey (KDHS). Majority (59 percent) opted to deliver at home assisted by TBAs or family members.  

The 2003 KDHS shows North Eastern leading with 92 per cent of women who delivered at home, Western Province (71 per cent), Coast Province (67 per cent) and Rift Valley and Nyanza provinces recording 63 per cent each. Only Nairobi, at 21 per cent, had the lowest number of women who delivered at home due to the proximity of health facilities.

This may be interpreted as showing that while women trust doctors and nurses for antenatal purposes, they seem to have faith in being delivered by traditional birth attendants or family members at home.                                                                                                                            

“The new approach will only work if the retired midwives understand the circumstances we live in and are warm to us like the TBAs,” says 29-year-old Caroline Were from Shiatsala in Butere district.

Rural women now want the government to enlighten the retired midwives - who have for along time been used to a salaried profession - on how they should handle poor women.

At the centre of the current debate is a new policy approved by the government last year that prohibits TBAs from undertaking the services they have known for several decades.

In the policy, the government has recognized and approved community midwives, who have retired from its service, to replace traditional birth attendants as the only professionals to deliver women with uncomplicated cases outside health facilities.

According to Dr Josephine Kibaru, Head of the Ministry of Health’s Division of Reproductive Health, retired midwives are linked with health facilities and paid by the client depending on her ability.

Kakamega, Butere, Mumias, Mwingi, Teso, Nyandarua, and Mt. Elgon districts are some of those where these midwives are in operation.

But medical experts warn that this new approach many not work effectively if TBAs perceive the government as an enemy and if certain key obstacles are not addressed.

“The government did not create TBAs and hence it cannot outlaw them. They have thrived because of our failures to put in place an effective safe motherhood programme,” says Dr Orero.

He warns that if the traditional birth attendants are criminalized, then they will go underground and continue offering services.

“The way forward is to take them as partners in health because they can be used successfully in the campaign around safe motherhood.”

Besides this, the government and other partners will also have to put in place an aggressive communication strategy to enlighten women why they need to consult retired midwives and not traditional birth attendants.

Even if this is to happen, health pundits believe retired midwives will perform dismally if the very challenges that confronted the TBAs are not addressed.

“There those challenges like lack of transport or communications gadgets to help deal with emergency cases.

Such problems were beyond TBAs and will affect retired midwives with a similar magnitude, resulting in little reduction of maternal and child mortality rates,” explains Grace Owino, a nurse working in Kibera slums.

Dr Orero concurs. He argues that retired midwives are going to make major impact on reducing maternal morbidity and mortality if they are provided mini comprehensive delivery kits.

Such kits usually assist the midwife to reduce the risk of death resulting from delivery associated complications. At the moment, most of the retired midwives lack these critical facilities.

Medical experts further claim the poor performance recorded by TBAs was as result of the government failing to offer proper training followed by refresher courses to TBAs. Or in many other instances, the programme was implemented without a supervision component to ensure they were doing the right thing.

L.M. Sibley, T.A. Sipe and  P.Buekens in their study “Traditional Birth Attendant Training Effectiveness: a Meta Analysis,” published in the 2003  and reviewed in Journal of Gynecology and Obstetrics, further found that there were 8 percent fewer deaths among women cared for or living in areas served by trained TBAs.

But they were fast to add that the impact of trained TBAs should not be expected to be much if there is no available effective health care system where referrals can be sent to as well as other critical factors being addressed.

This partly explains why the TBA programme might have failed in Kenya and other African countries. Indeed, a section of reproductive health pundits believe the TBA program has not been a success in Kenya because certain things were not done right. If the same are not tackled, the retired midwives may suffer the same fate.

These include: Lack of an organized system to supervise trained TBAs or retired midwives to ensure there is a good link between them and the formal health care system; no continuous training programmes; and lack of basic supplies and tools.

Others are: lack of transport and good infrastructure, which makes it difficult for them to refer complicated cases or high risk mothers to formal health centres for emergency obstetric care; and lack of enough safe medicines to be used by pregnant women under the care of retired midwives or TBAs.

With this existing challenges, health experts argue that even the new strategy may become a cropper if these issues are addressed in more concerted manner and as a matter of urgency.

An AWC-Feature