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