Dialogue through film: engaging midwives, TBAs, and mothers to improve maternal health outcomes in Ghana’s Volta region

Background: Indigenous populations in Latin America are often at the crossroads of traditional and Western healthcare systems. Despite the cultural significance of traditional medicine, integration into Western healthcare practices remains challenging. Ecuador has been at the forefront of embracing intercultural health, aiming to merge these distinct medical paradigms effectively. This study sought to systematize the experience of integrating Indigenous traditional birth attendants (TBAs) into the Western healthcare system in the Amazon region of Ecuador, identifying the enabling factors and challenges of such an integration to enhance healthcare access and quality for Indigenous communities. Methods: Employing a qualitative case study design, the research involved conducting key informant interviews with 15 participants, comprising TBAs and midwives, in the province of Orellana, Ecuador. Thematic analysis was utilized to interpret the data, focusing on the participants' experiences, perceptions, and the operational dynamics of the integration process. Results: The study revealed initial scepticism towards integration, which was gradually overcome through mutual learning and adaptation processes, highlighting the importance of cultural sensitivity and bidirectional knowledge exchange. Integration seemed to have facilitated healthcare access, with TBAs playing a pivotal role in bridging cultural and linguistic gaps, thus enhancing Indigenous women's comfort and trust in healthcare services. Despite these advances, TBAs faced significant challenges, including financial constraints and logistical difficulties, underscoring the need for continued support and sustainable integration strategies. Conclusion: Integrating TBAs into the Western healthcare system in the Ecuadorian Amazon has shown promise in improving healthcare access for Indigenous women by fostering an environment of mutual respect and cultural sensitivity. However, to ensure the sustainability and effectiveness of such integrative health models, it is imperative to address the identified challenges and support the continuous development of TBAs and healthcare professionals alike. Future research should aim to quantitatively evaluate the health outcomes of this integration and explore its scalability to other regions.

“I was on the way to the hospital but delivered in the bush”: Maternal health in Ghana's Upper West Region in the context of a traditional birth attendants' ban

A co-designed conceptual educational framework for midwives to train Indigenous traditional birth attendants in low resource settings of remote Papua New Guinea.

BackgroundPrior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana.MethodsThe design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings.ResultsThe findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood.ConclusionAlthough, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

<h3>&nbsp;Background</h3> Involving women in HIV programmes such as Prevention from Mother To Child Transmission of HIV is important because they are one of the most affected population groups. However, in rural settings PMTCT is a challenge lack easy access to health centres where they can be tested for HIV and for safer child births. This health service gap is filled-in by traditional birth attendants, who mostly lack adequate knowledge of HIV and how to prevent mother-child transmission. <h3>Methods</h3> The Zambia Traditional Births Attendants Association conducted a workshop for Traditional Birth Attendants in the Eastern Province. 24 Traditional Birth Attendants, 5 chiefs and their wives, from 5 villages attended the workshop. Clinical staff from a health, approximately 150 Km away facilitated. Pre-and post-workshop questionnaires were administered. <h3>Results</h3> 80% of the participants were aware of HIV but were not sure how to prevent it. 20% believed HIV was due to witchcraft. 72% did not see the wearing protective gear when helping women in labour as important. 97% were ignorant of HIV basic science. 93% had no idea of PMTCT. Myths and misconceptions included that children cannot get the HIV because they do not indulged in sex; that traditional medicine can treat and cure HIV/AIDS. The workshop noted the need to train Traditional Birth Attendants in PMTCT services counselling and oral rapid testing for HIV in pregnant women. The other need was training them how to administer single-dose Nevirapine to HIV positive pregnant women during labour and to their newborn babies. <h3>Conclusion</h3> It is important to involve traditional birth attendant in HIV and PMTCT programmes stop the spread of HIV. Village health committees should be established were they do not exist and integrated with HIV and PMTCT services. Sustained provision of PMTCT and HIV testing kits, and follow-ups by health staff is needed.

Most research on Intimate Partner Violence (IPV) focuses on the physical, sexual and psychological abuse, with less focus on the financial abuse. This study explores nursing mothers' experiences and perceptions of financial and material support from their significant others and traditional birth attendants' (TBA) observations of support to nursing mothers in their communities. Using purposive sampling, focus groups and interviews were conducted primarily in Ewe language among nursing mothers and TBAs in rural communities in Hohoe, Volta region, Ghana. All discussions were audio-recorded and transcribed for analysis. Thematic analysis guided by the social constructivist framework was used in data analysis. Twenty-seven women participated in the study, ranging in ages from 19 to 82 (20 nursing mothers; 7 TBAs). Most participants were married (19) and about 65% reported working outside the home (10 nursing mothers; 7 TBAs). Two themes emerged from the data analysis: Lack of support from partners for housekeeping chores and finances; and TBAs as mediators. Nursing mothers who reported lack of financial support did not perceive it as abuse, rather as hinderance to their efforts to care for their children. TBAs act as mediators interceding on behalf of nursing mothers with their husbands and fathers of their children, while also seeking resources to support them. Understanding the perceptions and socio-cultural meanings women attached to IPV experience is essential for effective intervention to reduce IPV. In addition, TBAs can be a resource in intervening to alleviate IPV in their communities, thereby improving maternal and child health.

BackgroundThis article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana.MethodsA structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained.ResultsHealth workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's).ConclusionThese findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.

Background: It cannot be denied that the dependence of pregnant women on the knowledge, knowledge and experience of traditional birth attendant is still very high. Traditional birth attendants are considered as figures who have abilities related to local culture. On the other hand midwives are the most well-known health care workers to rural areas, have medical knowledge, knowledge and technology, on average young, but have not fully gained public trust. Subjects and Method: This was a qualitative study with case study approach. The study was conducted in North Klaten District, Klaten Regency, Central Java. Results: Traditional birth attendants were people who were trusted by the community to have knowledge and experience in the health of pregnancy. Partnership Guidelines for Midwives and traditional birth attendant issued by the Ministry of Health are divided into stages of pregnancy, and childbirth. Conclusion: The implementation of midwive and TBA partnership in accordance with govern­ment guidelines can begin with regional regulations that stipulate the implementation of the WB, followed by providing physiotherapy training to traditional birth attendants in postpartum maternal massage and baby massage, so that the competency of the traditional birth attendant is more targeted. Keywords: empowerment, midwives, traditional birth attendant, partnership Correspondence: Sri Panuntun. Doctoral Program in Health Promotion/Community Development, SebelasMaret University, Jl. Ir. Sutami 36 A,Surakarta 57126, Central Java. Email: ichaku06@yahoo.com. Journal of Maternal and Child Health (2019), 4(4): 279-286 https://doi.org/10.26911/thejmch.2019.04.04.07

Background/objectiveGuatemala’s indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates.MethodsA pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume.ResultsForty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22–58) compared to the later-access arm (median 20 per 100, IQR 0–30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5–50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10–9.86).ConclusionsReferral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts.Trial registrationClinicaltrials.gov NCT02348840.

Maternal and child health and nutrition are important issues to address in Ethiopia. Poor socioeconomic context and inadequate healthcare affects availability, access, and utilization of health services. The Community‐Based Maternal and Neonatal Health and Nutrition (CBMNH‐N) project by the Micronutrient Initiative aimed at strengthening the health system capacity to improve access and quality of maternal and newborn health and nutrition services by increasing the knowledge and skill of community health workers, traditional birth attendants, and health care providers. We undertook a qualitative inquiry from the endline data from four intervention and six comparison woredas to understand the effect of CBMNH‐N project on iron and folic acid supplementation and breastfeeding practices in the Afar community in Ethiopia. We used open coding to identifying themes and analyzed 46 key informant interviews from fathers, health extension workers, midwives, traditional birth attendants, and clan leaders, and 11 focus‐group discussions with pregnant and lactating mothers. Overall, mothers, health workers, and community members in the intervention woredas were more knowledgeable about the use of iron and folic acid supplementation and showed improvement in early initiation and exclusively breastfeeding practices as compared to the comparison woredas. Mothers noted that health extension workers were instrumental in increasing knowledge and awareness of iron and folic acid supplements, and trained traditional birth attendants helped with follow‐up and compliance in taking the supplements. Program efforts helped the community, including clan leaders to be more aware and supportive of the importance of iron and folic acid supplementation during pregnancy and the post‐partum period. Community members and clan leaders also noted the importance of early initiation and exclusive breastfeeding. Most respondents also discussed the change from traditional feeding practices such as providing the baby with goat milk to putting the baby to the breast immediately after birth and exclusively breastfeeding. Mothers, health extension workers, and traditional birth attendants were aware of the health benefits of exclusively breastfeeding. Several respondents attributed their knowledge of infant feeding to health education provided by the health extension workers and traditional birth attendants. Our findings suggest that community‐based programs can build capacity, increase knowledge, and improve health practices that can ultimately promote maternal and child health and nutrition.Support or Funding InformationFunding: Micronutrient Initiative

Current healthcare planning and delivery in Malawi is guided by the Ministry of Health's Health sector strategic plan (Hssp): 'moving towards equity and quality' (2011-2016).1 this plan followed a sector wide programme of work between 2004 and 2010 intended to inform the implementation of interventions in the health sector.2 During this period, an essential Health package (eHp) was agreed and delivered free of charge to Malawians, including those interventions which can prevent and treat diseases and conditions affecting the majority of the population, especially poorer people. Good progress has been made since 2004 in reducing the unacceptably high rates of maternal and neonatal mortality, where infant mortality has reduced from 76 to 66 per 1000 live births between 2004 and 2010, and estimated maternal mortality has fallen from 984 to 675 per 100,000 live births.3the Community Midwife Assistant (CMA) initiative supports implementation of the national sexual and reproductive Health and rights strategy contained within the country's Hssp. it has high- level, political support from the presidential initiative on safe Motherhood and Maternal Health (pisMH), and despite the recent election of a new president, the creation of this new cadre is likely to continue. the global context is an increasing move towards task shifting (defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training) in low income countries. the primary objective of task shifting is to increase the number of healthcare services provided at a given quality and cost.4,5Rationale foR the CMa initiativetwo of the four strategic outcomes from the current Hssp are to increase healthcare coverage and to strengthen health systems, particularly by addressing the 'Human resources for Health' crisis.2 increasing women's access to high-quality maternity care is the most effective way of reducing deaths among women and babies, and this is essential to Malawi's efforts to achieve Millennium Development Goal 5 - the improvement of maternal health, specifically through reduction of the maternal mortality ratio. However, building system capacity in rural areas (where 80% of the Malawian population live) is challenging, particularly in recruiting and retaining clinical staff. typically, traditional birth attendants, who have no formal training, provide maternity care in villages to women who prefer not to attend formal health services or are unable to do so due to multiple barriers, such as cost, transport and cultural constraints. the CMA initiative aims to replace traditional birth attendants with a more skilled workforce working in these underserved areas who are better connected into the wider public health system and supported to deliver high-quality care.DevelopMent of CMasA pilot has been completed in six districts selected purposively on the basis of remoteness and high levels of maternal mortality. CMAs are recruited by the District Management team and must hold a secondary school Certificate, be female and prepared to sign a commitment to work in their home community for five years post training. CMAs undergo an 18-month training programme at a nursing and Midwifery College using a syllabus set by the nursing and Midwifery Council of Malawi, and a core curriculum that has now been standardised across all colleges. …

Purpose – to understand the awareness and healthcare preferences of pregnant women in Calabar municipal for traditional birth homes and hospitals. Materials and methods. The research is a qualitative phenomenology research, based on interpretative phenomenology, involving focus group discussion that explored the views of the traditional birth attendants on the reason for their patients’ preferences as well as indebt interviews that explored the pregnant women patronizing traditional birth homes preferences. Focus group discussion consisted of four major steps and included research design, data collection analysis and reporting of results. We used purposive sampling by taking from the list of registered midwives or traditional birth attendants (TBAs) of cross-river state Association, Calabar municipality chapter. The number of participants were 15 TBAs. Results. Results showed that there is diversity when considering the individual’s values. The TBAs in their focused group discussion attempted to emphasize on the importance of patience. Though they all consider that without patience, one cannot be a TBA and it is the secret of their patients’ attraction. Conclusions. There is no one «standalone» reason for the use of traditional birth attendant homes instead of the government hospital, but there is a mix of the reasons with some outstanding factors that influences Calabar pregnant women choice on the use of traditional birth homes instead of government hospitals.

Despite progress achieved in improving maternal health in Indonesia and Ethiopia, both countries still have high maternal deaths. To address this key issue, the Indonesian and Ethiopian governments prioritise health facility childbirth and discourage the use of Traditional Birth Attendant (TBA) care. The study aims to explore context and reasons of preference to use TBA care in Indonesia and Ethiopia. Employing a qualitative approach, 110 semi-structured interviews (SSIs) and 7 focus group discussions (FGDs) in Cianjur and Southwest Sumba (Indonesia), as well as 44 SSIs and 14 FGDs in Sidama (Ethiopia) were conducted. Study participants included mothers, TBAs, community health providers, men within those communities and village leaders. The study found that preference for TBA care persists in the study sites within both countries. TBAs' cultural, psychological and geographical proximity, TBAs' wide-ranging and culturally deep-rooted services are important context and reasons of the preference for utilising TBA care. Improving health system cultural sensitiveness and strengthening partnership between formal health workers and TBAs have potential to enhance maternal health in both countries.

Stunting associated to the increased risk of morbidity and mortality, reduced physical capacity, impaired development and function of children’s motor and mental condition. Efforts have been made by the Government through Integrated Healthcare Center (IHC), however it is less optimal as it didn’t involved all aspects of the community. Cadres and TBAs are important parts of the community that are strategic enough to be involved in this activity, because they are very close to mothers and the community.This program aims to improve the knowledge and practice of 31 cadres and traditional birth attendants (TBA) in early detection and prevention of stunting and implement their knowledge to the community by using lecture, discussion, practice, and film screening methods. There is a significant difference in the knowledge level of cadres and TBA between pre and post training (p value = 0.0005) with knowledge improvement of 30.68%. Furthermore, cadre and TBA did a Follow-Up Plan (FUP) in the form of stunting socialization and education, particularly to the expectants and mothers, with the results of about 124 people exposed to stunting. To monitor FUP, team formed a total of 3 Whatsapp Groups for each village as a forum of communication and discussion between fellow participants to PHC and Research Team. As the result, almost all trainees informed the FUP through Whatsapp group, in the form of socialization and education to other cadres and mothers during IHC, recitations, village activities, sports activities, as well as family or neighbors individually, etc. Through the empowerment of cadres and TBA, education on early detection and prevention of stunting goes according to expectations and is quite effective to the role of cadres and TBA in the community.Keywords: stunting, cadre, traditional birth attendant, empowerment

Review Objective/Questions The overall objective of this systematic review is to critically appraise, synthesize and present the best available evidence in relation to why women choose to undergo an “illegal or unsafe” abortion when abortion is legal and readily available in South Africa. Review question: Why do pregnant women choose “illegal or unsafe” abortions when legal abortions are freely available in South Africa? Inclusion Criteria Types of participants This systematic review will consider any qualitative study where the focus is on pregnant women of childbearing age who have had an illegal abortion and who live in Southern Africa. Phenomena of interest The phenomena of interest of this review are the reasons why women choose illegal abortions in situations where abortion is freely available; social and demographic data of participants in studies. For the purpose of this systematic review, studies that use terms such as “unsafe” abortion, or abortions conducted in “non-medical settings” will be considered to be illegal abortions and will be considered for inclusion in the study. Context This review will consider any qualitative study for inclusion that was conducted in South Africa. Studies that have been conducted in public or private health care settings will be considered for inclusion in the review. Health care settings may include hospitals, clinics and non-governmental organizations that offer supportive services to women who have had an abortion