TRADITIONAL BIRTH ATTENDANTS IN MALAWI JJM

Traditional Birth Attendants (TBAs) and traditional healers form an important link in the chain o f health personnel providing primary health care in Malawi. In spite of the establishment o f hospitals and health centres, it is to these traditional healers and TBAs that the majority o f people turn in times o f sickness and child-birth. Approximately 60 p er cent o f all deliveries in Malawi occur in the villages. It is therefore important that due regard be p a id to the activities o f these traditional practitioners in order to ensure the achievement o f the goal ~ ''Health for all by the year 2000". The training o f TBAs is seen as part o f the Maternal and Child Health Services in the country. The Ministry o f Health is responsible for the training and control o f Traditional Birth A ttendants and in 1976 opened a register in order to list all those trained In early 1978 a training course for selected TBAs was conducted a t the Kamuzu Central Hospital, Lilongwe and from 1982 the training programme evolved into a national training programme for TBAs. By February 1987, a total o f 841 Traditional birth A ttendants had been trained and the programme is still continuing.


INTRODUCTION
Approxim ately 60 per cent o f all deliveries in Malawi occur in the villages, where the patient receives prim ary care either from a close relative o r another village w om an acts as village midwife.These women are called Traditional Birth Attendants (TBAs).Before 1978, when training courses were c o n d u aed for such workers, the care that they provided, although undoubtedly loving, w as on the w hole unskilled, misdirected and harm ful.In The M alawian T B A is alm ost invariably a fem ale, aged betw een 35 and 60 years.She begins her m idwifery w ork only after she has had children o f her own, and usually learns from som e close relative w ho is an established TBA.She performs from 1 to 25 deliveries m onthly, ch arg in g betw een 20 cents and R 3.00 per delivery.A few do not charge.Two-thi rds o f TBA s carry out deliveries in the patient's own home, som etim es being called at the onset of labour, but som etimes only later w h en d if f ic u ltie s a rise .T he rem ain in g one-third have their own maternity units and tend to do more deliveries, to charge more, and to deal with normal cases rather than problem cases.
The TB A usually sees her patients antenatally and prescribes potions made from powdered bark, roots or twigs.She often administers sim ilar m edicine during labour.Nearly all T B A s w a n t c lo s e r a sso c ia tio n w ith the recognised health services and w elcome the id e a o f re c e iv in g tra in in g .T h o se w ith maternity units in their own homes are more uniform ly positive about this than the others.T h e m a te rn ity u n its o f th ese T B A s are typically a mud and thatch house partitioned to divide the labour ward from the post-natal or w aiting area.Some, however, have several b u ild in g s, for w aitin g patients, antenatal clinics, prem ature baby nurseries, and some have corrugated i ron roofs.The TBAs seem to select them selves for their work, and without an aptitude for and an i nterest i n thei r work are unlikely to embark on it.The few apprentice TBA s in the survey conducted by the Ministry o f Heal th, often "looked the brightest and most intelligent of the younger wom en available in the village" (Bullough, 1978:83).
The investigation into TBA s by the Ministry o f H e a lth (M O H ) r e v e a le d th a t th e ir m anagem ent o f labour is based on different principles from those o f W estern medicine.They have, however, adopted som e Western practices on their own initiative.For example, TBA s deliver their patients in the supine p o sitio n w h e re a s m o st h o m e d eliv e rie s conducted by relatives are believed to be managed with the m other in a semi-upright, sitting or squatting position.
The TB A is prepared to care for premature babies, deal w ith abortions and treat women fo r in f e rtility an d o th e r g y n aeco lo g ical diseases.They do not concern them selves wi th children's diseases.A small number, are also traditional healers and then they treat ail forms o f disease and include children am ongst their patients (Bullough, 1978;83)

T R .\IN IN G OF TR A D ITIO NA L HI RTII ATTENDANTS
A fter the investigation by the M OH this body approached the N urses and M idwives Council o f Malawi (N M CM ) to ask the Council to establish a training course for a grade of midwives w ho w ere w illing to w ork in the rural areas.The Council suggested that the training should last betw een six w eeks and three months (M NCM , 1976).
It w as then decided that the MOH should be responsible for the training and control of TBA s and in 1976 the M inistry opened a register in order to list all trained TBs.It was s u g g e s te d th a t th e s e w o m e n b e le f t independent o f the normal medical services, and kept free from oppressive paperwork and reports.This w ould preserve their dignity and at the same time ensure that costs did not escalate (Bullough, 1978: 83).
In early 1978 a training course for 15 TBAs w as conducted at Kam uzu Central Hospital, Lilongwe; they were selected from amongst those w ho carried out deliveries in their own maternity unit, and w ho perform ed five or more deliveries per month.They came for two w eeks training in groups of three and four, and afterw ards had three follow -up visits.
The syllabus included instruction in hygiene, the normal events o f pregnancy and labour, the recognition o f w om en at risk o f obstetric abnormalities, the m anagem ent o f labour, the puerperium and the new-born child.Some child care and developm ent w as taught.Great em phasis w as placed on the fact that normal labour is short and that referral to hospital is essential when delay occurs.
The basic concept stressed w as that their job w as to manage normal labour in a safe way, but that abnorm alities o f labour w ere the concern of hospital staff.It w as emphasised that they could im prove their results and reputation by learning to select and recognise p a tie n ts w ho m ight e x p e rie n c e p ro b lem labours, and then refer them to hospital.
On completion of the residential course they were issued with United Nations International C h ild re n 's E m e rg e n c y F u n d (U N IC E F ) midwifer)' bags.This bag is made of stainless steel and contains the following items needed duri ng a delivery: a plastic apron, a plastic sheet, a pair of scissors, a kidney dish, two round stainless steel bow ls, a pair o f cheatles, a scrubbing brush, a pair of scissors, soap in a dish, cottonwool, gauze, swabs for wiping the eyes o f the baby and protargol eye drops to instill into the eyes of the baby after bi rth.Other useful items of equipment such as hurricane lamps, blankets and soap were also given (Bullough, 1978, 84).An interview with TBA Mrs Marika Naphira, showed the author the contents o f her midwi fery bag, in O aober 1987.

EVALUATION OF TH E IN ITIAL TRAINING PROGRAM M E
The efficacy o f this first training program m e w as assessed during a fourth and final home v is it w hen a q u e stio n n a ire , u sed b efo re training had begun, w as repeated.Records o f deliveries performed were exam ined and the equipm ent issued to them inspected.The training team o f the MOH w as pleased with the resu lts and related th at th e p ersonal r e la tio n s h ip s w ith th e T B A s h a d b e e n excellent, and that a considerable degree o f mutual trust had developed.Referred patients arrived in considerable numbers, including antenatal patients with labour com plications, and puerperal infections (B ullough, 1978,84).
M uch building activity w as stim ulated by the fi rst course arranged by the M OH duri ng 1978, m an y o f th e p a rtic ip a n ts h a v in g s in c e extended or improved their prem ises.Before the course, all but one w ere delivering their patients on the ground, but since then, many have had labour beds constructed although no mention w as made o f this being necessary or desirable.The benefits of this first training course w ere compared with the costs.There w ere many hidden costs such as use o f staff time, but approxim ated costs w ere:- However, these 15 TBAs are responsible for about 2 000 deliveries per year, and no further cost, except for occasional follow-up visits, need be expected.Their combined w ork-load is equivalent to that of four or five small two-m idwife matem ity units.

NATIONAL TRAINING PROGRAM M E
B ullough (1978) hoped that these results w ould be considered positively enough to w a rra n t th e in tro   • Field trips to see pit latrines and p ro teaed well projects.
• Familiarization tours to health centre(s), ch ild ren's wards, care o f the new-born units, "under five"-clinics and nutrition clinics.
• Social and extra-curricula activities over the weekends covering the following: -Health-care and prevention o f infections; A s special attention is paid during the training course to local custom s and needs of the area, the TBA Ts use all sorts o f material to show how these TB A s can function in their own surroundings.T eaching hygiene, for example, is em phasised in many ways.O ne example is the way in which women are shown how to w ash their hands.The trainer uses water, soap, a maize cob, and a tin with a small hole in it, w hich is used as a running tap.This could also be taught with the aid o f pictures.The cutting o f the b ab y 's cord is demonstrated by using a rope or a soft cotton belt, which is tied in two places, m aking knots.A razor blade is then used for cutting in between the two knots.For equipm ent to cut the cord, the women are taught to prepare the bigger m atchbox in w hich they pack self-prepared boiled cord ligatures, a new razor blade and a piece of soap; they feel com fortable with this type of kit, and i t can be mai ntained and cl eaned easi I y (Chirambo, 1985:29).

PERSONAL VISIT TO A I'RADITIONAL BIRTH ATTENDANT
During a visit in 1984 to a local TBA, Mrs N ajere K um w em be, (also registered as a traditional healer at N anjira) the researcher found that she w as com bining traditional m edicine very successfully with her modern scientific knowledge o f obstetrics.She has built up a wide reputation since she started to practise there in 1968 because she has the ability to 'see inside the uterus' and spot any abnorm alities im mediately.The patient is then referred to the hospital at Lilongwe, A fter the abdominal palpation on an antenatal patient, she rubs medicine on the abdom en o f the patient as well as on a hand mirror.The mirror is then held in front o f the abdom en and ' reflects' the contents i nside.Accordi ng to her, it w orks like an X-ray photo.The medicine is made of roots o f a certain tree w hich her husband obtains from the Dedza-district, and these roots are then boiled in a tin.Qualified nurses num ber am ong M rs K um w em be's patients.Her practice is inspected regularly by the MOH and she attends updating courses in midwifery when it is expected o f her.
M rs Kumwembe also functions as a traditional healer and treats 'mentally confused patients that scream and sh o u t'.She g iv es them medicine consisting o f dried roots which are first ground into pow der, then sieved and mixed with water.The patient receives two teaspoonfuls of this m ixture twice a day.The medicine calm s the patient dow n but if the patient does not im prove she refers the patient to the psychiatric hospital in Zomba (V isit to Mrs N. Kumwembe, 14 July 1984^ This corresponds with a statem ent by Dr Stevenson that the local treatm en t o f neuroses and hysteria may be as effective in many cases as the treatment w hich conventional medicine can offer (Stevenson, 1964:10).

NATIONAL EVALUATION OF TRADITIONAL BIRTl I ATTENDANT PROGRAMME
1973 the S ecretary for Health in M alawi a u th o r iz e d an in v e s tig a tio n in to h o m e d e liv e rie s in th e Z o m b a and M ach in g a districts, and in 1976 in the Lilongwe district.(Bullough 1978).T1 IE T Y PIC A L M ALAW IAN TR A D ITIO NA L BIRTH ATTEN DA N T B a s e d o n th e a b o v e in v e s ti g a ti o n s , characteristicsoftheM alaw ianT B A emerged.
d u c tio n o f a N a tio n al P ro g ra m m e for tra in in g th e T B A .H e suggested that such a program m e would be b e st arra n g e d in th e fo rm o f an in itial saturation program m e trying to cover the country and then later as a sm aller programme m aintaining supervision, w hich w ould be essential, and running sm aller n u m b erso f new courses.It w as pointed out that TB A s only conducted a minority o f village deliveries during 1978, but it w as postulated that a national training programme w ould increase their influence, make them m ore successful and increase the amount o f w ork they do.In this way the effects o f their training could spread to affect all home deliveries (B ullough, 1978, 84-85).The vision regarding a National T raining Programme for Traditional Birth Attendants becam e a reality through the hard w ork and enthusiasm o f Dr C. Bullough and the medical an d n u rsin g s ta ff o f th e M O H w ith the c o -o p e r a t i o n o f th e P r i v a te H o s p ita l A ssociation o f M alawi (PH A M ) personnel.The training program m e started in 1978 in the district o f Lilongwe and three more districts w ere added in 1980, nam ely M zimba, Dowa and Mwanza; training w as extended to cover the w hole country in 1982.T he training program m e w as i mpl emented i n support of the m ain objective o f the M aternal and Child H e a lth P ro g r a m m e e n u n c ia te d in th e M inim um Plan, M iniplan, w hich is: "... to increase protection o f the high risk group, that is children, under the age o f five years and m others in the child-bearing age, against causes of high morbidity and mortality" (By February 1987, a total o f 841 TBAs had b e e n tra in e d and the p ro g ram m e is still continuing. -care and nutrition; -P e rs o n a l h y g ie n e , e n v ir o n m e n ta l hygiene and sanitation; -M anagem ent of antenatal clinicpatients, that is, identification and referral o f at-risk m others to the nearest health centre; -Use, managem ent and care o f UNICEF Traditional Birth Attendant kit; -M a n a g e m e n t o f la b o u r , d e liv e ry , post-partum or perinatal care o f the new-born; -Recognition o f obstetric com plications th a t m ay a ris e d u rin g la b o u r a n d delivery; -The role of the health team, the TBA and her re latio n sh ip w ith o th er prim ary health care workers; (M inistry o f Health, 1987 2-3).I'R A D ITIO NA L BIRTl I A 'lT E N D A N T TRAINERS In tandem with the TBA s training programme, supervision w as equally im portant for the functioning o f the programme.As it was not possible for the personnel o f the Head Office o f the MOH tosuperviseall the trained women in their area, the M inistry decided to train specific personnel to educate TBA; they are called Traditional Birth Attendant Trainers (TBATs).The first trainees' workshop w as conducted in May 1981, fol lowed by tw o further workshops in June and July 1982.T w o nurses were trained from each district, that is, a Registered C o m m u n ity H ealth N urse o r R eg istered N urse/M idw ife or an Enrolled Nurse/Midwife or Enrolled Comm unity Health Nurse.One o f the two w as the Maternal and Child Health C o-ordinator.No specific selection criteria w ere applied (M inistry o f Health 1987:51).The objective o f these w orkshops was to equip the participants with knowledge, skills and a t t i t u d e s f o r p l a n n i n g , o r g a n i s in g , im plem enting and evaluating a TBA training program m e. Special attention w as paid to local custom s and needs.T he content o f the training was: 1. Concept o f culture and relation to health in a comm unity.ssessm ent and supervision of the TBA, including assessm ent of knowledge and use o f delivery records and quarterly returns (M inistry o f Health 1987; 51).In April 1985, a National TBA T workshop w as held in Lilongwe.The objectives of the w orkshop were: 1. T o review critically the T B A 's training activities and identify areas needing improvement.2. To exam ine the T B A 's activities and find out how other activities as recom m ended by the 1984, Maternal and Child Health Review Mission, could be incorporated into their training and services(M inistry o f Health 1987,5).O ne o f the main recom mendations w as to i n c o r p o r a t e r e f r e s h e r c o u r s e s in th e program m e to include new areas o f child spacing, m alaria and diarrhoea management in c lu d in g u se o f c h lo ro q u in e and oral rehydration solutions.This activity started in July 1985.By February 1987, 123 trained T B A s had u ndergone a w e e k 's refresher c o u rse .T h is ac tiv ity is still co n tin u in g (M inistry o f Health 1987, 5-6).
Since the T B A 's training programme started in 1 9 7 8 , n o c o m p r e h e n s i v e n a tio n a l e v alu a tio n h as been u n d e rta k e n .D u rin g A ugust 1980, the U nited N ation's Family Planning Assistance (U N D PA ) programme, visited Malawi and gave their support to the programme and the evaluation o f Maternal and Child Health services.The evaluation of the Traditional Birth A ttendants' program m e w as then undertaken jointly during 1985 and 1986 by the G overnm ent o f Malawi with W HO and UNFPA.It w a s r e c o m m e n d e d th a t th e T B A 's programme becom es an integral part o f the family health program m e at national, regional and district level.T his w as im plem ented and the training o f Traditional Birth A ttendants is seen as part o f the M aternal and Child Health Services (M inistry o f Health, 1986, 7-13).One o f the mai n findi ngs o f the worki ng group was that there was a need to increase the level o f aw areness am ong the com m unity o f the activities and role o f the TBA s, and their participation in primary health care o f Village H e a lth C o m m itte e s in o rd e r to e x te n d coverage o f maternal and child health.It was recom mended that this orientation should be done by the trainer on com pletion o f the T B A 's tra in in g se ssio n s, at c o m m u n ity leadership m eetings in their hom e areas after consultation w ith the TBA T. C om m unity support for the TBAs needed strengthening, particularly with regard to referral o f high risk m others (M inistry of H ealth 1987, iii).