Abstract
Effective from May 2014, community-based traditional birth attendants (TBAs) in Yirol West County, South Sudan, were directed to start referring all women in labour to health facilities for childbirth instead of assisting them in the villages. This study aimed to understand the degree of integration of TBAs in the health system, to reveal the factors influencing the integration, and to explore the perceived solutions to the challenges faced by TBAs. A qualitative study utilising 11 focus group discussions with TBAs, 6 focus group discussions with women, and 18 key informant interviews with members of village health committees, staff of health facilities, and staff of the County Health Department was conducted. Data were analysed using qualitative content analysis. The study found that many TBAs were referring women to health facilities for delivery, but some were still attending to deliveries at home. Facilitators of the adoption of the new role by TBAs were: acceptance of the new TBAs’ role by the community, women and TBAs, perceptions about institutional childbirth and risks of home childbirth, personal commitment and motivation by some TBAs, a good working relationship between community-based TBAs and health facility staff, availability of incentives for women at health facilities, and training of TBAs. Challenges of integrating TBAs in the health system included, among others, communication problems between TBAs and health care facilities, delays in seeking care by women, insecurity, lack of materials and supplies for TBAs, health system constraints, insufficient incentives for TBAs, long distances to health facilities and transportation problems. This study has revealed encouraging developments in TBAs’ integration in the formal health system in Yirol West. However, there is need to address the challenges faced by TBAs in assuming their new role in order to sustain the integration.
Highlights
The era of Millennium Development Goals witnessed a 59% increase in the deliveries assisted by skilled birth attendants (SBAs) and a 44% reduction in Maternal Mortality ratio (MMR) worldwide [1, 2]
Our study found that only a bit more than one year after banning traditional birth attendants (TBAs) from assisting women to deliver at home in Yirol West, South Sudan, many TBAs were systematically referring women to health facilities for delivery, some were still attending to deliveries at home, sometimes out of necessity
The factors facilitating the acceptance of this new “health promotional” role found in our study are similar to those of studies conducted in Somaliland [15] and Kenya [21]. These studies found that proper training of TBAs, strengthening the capacity of the health system to meet the needs of women, and providing adequate incentives to TBAs made the TBAs to change their role
Summary
The era of Millennium Development Goals witnessed a 59% increase in the deliveries assisted by skilled birth attendants (SBAs) and a 44% reduction in Maternal Mortality ratio (MMR) worldwide [1, 2]. Despite this achievement, each year, 45 million women still deliver without skilled attendance [1] and 303,000 die from complications related to pregnancy or childbirth worldwide [2]. The use of skilled birth attendants (SBAs) became the key strategy to reduce maternal mortality in developing countries
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