Rural maternity

care in Sierra Leone

Ah!&& The training and duties of a new category of health worker. de Maternal and Child He&h Aide. is described. She is II literate women recruited from the pIace where she will eventually work. She has become the immediate supervisor of the traditional birth attendants (TBAsl, who continue to conduct most deliveries in Sierra Leone.

KeywordszTraditional birth attendants; Midwifery training; aides.

Maternal and child health

In the maapower pyramid of health workers, inadequate human resources often dictate

the delegation of each health care task to the least trained member of the team capable of performing the task 121. In selecting which cadre of staff should do what, it is important that the leadership sets clear goals and defines specific tasks to be carded out. Goats staff performance in the right direction and permit analysis of a subordinate’s competence and commitment to perform well. The goals in midwifery should be carefully delineated, measurable, attainable, relevant, and trackable, taking into accoum the environment in which he or she is working. This paper discusses maternal and child health (MCH) aides and traditional birth attendants (TBAG, the lowest subprofessionals who have formed the bedrock of primary health care in Sierra

Leone. Using these basic wncepts, training manuals have heen designed for both CHCgOkS.

MCH aides are womm at least 25 years of aae who have tioished orimarv education and Gay have reached up to 3 years in a secoodary school. They are give0 18 months comorehensive train& 6 midwifery cons&g of antenatal, natal. and postnatal care, family planning (nonprescriptive and re-issue of prescriptive contraceptives) and child care, including immunization. They are taught to carry out midwifery and child cli for those under five years of age at the village level in the maternity post and health post. It is also part of their duties to train TBAs, keep records of their own work and that of TBAs. Tbp are supervised by the District Health Sister. Aoart from their formal IS months’ training, *frequent refresher courses and up dating of knowledge is done in areas such as immunization, family planning, nutrition, growth mooitoring, and community mobilization. In all these, the principle of breaking down oroblems into tasks is emphasized. The impmiance of the referral system in midwifery is explained. Because of their abiliiy to evaluate an obstetric problem and refer it to a Health Center or District Hospital, this cadre of staB has been invaluable ia our effort to reduce the high rate of maternal deaths at the village level. TBAs have carried out midwifery in the villages throughout history and may be old and illiterate. They are still responsible for 70% ofall deliveries in Sierra Leone. From the viewpoint of the modem obstetrician, the

TBA may appear to be of limited value. Her utilization is at best a stopgap measure and should be phased out eventually. Some cou”tries have outlawed her while others do not accept her existence. To the TBA, the modern doctor or midwife is an arrogant imposter pretending that their methods arc superior to hers, althouah. they. too, are ineffectual. In Sierra Leon;, ‘the TBA is a very important and powerful woman. She is the midwife, gynecologist, pediatrician, general practitioner of the village and the surgeon in the female initiation ritual into society. It is a prestigious title achieved after years of aporenticeshio in midwiferv and sur.ac:ery.She is kersed not-only in the techniques-of surgery (female circumcision) but also in the society’s herbal medicines, poisons, and rules. Her prestige in the societv elevates her to other nonsurgical or maternal roles such as in politics: trade and judicial matters (traditionall. In nvnecoloav. she deals with all female probErus in&&g care of terminal fern&cancer patients. In a typical village she wou!d have delivered most of the children.

Such a woman now becomes grandmother of every family in the community. She is adept at gardening and village gossip and knows the intimate history of every patient. In early years of my obstetric work in the rural areas, I noticed a disparity between the monthly attendance at the antenatal clinic of 30@-400 cases and the small number of women who actually gave birth in the ward. It appeared that most of the mothers came for antenatal care but went back to their villages or homes to be delivered by the TBAs. If the TBA said they should not come to the hospital. they obeyed. The same observation has been made by many doctors working in the rural areas of Sierra Leone. So how are we to talk of deleeatine resuonsibilitv? In this case who is delegating to*whom? * Several studies [3,4] in Sierra Leone rcvealed that there are about 12000 TBAs in the country, organized in an intricate network of traditional midwifery. Since there is a TBA in every 3 miles2 of the country, they arc readily

accessible, so that no pregnant woman need walk more than 3 miles to get help. Each TBA is supervised by a more sfmior member of their hierarchy up to the h,ghest member of the echelon, ‘Digba’ or ‘Major’, who is the leader of the female secret society. This network is not to be rivaled by our modern midwifery program. Obstetric kuowledge The TBAs possess considerable expertise in the area of phytotherapy. They have mcdicinal herbs to procure or prevent abortion, decrease or increase uterine contractions, stop hemorrhage in pregnancy, at delivery and

after delivery and produce diuresis in patients with edema. They possess some knowledge of the physiology of pregnancy. The medicinal herbs given during pregnancy are based on knowledge about the behavior of the pregnant uterusand a patient’s reaction to p&army IL4.61. Their thorouch knowledee of the oa. tien?s domestic and -&al problems and her environment give them an advantage in the psychological management of the patient which is seldom possessed by a busy physician in an antenatal clinic. They are ignoraot of the germ theory of disease. In other words, the T’BAs are still practicing in the era before Ignaz Semmelweiss (1847). They see no relationship between the anatomy of the female pelvis and the part it plays in childbirth. Obstructed labor is blamed not on the mechanics of cephalopelvic disproportion but on witchcraft, or the patient’s infidelity or wrongdoing. Methods of management tend to be punitive and bizarre [3]. Based on these studies, a training manual and program was devised utilizing the TBAs’ strengths and weaknesses in order to make them more effective as part of tbe health team. Begun in earnest in 1972, about 41300TBAs have taken the Ministry of Health’s course and we are cncouragcd by their willingness to learn new methods and their pride in receiving modern training.

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In a country with a fragile economy and poorly developed infrastructure. strengthening what already exists is the best way we have found to reduce high maternal mortality. Once the rationale for referring a patient to the Health Center and District Hospital is ac-

cepted and practiced by the TBAs, they have been found to be invaluable. After training. they can: carry out antenatal care and delivery of patients &de; hygienic wndirions using

sterile instruments at the vhlage; refer high risk cases to the nearest hospitals; serve as a listening post for the outbreak of epidemics, such as measles and cholera; observe the resurgence of any of the diseases that have been .zradicated, such as smallpox or yaws; and actasvehicles through which community mobilization can best be achieved for any health activity in the villages. In the area of family planning, apart from their traditional methods, they function in community-based distribution programs [S]. The mysticism of witchcratI and demonology that previously dominated their thought is being replaced by a more rational approach. It goes without saying that they need constant supervision and logistic support.

The final question is always this: looking at the situation as a whole, and not merely at the professional or technical standards of anyone,

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or of special interests, what course of action yields the best results as judged by the common purpose, the goal of the whole undertaking - the well-being of the people of the region? We have concluded that the training of local residents of our rural areas in maternity care is our best option. References

Rural maternity care in Sierra Leone.

The training and duties of a new category of health worker, the Maternal and Child Health Aide, is described. She is a literate women recruited from t...
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