Combining Tradition and Technology for Safe Motherhood:

Success with Traditional Birth Attendants (TBAs) in

Bridging the Human Resource Gap in a Very Resource Limited Emergency Setting in South Sudan

Juma Hayombe, Project Manager,

Safe Motherhood Project CCIH 2014

Presentation Contents

• Background • Objectives • Design and Implementation • Outcome • Success stories • Next steps • Discussion/recommendations

Introduction and background • Globally, an estimated 287,000 women die in child

birth, there are 2.6 million still births, and 3 million newborn deaths (WHO, UN 2013).

• 80% of the maternal deaths are in 20 countries in the developing world (WHO, 2013).

• Most of the deaths are associated with emergency and humanitarian conditions; inadequate infrastructure and personnel; and cost of services.

• Despite spirited effort and huge milestones, MDG 4 and 5 goals remain unmet

Introduction-South Sudan

• Maternal and neonatal outcomes are worse in South Sudan as decades of political unrest has left few sites with infrastructure and other resources for training of HCWs and for providing maternal care services.

• The youngest country in the world, South sudan got independence in July 2011, 6 years after comprehensive peace agreement (CPA) with Sudan in January 2005 following decades of fighting.

• According to HMIS report 2012, only 11% of deliveries occur in the facility, the rest 89% occur at home/community.

Introduction Cont.

• Of the facility deliveries, 26%(or 2.5% of the total deliveries) are conducted by skilled birth attendants (HMIS Report 2012).

• Most facility ANC and deliveries are manned by MCHW and TBAs, (HMIS 2012).

• At 2,054 per 100,000 live births (SSHHS-2010), MMR in South Sudan is the highest in the world.

• Local causes of maternal deaths are bleeding, obstructed labor, post-abortal/partum sepsis, and other pregnancy conditions in that order.

The Safe Motherhood Project • In January 2013, CMMB with support from AMHF, a

private US donor initiated a two-year emergency Safe Motherhood Project in Ezo County.

• Ezo County has the highest MMR in South Sudan at 2,327 per 100,000 live births.

• One of the ten counties of Western Equitoria State, South Sudan, it borders Central African Republic and Democratic Republic of Congo.

• The population of Ezo is estimated at 310,000, and includes refugees and IDPs from Lords Resistance Army (LRA) attacks from 2008 to date.

Project Objectives

The project has four objectives: Renovating and outfitting Ezo PHCC to offer EmONC

services on 24-7 basis. Improving knowledge base and skill set for HCWs,

TBAs and the community leaders on SM. Creating linkage, networking and referral systems

between community, TBAs, PHCC/CU and Ezo PHCC. providing communication and transport in

pregnancy , delivery and neonatal emergencies.

Objectives cont.

• These objectives aim at addressing 3-delays that result in poor maternal and neonatal outcomes.

• The three delays are; Delay in decision making at the households. Delay in accessing health care facilities. Delay in access to and provision of appropriate

quality treatment at the facilities. • The project is modeled on RESCUER- Rural Extended

Services for Ultimate Emergency Relief in Northern Uganda that used TBA referral and linkage.

Design and Implementation

• Project started with hiring of expatriates to provide project leadership (1 Doctor and 2 midwives).

• At Ezo PHCC, a new labor suite was built, a room renovated to become maternity ward, and equipments and other supplies were procured.

• The activities were cascaded and now operates in 20 facilities (2PHCC and 18 PHCU), and with 40 TBAs, selected by facility health committees.

• TBAs, CHWs, CHPs and community leaders have been trained on Safe Motherhood.

Design and Implem. cont.

• Facility based mentorship HCWs on quality service provision is conducted on quarterly basis.

• Two Rickshaw ambulances operate and transport patients in emergency.

• The TBAs map and link the pregnant women for ANC, and conduct home visits in pregnancy and to post-partum mothers/infants.

• They also assist CHWs in providing ANC services at the facilities.

• Standard medicines- TT, IPPT, LLITNs, folic/ferrous, and de-wormers are provided during ANC.

TBA Supplies and Roles

Supplies • Safe delivery kit with disposable

single use items modeled on UNFPA/maama kit.

• Solar charged mobile phones • Solar lighting source • Gumboots, aprons • Bicycles • Medicines- Paracetamol and

misoprostolol

Roles • Mapping and linking Pregnant

mothers to PHCC/CU for ANC • home visits for pregnant and

postnatal mothers • Assisting with ANC at PHCC/CU • Referring high risk pregnancies • Conducting simple uncomplicated

deliveries • Calling for emergency transport

Design and Activities cont.

• High risk mothers are identified using agreed criteria by TBAs and referred to Ezo PHCC.

• TBAs conduct normal deliveries and administer misoprostol for PPH prevention.

Emphasis is laid on facility deliveries for timely reporting of adverse events and ease of evacuation in emergency.

• The project has made use of technology in transportation, solar-lighting, solar phone charging, and in mobile communication.

• SMP has been in operation for 18 months, and is set to end in 6-months.

Where We Work

MAP OF SOUTH SUDAN

Facility Committee TBA Training Session

TBAs Outfitted TBA Issued with bicycles

Outcomes to Date

• The project has recorded marked improvement in core target: ANC attendance, mother-infant pair attended, and maternal and neonatal outcomes.

• ANC and birth records in facilities have improved. • 300-500 monthly ANC attendance from under 50 is

now being recorded. • 150-200 deliveries occur every month at home and

in the facilities. • 40-60 referred to Ezo PHCC maternity unit every

month and the number is increasing.

Cadre Before Now

Doctors 0 1

Midwives 0 2(2)

MCHWs 10 10

CHWs 22 22

TBAs 40 40

Trained leaders 0 20

CHPs 0 20

• TCNs are responsible for project supervision.

• PHCC has new labor suite, renovated maternity, supplies stocked, clean piped water system.

• 2 Rickshaw ambulances are operational.

• EmONC services are available on 24-7 at no cost to women.

Outcome cont.

• 5-10 TBA calls are made monthly for emergency evacuation.

• Maternal mortality stands at 0 for over 3200 deliveries recorded.

• Facility deliveries range 40-50% compared national rate of 11% and is set to increase.

• The project still birth rate is 12 per 1,000 births. Every still birth and neonatal death are reviewed

monthly to identify preventable causes.

Table-Outcomes Oct –Dec 2013 Jan-March 2014

Follow up/linkage 804 782

ANC Attendance 356 919

Total Deliveries 590 503

Facility deliveries 247 199

Home deliveries 296 304

Referrals-Other 94 151

Emergency referrals 17 20

Emergency calls 25 19

Surgical Interventions 6 11

Maternal deaths 0 0

Still births 6 7

ANC Attendance Jan-Apr 2014

0

100

200

300

400

500

600

700

800

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Ezo PHCC

Other PHCC

Total

F-ANC

Rickshaw Ambulance

TBA visit following a referral

Labor Suite

Kangaroo Care being demonstrated TBA visit following a referral

FP

EQUITY FOR WOMEN EmONC Services

BEOMNC

Safe Motherhood-Normal Setting

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Tran

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Midwifery F-ANC

EmONC Services

Safe Motherhood-Resource limited settting

Com

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Prog

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Em

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Success Stories

Brief stories on these(Presentation, Management ) • Lady in coma • Severe poly-hydramnios • Abruption placenta • Cord prolapse • Prolonged labor, commonly cervical dystocia • Others; Retained placentas, incomplete abortions etc We have recorded no surgical or theatre related

complications

Program Challenges

• Supply chain and logistical difficulties resulting in delays in delivery of medicines inherent in such emergency situations.

• Cultural/traditional practices, beliefs and norms that encourage home deliveries and keeping of newborn for 6 months in the homestead.

• Unreliability of mobile telephone network. • Only about 25% mothers attend ANC four times or more, with

an average 2.2 sessions. • Literacy levels of TBAs; can not fill cards &registers. • Bad roads, and other essential elements of dignified

livelihood lacking.

Bad TBA Practices Noted

Delay in referral in prolonged labor Over-examination (vaginal) Over - Zealous massage Use of herbs in pregnancy

Future Plans

• BCC and male involvement initiatives. • Initiate mobile outreach services to improve quality of ANC. • Open more sites for BEmONC services. • Holding maternity units for sparse population, bad road, no

phone network – Bagidi. • Train more of skilled birth attendants take in newly qualified

nurse/midwives for fellowship. • Have the supplies built into the government supply chain. • Utilize the android mobile phones GIS system to map and

document emergency calls.

Discussion

• We know what works: infrastructure, equipments-ambulance, and supplies; trained and motivated health providers; affordable EmONC services.

• MDG 4 and 5 may not be achieved due inadequate resources for these.

• What we don’t know is what to do in the absence or scarcity of the resources.

• MoH policies don’t address resource gaps. • Use of TBA is a centuries old practice that presents

mixed outcome in the literature review.

Discussion cont.

• Primary Surgery, popular book authored (1990) by renown medical specialist advocates use of TBAs.

• TBAs interventions based on referral system have been successful in Brazil and Guatemala.

• Yet, some countries banned in the 90’s and others recently despite evidence numerous home deliveries.

• Malawi in 2010 banned TBAs, maternal deaths increased, and the ban got lifted.

• In many countries there has been a change in nomenclature-HHPs, CHWs, but TBA like activities continue.

Discussion cont.

• Why did previous TBA interventions fail? • Simple; means of communication, affordable means

of transport; and accessible EmONC was not part of the package.

• The pre-technology ban in 80’s and 90’s may have been acceptable, review needed in tech. era.

• Community misoprostol distribution strategy will use among other cadres, TBAs and is being put to scale. There is need to re-consider TBAs role in the evolving scenario.

Discussion cont. • There is need to tie African MOH policies to

resources and practice. • 80% of maternal deaths occur in 20 countries

offering perfect opportunity to focus programs. • Simple technology-tradition/community based

models could provide the much needed push for MDG achievement.

• These are low-cost solutions with immediate outcomes.

• They are scalable with potential for substantial impact in resource poor settings.

Conclusion/Recommendation • The huge resource gap in maternal care is a reality. • MDG 4 and 5 remain unmet. • Immediate/mid-term solutions need to be put to

scale to prevent maternal deaths. • Combining technology with tradition/community is

as effective response to maternal mortality. • The project further recommends operations research

around such technology-tradition based models.

References 1. South Sudan HMIS report, 2012 2. South Sudan Household Survey (SSHS) 2010 3. Reproductive Health Needs assessment report, 2012 4. Maurice King et al.; Primary Surgery 1, 5. http://maternalhealthinuganda.weebly.com/traditional-birth-attendants.html 6. http://www.theguardian.com/katine/katine-chronicles-blog/2010/mar/30/traditional-birth-attendants-ban 7. Traditional birth attendants are an effective resource; http://dx.doi.org/10.1136/bmj.e365 (Published 18 January 2012): BMJ

2012;344:e365 World Health Forum. 1995;16(4):409-13. 8. Matthews MK, Walley RL, Ward A, Akpaidem M, Williams P, Umoh A; Training traditional birth attendants in Nigeria--the

pictorial method. 9. http://www.ncbi.nlm.nih.gov/pubmed/8534350 10. Traditional birth attendants filling the blank space. Ngal E. M.

http://amplifyyourvoice.org/u/elngala/2012/12/11/traditional-birth-attendants-filling-the-blank-space-in-rural-cameroon 11. Ngozo C. Malawi: Uncertainty over role for traditional birth attendants. Global Issues March 2011.

www.globalissues.org/news/2011/03/15/8880. 12. Bisika T., The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi; East African

Journal of Public Heath; Issue 2008 5(2): 103-110 13. Marilza et al; The safe motherhood referral system to reduce cesarean sections and peri-natal mortality - a cross-sectional

study [1995-2006]: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256099/ 14. Marge et al; Issues of programming for Safe Motherhood: http://pdf.usaid.gov/pdf_docs/pnack513.pdf

Acknowledgements

Questions?

“Together, we can change the fate of mothers at birth and

achieve MDG.”

Thank you