Training of Traditional Birth Attendants, Pakistan

Traditional birth attendant training Pakistan: Swabi and Wadaga Districts.

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TBAs Trained in Nowsherra Refugee Camps

Supported by a grant of $6000 from The Hillman Medical Education Fund, Frontier Primary Health Care recently completed training for an additional 45 Female Health Workers (FHW) in maternal and newborn health. In addition to usual traditional birth attendant activities, the FHW assist in general health education and immunization in the remote, rural region of North Western frontier Province in Pakistan. The women are carefully selected by the community. For many of them it is the first training of any kind they have received. They are proving to be ardent and committed communicators and change agents in their own communities as the following story illustrates.

Mero’s sister-in-law was due to deliver shortly after she completed her training with Frontier Primary Health Care as a Female Health Worker. Most of the deliveries in the refugee camp where she lived, were done in rooms set aside for animals or for bathing. This made the cleaning up afterwards easier. Mero had seen how careful the nurses were about hygiene in the labour rooms. Mero had been impressed by the importance her trainers placed on having a delivery done in clean surrounding.

So Mero shared this new information with her sister-in-law and together they began to prepare a room for the delivery and arranged clean clothes, pads, soap and basins. While Mero and her sister-in-law were preparing the room, other women in the camp were watching them and learning. They admired Mero’s efforts. They were glad Mero would be able to assist them to have healthy deliveries.

The baby was born safe and healthy in hygienic conditions with Mero using her new Clean Delivery Kit. Things were already starting to change in the camp .

45 new TBAs were trained in Akora and Kairabad Refugee Camps in Nowsherra district of Northwestern Frontier Province in Oct and Dec, 2009. Training of these female health workers will ensure women in this remote area of Pakistan have ready access to accessible skilled maternal and newborn care. 32 in Akora and 13 in Khairabad.

A comprehensive community selection process ensures that the female health workers are trusted and respected individuals in their own community who will be allowed to visit women and care for them in their homes. The TBAs are provided with three weeks of interactive training in primary health care with an emphasis on maternal and newborn care. They are coached in to recognize and refer pregnancy complications early and to provide health promotion over the three weeks of their training. More than 15 days is spent in health center labour rooms and first level EmOC facilities of Frontier Primary Health Care.Improvements have already been noticed in Ankora within the first three months since the training was done. New registrations of mothers has increased 25% from 88 in Oct to 101 in Dec. while babies weighed within the 72 hours has increase from 92 to 131 in the same periods. The number of women delivered by skilled workers also increased 30%, from 98 to 127.

Photos from FPHC, TBA training in Akora and Khairabhad

Successful TBA Training in the Midst of War

Almost 60-70% of women and their families in the isolated communities of Wardaga and Ismailia prefer and use traditional birth attendants. Over the past ten years, due to illness, old age, insecurity and relocation, the number of Traditional Birth Attendants in Wardaga and Ismailia village in Northwestern Frontier Province has decreased drastically. As the area is conservative and rigorous purdah practiced, women rarely venture outside their own homes. In these areas linking pregnant women up to women within their own community who are knowledgeable about pregnancy and child birth is crucial to reducing deaths from child birth.

$4000 was provided by the Hillman Medical Education Fund and Society of Rural Physician donors to train 30 TBAs. A lengthy consultation with the two communities ensured they were supportive of the plan to improve maternal health services; were willing to have their wives and mothers trained as TBAs and/or visited by the TBAs in their homes and had agreed upon a minimal fee for provision of birth kits and TTBA care. Discussion of the qualities needed for being a TBA lead to development of a set of criteria and identification of suitable candidates for each community. At the end of the process the communities had identified a total of 38 women were needed.

Wardaga’s population is 12,000 while Ismailia’s is 30,000. It was recognized that these female health workers as the only ones in their community would also be important conduits of health information on diarrheal diseases, immunization and nutrition as well as pregnancy and newborn care. Wardaga has a day labour room staffed by two nurses and 3 dais while Ismailia has a basic emergency obstetrical center (EmOC) providing 24 hour coverage with 3 nurses, 1 assistant nurse and 4 dais. So skilled TBAs were an important adjunct to getting services to women and women into the health centers for delivery when needed.

The need for skilled female health workers in the community resulted in the extending the training from four weeks to six weeks. This 50% increase in enrolment and training period were accomplished with cost efficiencies within the original budget with $4000 training 38 TBAs, or approximately $105 per TBA trained. This cost included provision of a supply of individual birth kits containing rubber gloves, soap, razor and tie. The individual kits form a rotating supply that will be sold to pregnant women at cost plus a small amount for the TBA which is agreed in advance by the community, approximately $0.50. In addition each newly trained TBA received a TBA kit with rubber sheet, nail brush, towels, gloves, soap, plastic apron, containers and a supply of oral rehydration packets.

The project did not include an evaluation component and information is available for only 4-6 months following the training but data from the health units show a real impact. Ismailia Health Center, where 38 TBAs were trained, reported an increase of more than thirty percent of women, from 240 to 320 women attending ANC in the first four months following training of the TBAs and a >200% increase, from 30 to 68 in the number of women delivering at the Health Center. Prior to training. almost half of the women admitted to the obstetric unit did not proceed to delivery prior to training while six months following training less than 10% of the pregnant women who initially admitted were discharged without delivering.

Health Center, where nine new TBAs were trained, ANC attendance doubled from 51-106 within six months and the number of women receiving at least two doses of tetanus toxoid rose from 36-51 in three months.

While the follow-up period is short and the data preliminary, these figures suggest that not only do trained TBAs refer more pregnant women to ANC and for delivery in this region but they appear to be appropriate and effective in their referrals. The Hillman Medical Education Fund is proud to be assisting to develop skilled Trained Traditional Birth Attendants in Northwestern Frontier Province who are reaching women in their homes and linking them to appropriate delivery and antenatal care. The pride and dedication of these TBAs to improve the care of pregnant women is humbling.

Photos: TBAs in class; TBAs using models; TBA with certificates