Collins Mtika
GEZAMGOMO, Malawi , Nov 23 2010 (IPS) – Cecilia Tomoka s birthing centre stood unused for three years before the 2009 earthquake flattened it. Now she s rebuilding the house and her practice as Malawi s government lifts a ban on traditional birth attendants.
Tomoka lives in Gezamgomo village, about a kilometre outside Malawi s third largest city, Mzuzu. She started assisting with births in 1989, after her grandmother renowned for communing with the spirits told her it was her calling.
United Nations agencies project Malawi s maternal mortality rate is presently 510 deaths per 100,000 live births; down from the 2005 estimate of over 1,100 per 100,000. In 2007, traditional birth attendants were banned in an effort to push more women to give birth with qualified medical assistance.
So for two years, weather weakened the thatched roof and unburnt earth brick walls of Tomoka s unused birthing centre, while children played hide and seek around it. The earthquake that struck northern Malawi in December 2009 destroyed the birthing hut and Tomoka s house adjacent to it.
Flat, like this, Tomoka s hand makes a sweeping motion. For me it was a lot of damage.
Fresh chance for traditional attendants
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In October, Malawi s president announced the ban on TBAs would be lifted. In January 2011, the Malawi government will select a first cohort from across the country to be trained as community midwives.
We reduce the work at the hospitals, because there are too many pregnant women out there, says Tomoka. Those doing good work must be given incentives, because we get nothing for our work.
Dr Odongo Odiyo, who manages family planning and reproductive health programmes for the East, Central and Southern Africa Health Community, disagrees.
He says Malawi is making a mistake integrating TBAs into the maternal health sector, as they cannot be trusted with deliveries. These can only act as the first contact point in transit to a conventional health facility.
Odiyo says that although TBAs have long assisted women with delivery, many women died giving birth under their care.
This was a sign that training was not enough for them to handle complicated cases beyond their skills, Odiyo said.
There is evidence to the contrary. Solomon Chih-Cheng Chen and his colleagues studied 81 midwives trained in Mzuzu in 2004 and 2006 by the Taiwan Medical Mission. Over three years beginning in 2004, this group of trained TBAs saw just under 2,000 pregnant women. Seventy-nine were referred to health facilities; not a single maternal death occurred among the remaining women. Twenty-six newborn deaths were recorded among the 1,905 babies delivered by the group being studied.
Professor Anthony Costello, a University College of London paediatrician with experience working in developing countries such as Malawi, says TBAs and community workers can effectively reduce the rate of maternal deaths. He argues for a maternity kit containing two critical drugs; antibiotics to prevent infection and misoprostol to deal with haemorrhage.
Many African women enter labour with their health already compromised. Parasitic infections such as malaria and schistosomiasis; maternal malnutrition (including vitamin A deficiency), excessive blood loss, anaemia, chorioamnionitis (inflamation of foetal membranes) from untreated STIs or other infections these are big killers of women in rural areas because they deliver in unhygienic and insanitary maternity huts, Costello said.
Preparing to practice
In Gezamgomo, a new birthing hut is rising from from the wreckage of the old as a southern hemisphere summer takes hold. Three brown dogs circling her playfully, Tomoka leads the way to her former place of work, just 20 metres from her house.
Scores of women from the surrounding villages, some singing lullabies to babies on their backs, are busy clearing debris, oblivious to scorching November sun.
The reception and the guardian shelter were adjacent, while the delivery room was on the eastern side. Tomoka gestures at the pile of broken bricks, rotting roof poles and bits of thatch, perhaps recalling her twenty-plus years of service.
Since I started keeping records in 2005, I have safely delivered 200 babies. None died, she says, carefully turning the pages of a dog-eared exercise book filled with names. Handwritten notes record details like a mother s age, the number of children she has, time elapsed during delivery, the condition of the newborn baby, what basic drugs painkillers the labouring woman was given.
Part of the solution
Traditional birth attendants are not a panacea to Malawi s high maternal mortality rate, says maternal health expert Lennie Kamwendo, but in a country abound with horrific stories of pregnant women giving birth on river banks or dusty roadsides, overtaken by birth pains as they laboured towards chronically understaffed health centres, TBAs contribution to safer motherhood should not be underestimated.
TBAs in Malawi have for long filled the gap in the maternal health sector by assisting pregnant women. I think they must be regularly given basic training and encouraged to keep statistics of births and deaths, says Kamwendo, who is president of the Association of Malawian Midwives.
He is sharply critical of the performance of many qualified health personnel. Malawi needs to clearly define training in nursing and midwifery as trained health workers deliberately avoid working in maternal wards due to lack of direct training, he says.
Aside from that, you frequently find health workers have gone shopping or to a hair salon during working hours leaving pregnant women to die unattended. They are not disciplined.
Dorothy Ngoma, executive director of the National Organisation of Nurses and Midwives, says she opposed the banning of TBAs from the start. Instead government should support and train TBAs so that they should be able to diagnose pregnancy complications. In terms of statistics we lost as country because death and births from this sector were not recorded.
Responding to the charge that trained nurses mistreat pregnant women, she blames the government for failing to motivate health workers, saying that is why so many migrate to Europe in search of greener pastures.
Inspecting freshly-molded bricks drying in the sun, Tomoka is looking no further than returning to the work she loves: Most women who come to us complain of ill-treatment at the few health facilities [in rural areas]. We [traditional birth attendants] live with the people and understand them very well.
