On the hilly and rugged terrain of Emuyaha constituency, a pregnant woman groans in pain as another bewildered old woman looks on helplessly.

Few months ago, Jane Esitwati, who operates in this village as a revered Traditional Birth Attendant (TBA), would have delivered this woman without hesitation. 

But from early this year, the government sent a stern warning to women like her not to deliver pregnant women. Instead they are expected to refer them to health centres or retired midwives, to deliver under the care of skilled birth attendants.

Celebrated as the only way to reduce maternal mortality in Africa, this new government directive has left TBAs like Esitwati under siege, with some resisting the move they consider as destroying their source of livelihood.

This strategy also contradicts the scenario 20 years ago during the 36th World Health Organization meeting of the African Health Ministers in Bamako, Mali, dubbed the Bamako initiative, in which TBAs profile was enhanced when experts chose them as the best strategy to roll back the high maternal mortalities.

The Initiative, which Kenya adopted, focused largely on primary health care and how communities would finance their own healthcare.

Now the government is discarding them like hot coal, notwithstanding the millions of shillings which have been spent to train them to help attain the Millennium Development Goals of reducing Kenya’s over 414 maternal deaths per 100,000 live births by three quarters by 2015.

Ministry of Health officials say TBAs have not achieved the objective of reducing deaths as envisioned in Bamako, and are instead to blame for high maternal and child mortality rates being experienced in the country.

“TBAs initiative has failed since our review shows that over 15 years since we trained them, maternal and neonatal deaths have gone up,” says Dr Josephine Kibaru, Head of Division of Reproductive Health in the Ministry of Health.

Increased numbers of women with pregnancy related disabilities such as uterine prolapse, infertility, or mental problems, are blamed on TBAs as well.

Taking all this into consideration, the government says they are a danger to women’s survival and should not be allowed to deliver them.

“The initial objective of the TBAs was to identify complicated cases and rush them to hospitals. But they have become experts themselves, who rarely see the need to take the women to health facilities,” laments Dr Kibaru.

Kibaru notes that the government started getting concerned about this development four years ago, and decided to do something about it.

Likewise, after doing in-depth reviews of their impact, the World Health Organisation has noted that TBAs lack capacity to anticipate pregnancy related complications. It has asked governments to bite the bullet and come up with fresh strategies.

A new policy that puts the last nail in the TBA coffin, and which was approved by the government last year, prohibits them 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 them as the only professionals to deliver women with uncomplicated cases outside health facilities.

Dr Kibaru says these 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.

TBAs are not taking this decision kindly, and are resisting any move to consign them to the annals of history. While the ministry of health wants them shunned, they argue that women love and adore them in villages, and the government is likely to regret its decision.

“We have done this thing (delivering women) for many years and have more experience than those midwives they claim are trained. Some of them were delivered by us,” an irate Esitwati says.

Other TBAs like her bemoan that the government has reduced them to condom distributors, leaving their midwifery skills to rot. In western Kenya, some of them have been caucusing on how to respond to what they perceive as a major blow to their territory.

Many are now arguing that the high maternal rates the government is accusing them of are due to its failure to equip them with necessary tools, communication gadgets and transport facilities for transferring women with complicated cases to health centres.

“Every TBA does her level best to help the woman deliver safely. However, there times things happen which are beyond our control,” says Mary Amutete, a TBA.

An estimated 59 percent of the Kenyan women are said to deliver at home, without the services of skilled birth attendants, according to the 2003 Kenya Demographic Health Survey. Of these, 28 percent were delivered with assistance of TBAs and 22 percent by relatives and friends.

Although some women in the rural areas admit TBAs are incapacitated in certain ways, they see them as the only salvation in time of need. In every village, every poor township or communities, they are revered as the saviour of the underprivileged or those far away from health facilities.

Many women prefer their services because they are cheap and can be paid in kind or the payment can be staggered over a period of time.

Others like Fanis Ongoche from Kakamega district, argue that TBAs are compassionate and cost less compared to what they would have incurred by going through the hassles of hospital bills and transport costs.

While Dr Kibaru admits the government’s prohibition of TBAs from delivering women faces challenges since they are deeply entrenched in communities, and many people believe in them; is emphatic that the decision to stop them from assisting with delivery is final.

“Although in the past we had agreed to invest in the TBAs to reduce the high rates of maternal mortalities, the situation on the ground is not good,” Dr Kibaru notes.

Her ministry has directed the district health committees to ensure that TBAs do not violate the order and deliver women. These committees have been asked to include such women into teams that will propagate health messages in communities.

“We do not want to criminalize them, but work with them as partners in health,” says Dr Kibaru.

With such new roles, the TBAs are being encouraged to refer to health facilities or retired midwives any pregnant woman seeking their services.

Non Governmental Organizations that train TBAs have too been directed to wound up such programmes. The decision has left some of these organizations in problems since this has been one of their main sources of funding. Those whose programmes were running up to the end of next year are equally confused on the next move.

But there are others who think the new government directive is going to improve safe motherhood indicators.

Gladys Okalo, a retired midwife from East Bunyore, Emuhaya district, supports the government directive. She says the TBAs have sometimes mismanaged women, resulting in deaths of either the mother or child or both.

“There are times these women miscalculate and use herbal medicine to induce pain long before the woman is ready. When things get out of hand, they rush to hospitals and refuse to divulge any information of what they have done,” whines Okalo.

Other TBAs tell the pregnant women under their care that everything is fine, only for them to experience complications, she adds.

“A TBA finds it difficult to tell a woman that she cannot manage for fear of losing the payment. Hence women who would have not died do so under their watch.” 

Still, even as the government put emphasis on retired midwives, the latter are not happy either. Those interviewed by Horizon complained of getting no pay or incentives from pregnant women who argue that the government has made maternity free.

“When these women come to deliver in your house, we use money to buy them food and provide beddings, some of which they turn into clothing for their newborns. Yet they are not paying us,” says Okalo.

Used to getting a salary every month, the retired midwives are finding the new roles taking away a lot from them than what they are receiving.

“I think the government should consider giving us incentives such as a stipend every month,” she proposes.

Apart from using retired midwives to replace TBAs, the government has come up with two other new strategies.

A campaign to have husbands or partners prepare in advance for emergences and where their partners will deliver is underway.

Another initiative, which is currently being implemented in Wajir, Malindi, West Pokot, Suba, Kilifi, and Kinangop, is the use of Maternal Shelters. Located near health centres or hospitals, these shelters house expectant women close to the health facility before the onset of labour.

Under this arrangement, pregnant women are usually brought from the hinterland to these shelters two or three weeks before the day of delivery. While at this shelter, they are provided with food and other care as they wait to deliver in the hospital.

But even as the government engages in these new initiatives, one big question that begs for answers is where did the rain start beating us on the TBA issue? Did the government fail to offer proper training followed by refresher courses to TBAs or was the programme implemented without a supervision component to ensure they were doing the right thing?

The Bamako initiative that gave TBAs greater status was based on the argument that developing countries, particularly in Africa, lack resources and qualified doctors and nurses to provide skilled attendant to pregnant women. Hence, training TBAs was seen as the right intervention to help reduce the high maternal mortalities and obstetric complications. 

Immediately after the meeting, Kenya like other African countries, embarked on an aggressive TBAs training programmes.

Such trainings were designed to empower traditional birth attendants with skills in the following key areas: care for mothers before, during and after delivery; identification and referrals of mothers at risk; and avoidance of harmful traditional practices and embrace those that contribute to psychosocial support of an expectant woman.

The TBAs were also required not to interfere during labour and embrace high standards of hygiene during delivery time.

Past studies have shown TBAs who been trained well in these areas to be better placed to deliver women in acceptable conditions as well as create awareness on obstetric complications.

Dr. Rana Jawad Asghar, writing in the 1999 January Journal of College of Physicians and Surgeons Pakistan, on the topic “Obstetric complications and role of Traditional Birth Attendants in developing countries”, says by training TBAs in timely recognition and referral of pregnancy, delivery, and other complications, can significantly help improve the health situation of pregnant women.

A study done in 2000 by Elizabeth A Goodburn of Centre for Sexual and Reproductive Health, John Snow Inc., UK, and others also established that trained TBAs were significantly more likely (45 percent) to practice hygienic delivery than untrained TBAs  (19.3 percent).

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.

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

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 TBAs.

With this existing challenges, health experts argue that even the use of retired midwives may not achieve much if issues such as lack of transport, difficult-to-reach health facilities, and poor roads, which have dogged the TBA programmes, are not addressed.

An AWC-Feature