literature review traditional birth attendants

Research Article

The benefits of traditional birth attendants on maternal and fetal outcomes in sub-Saharan Africa: A systematic review and meta-analysis

Jerome Ateudjieu, Joseph Nelson Siewe Fodjo, Calson Ambomatei, and 4 more

This is a preprint; it has not been peer reviewed by a journal.

https://doi.org/ 10.21203/rs.3.rs-2491621/v1

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The role of traditional birth attendants (TBA) in improving outcomes related to maternal and child health remains controversial. We performed an up-to-date systematic review to pool together available data on the impact of TBA interventions on materno-fetal outcomes.

A systematic literature search was conducted on PubMed, Cochrane, Scopus, and 3ie databases (search date: 22nd August 2022) to identify original research articles which studied health outcomes in populations of pregnant women and children following TBA-related interventions. Data on the frequency of the outcome (expressed as proportions) occurring in study populations with and without the intervention were extracted. The data were synthesized and used for meta-analysis, with the creation of sub-groups as appropriate for comparisons. The Cochran-Mantel-Haenszel method was used to generate Odds ratios (OR) with 95% confidence intervals (CI) for data analysis.

Of the 744 studies found during the initial database search, data was extracted from 45 eligible studies representing observations from 194,699 women and 199,779 children. We found that the involvement and/or training of TBAs in maternal and child healthcare does not significantly contribute to reducing maternal mortality (pooled OR: 0.91, 95% CI: 0.42–1.98) or infant morbidity (pooled OR: 0.85, 95% CI: 0.57–1.27). However, TBA-related interventions proved useful in curbing both neonatal mortality (pooled OR: 0.77, 95% CI: 0.71–0.84) and maternal morbidity (pooled OR: 0.63, 95% CI: 0.43–0.93). Overall, TBA involvement was associated with increased uptake of some health interventions including antenatal consultations, delivery by a skilled birth attendant, early breastfeeding, and immunization (pooled OR: 2.42, 95% CI: 1.75–3.35).

Conclusions

Based on studies conducted in the past, it appears that proper training and supervision could render TBAs useful in addressing shortages in maternal and child health actors. This finding is particularly relevant for remote communities with few trained healthcare workers and even fewer health facilities. Large community-based prospective studies may be required to investigate the materno-fetal benefits and cost-effectiveness of integrating TBAs within present-day health systems in SSA.

Registration:

This systematic review was not registered.

Despite efforts to reduce infant and maternal mortality rates and improve pregnancy outcomes, low- and middle-income countries (LMICs) still report high mortality rates and frequent unfavorable obstetrical outcomes, with the main reason being poor access to and low quality of healthcare services [ 1 ]. With this limited access to high-quality services, women in LMICs often resort to giving birth at home and have turned to traditional birth attendants (TBAs) for obstetrical care [ 2 ].

The World Health Organization (WHO) defines a TBA as “a person who assists a mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants” [ 3 ]. Since they are members of the community themselves, TBAs have the advantage of being more accessible, affordable, and relatable than conventional healthcare providers in health facilities [ 4 ]. They also provide their services at home where the pregnant woman feels more at ease [ 5 ]. These advantages, coupled with the religious values and socio-cultural beliefs regarding motherhood safety which are prevalent in such settings [ 6 ] cause many women in LMICs, especially those in rural areas, to prefer soliciting the services TBAs. Thus, the integration of TBAs within a country’s healthcare system, especially in the field of maternal and child healthcare, has proven to be helpful in certain developing countries [ 7 ].

In sub-Saharan Africa, trained TBAs have been found to play critical roles in improving maternal and child health. For instance, they contribute to the prevention of the mother-to-child transmission (PMTCT) of HIV by educating pregnant women on perinatal HIV transmission, identifying pregnant women in their communities and referring them to nearby antenatal care facilities, performing routine HIV counseling for women and their partners, facilitating and supervising antiretroviral treatment for infected mothers and nevirapine prophylaxis for newborns, and taking the necessary precautions to prevent HIV transmission during delivery [ 8 ]. According to a review conducted by Sibley et al. , the interventions of trained TBAs were associated with improved pregnancy outcomes, especially in regard to maternal mortality, stillbirths, neonatal death, perinatal death, postpartum hemorrhage, and puerperal sepsis [ 9 ]. Furthermore, other studies have reported that compared to unskilled TBAs, the interventions of trained TBAs were associated with lower rates of post-partum hemorrhage, less blood loss during delivery, and higher rates of early breastfeeding [ 10 ]. Such pieces of evidence indicate that TBAs can be trained, harnessed, and forged into major contributors to improved outcomes in obstetric care. However, their formal inclusion into the healthcare system is yet to be unanimously accepted [ 11 ].

Over the years, many low- and middle-income countries have invested in training TBAs to enable them provide better services and quickly recognize complications that warrant urgent referrals of their clients for better management to ensure optimal outcomes [ 12 ]. A meta-analysis conducted 10 years ago revealed that TBAs can be promising in terms of improving materno-fetal outcomes but the evidence was insufficient [ 9 ]. In the current paper, we aimed to conduct a more comprehensive review of the impact of TBAs on both clinical and healthcare utilization outcomes among pregnant women and neonates. By exploring the role of TBAs, especially the trained ones, in modifying the health-seeking behaviors of pregnant women in low- and middle-income countries toward maternal and child health services, we may identify specific gaps within these countries’ healthcare systems which could be filled by TBAs for optimal impact.

Research question

Can maternal and child health outcomes be improved by TBA interventions and/or training in SSA countries?

Database search and abstract screening

On the 22nd August 2022, a systematic literature search was conducted on PubMed, Cochrane, Scopus, and 3ie using the keywords “traditional birth attendant,” “pregnancy outcome,” “Maternal Health Services,” and “Health Services Accessibility.” The search was geographically restricted to studies conducted in SSA (see Appendix 1 for exact search strings); only texts in English or French were retrieved. References obtained from the database search were transferred to the Rayyan online platform to facilitate abstract review [ 13 ]. Two authors independently screened the abstracts using the Rayyan platform, with the blind function activated. Results from each reviewer were then compared, and any conflicts resolved by discussion and consensus with the lead author. The following criteria were used for retaining abstracts during the review process

Must report original quantitative research (or mixed methods). Therefore, purely qualitative studies, case reports, opinion papers, scoping and systematic reviews were excluded.

Must include (pregnant) women and/or neonates as the study population.

Must include services provided by TBAs (as defined by the WHO [ 3 ]) as study intervention, with/without other measures. For the purpose of this review, we also included studies in which the birth attendants were referred to as village / community / traditional midwives.

Must include one or more comparison groups for outcomes: either trained vs untrained TBAs, TBAs vs standard care, or before vs after intervention comparisons.

Must report at least one clinical or behavioral materno-fetal outcome.

Data extraction : We searched the full text articles for the abstracts which were retained during the screening phase. When available, dichotomous outcomes reported as disaggregated data were extracted and summarized in a Microsoft Excel spreadsheet. The variables of interest were: maternal mortality, neonatal mortality (first 28 days of life), maternal morbidity (bleeding, infection/sepsis, prolonged labour), neonatal morbidity (omphalitis, low birth weight, hearing problems), and maternal behavior (antenatal consultation attendance, breastfeeding initiation soon after childbirth, contraception use, iron/folate intake during pregnancy, misoprostol intake during the third stage of labor, antitetanic vaccination of the mother, child immunization, referral to health facility /skilled health attendant). Outcomes such as pre-eclampsia, jaundice and prematurity were not collected because they seldom resulted from the care delivered by TBAs or other birth attendants to the pregnant women. However, for one of the included studies [ 14 ], low birth weight was extracted because it served as outcome for a TBA intervention towards pregnant women. Exceptionally, we also extracted data on perinatal mortality (stillbirths and neonatal deaths combined) from two studies [ 15 , 16 ], and infant mortality (deaths below one year of age) for one other study [ 17 ] as these were the only available information on the baby outcomes in these studies. The publication year, population, implemented intervention(s) and outcome(s) for each included study were noted.

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan version 5). The risk of bias of the included articles was assessed using the inbuilt tool within RevMan. Studies was grouped based on the similarity of the intervention and/or population, and random-effect meta-analysis used for combining data in forest plots. Measures of association included odds ratios with 95% confidence intervals and estimates generated using the Cochran-Mantel-Haenszel method. Sub-group analysis was performed to obtain pooled data regarding a given intervention or set of outcomes.

The crude literature in each database cumulatively yielded 744 studies, including 73 duplicates (Fig.  1 ). After removal of duplicates, screening of the remaining 671 abstracts and subsequent examination of the available full texts led to the inclusion of 45 studies for data synthesis (Table  1 ). Overall, the extracted data represented observations from 194,699 women and 199,779 children. Risk of bias analysis found that most of the included articles were subject to moderate-high levels of bias (Appendix 2). The PRISMA checklist was used to ensure adequate reporting of findings (Appendix 3).

Figure 1 . PRISMA flowchart for the systematic review

Table  1 : Characteristics of included studies

Benefits of TBA (training) on maternal and neonatal mortality

Meta-analyses showed that compared to standard care, TBA interventions had no significant impact on maternal mortality (Fig.  2 ) and child mortality (Fig.  3 ). However, TBA training was significantly associated with fewer neonatal fatalities.

Figure 2 . Benefits of TBA interventions on maternal mortality in SSA

Figure 3 . Benefits of TBA interventions on child mortality in SSA

Benefits of TBA (training) on maternal and neonatal morbidity

Despite a modest beneficial impact of TBAs on the occurrence maternal morbidity during pregnancy and childbirth, no significant impact on neonatal morbidity outcomes was found (Figs.  4 and 5 ).

Figure 4 . Benefits of TBA interventions on maternal morbidity in SSA. Morbid conditions analyzed by Bailey et al. and Liambila et al. included: Fever / infection, bleeding, headaches, anemia, prolonged labour

Figure 5 . Benefits of TBA interventions on neonatal morbidity in SSA

Benefits of TBA-related interventions on health-seeking behavior among pregnant women and nursing mothers

Interventions and training of TBAs were found to significantly improve the likelihood for pregnant women to attend ANC, to be referred to skilled birth attendant for delivery, to breastfeed the neonate soon after delivery, and to take the anti-tetanic vaccine. TBAs also contributed to significantly increasing the immunization rate among the children. However, based on the one study which investigated the role of TBAs in improving HIV detection and prevention of mother-to-child transmission, no significant difference was found when compared to standard care (Fig.  6 ). Overall, TBA interventions were associated with higher odds for medications/vaccine uptake among the pregnant mothers and their children, as well as higher odds for referral to health facilities during labour.

Figure 6 . Benefits of TBA interventions on health-seeking behavior among pregnant women and nursing mothers in SSA

This systematic review aimed to explore the contribution of TBAs on both clinical and healthcare utilization outcomes among pregnant women and neonates in SSA countries. We searched four online databases using appropriate keywords, which ultimately resulted in the inclusion of 45 studies. The available data suggest that the involvement and/or training of TBAs in maternal and child healthcare does not significantly contribute to reducing maternal mortality or infant morbidity. However, TBA-related interventions proved useful in curbing both neonatal mortality and maternal morbidity, while significantly improving the demand for antenatal and postnatal health interventions recommended by the health system for better mother and child health outcomes.

Similar to previous reports [ 9 , 18 ], we found that TBA-related interventions were not associated with a significant decrease in the maternal mortality rate. Possible reasons for this observation include: (i) the fact that interventions targeting TBA and or mother-child pairs were not standardized, and their effects were assessed on different outcomes and in different contexts; (ii) the lateness in the diagnosis of obstetrical complications and referral of high-risk cases by TBA. It is therefore important that TBAs be trained in rapid recognition of red flags during labour and to be spontaneous in referring such cases to skilled healthcare providers, who are likely to register fewer maternal deaths [ 19 ]. The importance of such training was highlighted by Okafor et al. who reported that delays at TBA centers are common before referral and most patients are referred in poor clinical state [ 20 ]. Meanwhile, TBA training can significantly increase the rate of referral of delivery cases to hospitals resulting in fewer maternal and neonatal deaths as demonstrated by a study in Nigeria [ 21 ]. It is also worth noting that about half of the women in LMICs, especially those in rural areas, still prefer TBA practice over western medicine [ 22 ] and are therefore less likely to spontaneously resort to nurses or physicians for childbirth.

Our study found that interventions by trained TBAs were associated with reduced neonatal mortality. This can be explained by the fact that most of these trainings and interventions targeting TBA reportedly focused on obstetrical care targeting the perinatal period which in most developing countries contributes to at least two-fifth of infant mortality [ 23 ]. Untrained TBAs tend to indulge in birth practices that are deleterious for the neonate such as avoiding colostrum, cutting the umbilical cord using unsterile sharp materials, delaying the initiation of breastfeeding, early bathing of the neonate, giving butter and/or water to the newborn, and the use of “ Koso” (a traditional herb) [ 24 ] among other harmful practices. Thankfully, these practices can be improved by properly training and supervising TBAs in their obstetrical duties within the community [ 25 ]. Training traditional birth attendants to manage common perinatal conditions including birth asphyxia and neonatal sepsis and providing them with basic equipment was shown to be feasible even in low-resource countries and had the potential to reduce neonatal mortality rates by up to 50% [ 19 , 20 , 21 ]. TBAs could indeed be trained to clinically examine neonates and commence management (resuscitation, drying & warming, antibiotics, etc.) based on their initial assessment before referring them for further management, thereby minimizing neonatal deaths [ 29 ]. Thus, we recommend that in resource-poor rural settings with limited skilled healthcare workforce, TBAs could be trained to proffer a solution to this major public health issue associated with their interventions.

We also found that TBA interventions did not significantly impact neonatal morbidity outcomes, despite benefiting maternal health. This is not surprising, as previous studies have reported that the TBA training programs initially focused on clean delivery and maternal health outcomes; interventions targeting neonatal health were only considered much later [ 19 , 22 ]. While most baby deaths result from unskilled management of the early neonatal period [ 31 ] (which can be addressed by implementing adequate TBA interventions), childhood morbidity is more dependent on parameters such as home hygiene practices, environmental exposure, access to immunization, access to potable water, and socio-economic contexts all of which are unlikely to be controlled solely by TBA involvement. This suggests that the training or involvement of TBAs in maternal and child healthcare as a generic intervention may not be a priority if we wish to reduce infant morbidity. However, a certain portion of this infant morbidity could be averted by leveraging TBAs or other appropriate actors in the implementation of interventions geared at reducing infant mortality such as proper obstetric and neonatal care, nutrition including breastfeeding, immunization, and the prevention of malaria in the SSA context.

Sabin et al. conducted a health economics analysis on TBA training to reduce neonatal morbidity and mortality, and found this strategy to be highly cost-effective, particularly for remote rural populations with limited access to healthcare [ 32 ]. In such communities, banning TBAs could instead be disadvantageous as this would result in increased workload for the already limited healthcare workforce, high cost for transport and lodging at health facilities [ 33 ]. In Ghana, the ban on TBAs resulted in intense community-level conflicts between TBAs, who still saw themselves as legitimate culturally mandated traditional midwives, and nurses in health facilities. Thus, a win-win approach that involved retraining of TBAs, partnership with health practitioners, and task-shifting seemed more profitable [ 34 ]. Qualitative research among TBAs reveals that they are ready to collaborate with the formal healthcare system and require that their inputs into maternal healthcare be acknowledged [ 22 ]. In addition to improving maternal and child health specifically, our study revealed that TBAs and the community-based approaches that involve them would also improve health-seeking behaviors, a crucial pre-requisite for any successful health intervention. While the WHO recommends that healthcare provision by TBAs be discontinued [ 34 ], the multiple barriers to access skilled practitioners (poverty, long distances to travel on poor road networks, cultural considerations in favor of TBAs, etc. [ 28 , 29 ]) render this approach unfeasible at the moment. Based on the understanding that TBAs can bridge the gap between formal health care and women's cultural beliefs and practices with regard to childbirth [ 37 ], some countries such as Zimbabwe have successfully integrated TBAs into the primary healthcare system and fostered their collaboration with midwives and TBAs [ 38 ].

Our study is not void of limitations, the first being the high heterogeneity among the included studies resulting from several differences in study methodologies, populations, and interventions. TBAs' skills level in the different study sites could also be marred by the various cultural and socio-economic contexts, which can compromise the effects of the interventions explored per study. The risk of bias was also high for many of the included studies, since several of the latter had an observational design. Finally, the wide time span during which the included studies were conducted makes it difficult to disentangle present-day realities from the situation decades ago when healthcare practices and access to health facilities were worse than today.

Our findings seem to point to the fact that if properly trained, supervised and motivated, TBAs can be game changers for maternal and child health particularly in remote underserved communities. We recommend that for such communities, TBA training interventions should be implemented to improve their knowledge and practices regarding pregnancy, delivery, and post-natal care alongside the establishment of strong referral systems towards health facilities. In addition, TBAs can be equipped with the right information and tools to promote health utilization behaviors during pregnancy and childbirth. Large community-based prospective studies may be required to investigate the materno-fetal benefits and cost-effectiveness of integrating TBAs within present-day health systems in SSA.

Abbreviations

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 

SSA: Sub-Saharan Africa

TBA: Traditional Birth Attendant

WHO: World Health Organization

Declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Availability of data and materials

All the data used in this systematic review are available in the cited publications. The dataset summarizing all extracted data is available from the corresponding author upon reasonable request.

Competing interests

The authors have no conflicts of interest to declare.

No funding source supported the conduct of this study.

Authors’ contributions

AT conceived the study. SFJN performed the database search SFJN and AC screen abstracts and full texts for inclusion and data extraction. All authors participated in writing and revising the successive drafts of the manuscript. 

Acknowledgements

Not applicable. 

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Reconsidering the value of traditional birth attendants: a literature review

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• Traditional Birth Attendant Nursing and Health Professions 100%
• Literature Review Nursing and Health Professions 100%
• Mortality Rate Nursing and Health Professions 100%
• Maternal Mortality Nursing and Health Professions 100%
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T1 - Reconsidering the value of traditional birth attendants

T2 - a literature review

AU - Dietsch, Jennie

AU - Mulimbalimba-Masururu, Luc

N1 - Imported on 12 Apr 2017 - DigiTool details were: Journal title (773t) = African Journal of Midwifery and Women's Health. ISSNs: 1759-7374;

N2 - The maternal mortality rate is unacceptably high in sub-Saharan African nations. Policies and strategies to reduce the maternal mortality rate focus on encouraging skilled birth attendance and discouraging the practice and training of traditional birth attendants (TBAs). The purpose of this literature review is to uncover the impact of current, globally accepted policies. An integrative literature review methodology was used and found that current strategies to reduce the maternal mortality rate are proving inadequate. In the interim, the role of the TBA is becoming increasingly more devalued by global institutions,including the World Health Organization. The review argues that the emphasis should be directed away from the category of person providing care to women during childbirth and toward addressing social factors, including reducing poverty, increasing food and water security, reducing conflict/war, improving transport and communication infrastructure and eliminating gender inequity.

AB - The maternal mortality rate is unacceptably high in sub-Saharan African nations. Policies and strategies to reduce the maternal mortality rate focus on encouraging skilled birth attendance and discouraging the practice and training of traditional birth attendants (TBAs). The purpose of this literature review is to uncover the impact of current, globally accepted policies. An integrative literature review methodology was used and found that current strategies to reduce the maternal mortality rate are proving inadequate. In the interim, the role of the TBA is becoming increasingly more devalued by global institutions,including the World Health Organization. The review argues that the emphasis should be directed away from the category of person providing care to women during childbirth and toward addressing social factors, including reducing poverty, increasing food and water security, reducing conflict/war, improving transport and communication infrastructure and eliminating gender inequity.

KW - Sub-Saharan Africa

KW - Traditional midwifery / birth attendant

U2 - 10.12968/ajmw.2010.4.3.48973

DO - 10.12968/ajmw.2010.4.3.48973

M3 - Article

SN - 1759-7374

JO - African Journal of Midwifery and Women's Health

JF - African Journal of Midwifery and Women's Health

Community Traditional Birth Attendants and Cultural Birthing Practices in Nigeria

Social Work Implications

• Living reference work entry
• First Online: 23 December 2019
• Cite this living reference work entry

• Augusta Y Olaore 4 ,
• Nkiruka Rita Ezeokoli 4 &
• Vickie B. Ogunlade 5  

Part of the book series: Social Work ((SOWO))

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Africa and South Asia account for over half of the births in the world, with 65% of these births occurring in non-orthodox traditional settings.

Studies show that affordability and accessibility are reasons why women choose the utilization of the services of traditional birth attendants (TBA) in Nigerian rural areas. However, urban women with better accessibility to hospitals and greater financial capacities also prefer TBA above hospital deliveries and midwives. It has been observed that the use of TBA is rooted in indigenous practices and beliefs that may not have western scientific explanations yet have served Nigerian communities for many generations. There are also factors of trust between the women and the TBA because they are members of the community, and they speak the same language and can relate to idiosyncrasies which otherwise might be ridiculed by medical practitioners. Social and emotional closeness that is not replicated in hospital settings are reported with TBA services.

Cultural birthing practices include the teaching of behavioral avoidance among pregnant women, disposal of the placenta, and provision of healing medicine, among others. Prayers are also made to address inherent fears of metaphysical influences that are believed to impact the health and safety of mother and child.

This chapter explores the roles of TBA, cultural practices, and indigenous beliefs, as well as the perceived tensions between the traditional birthing systems and mainstream healthcare systems. Utilizing primary and secondary sources, the authors identified challenges faced by TBA such as lack of adequate training, affirmation from medical systems, and lack of equipment. The authors also propose ways social workers may bridge the divide between TBA and orthodox medicine such as affirming TBA practices as community development, building trust, promoting interdisciplinary dialogues, and advocacy for TBA training, and promoting a mutually integrated referral system.

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Olaore, A.Y., Ezeokoli, N.R., Ogunlade, V.B. (2020). Community Traditional Birth Attendants and Cultural Birthing Practices in Nigeria. In: Todd, S., Drolet, J. (eds) Community Practice and Social Development in Social Work. Social Work. Springer, Singapore. https://doi.org/10.1007/978-981-13-1542-8_5-1

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Empowering traditional birth attendants as agents of maternal and neonatal immunization uptake in Nigeria: a repeated measures design

• Chinedu Anthony Iwu   ORCID: orcid.org/0000-0002-8139-283X 1 ,
• Kenechi Uwakwe 1 ,
• Uche Oluoha 1 ,
• Chukwuma Duru 1 &
• Ernest Nwaigbo 1  

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Adequate immunization coverage in rural communities remain a challenge in Nigeria. Traditional birth attendants (TBAs) form an integral part of the social, cultural and religious fabric in most rural communities in Nigeria. Despite their limitations in handling the complications of childbirth, TBAs are widely accepted and patronized, especially in rural areas. The objectives of the project were to empower TBAs and assess the use of a culturally adapted audio-visual workshop intervention to change their knowledge, attitude and willingness to promote immunization uptake.

A repeated-measures design that used a convenience sampling technique to select 90 TBAs from the three geopolitical zones of Imo State, Nigeria. The TBAs were engaged through a culturally adapted audio-visual workshop. Data were collected before and immediately after intervention using a pretested questionnaire. Chi square test was done to determine any significant association with the zone of practice and paired sample t-test analysis to determine any significant pre and post intervention change. Level of significance was set at p  ≤ ·05.

More than half of the TBAs had at most, a secondary level of education (54·4%). The average length of time they practiced as TBAs was 16 years with an average of ten birth deliveries per month. After the intervention, all the respondents (100%) reported a willingness to always promote immunization uptake and also, there was a statistically significant increase in Knowledge ( p  < ·000). Similarly, the level of knowledge in the post intervention period appeared to be significantly associated with the zone of practice ( p  = ·027).

The workshop intervention empowered the TBAs irrespective of their zones of residence by successfully improving their knowledge, though at varying levels; and consequently, their willingness to always promote immunization uptake.

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Attaining optimal immunization coverage in the rural areas remain a challenge and this may be associated with uptake factors rooted in cultural, traditional and religious beliefs which may vary within different parts of a region or country. This situation of less than optimal coverage, observed especially in the rural communities may be compounded by the high proportion of home birth deliveries undertaken by traditional birth attendants (TBAs) as this reduces the contact of mothers with the health facilities where immunization sensitization and uptake usually takes place. Furthermore, contributing to this situation, may be the lack of awareness, incorrect information, misconception and vaccine safety concerns [ 1 , 2 , 3 ].

Globally, there is an observable gap in the proportion of births delivered in a health facility by skilled birth attendants between the high and low income countries. This gap may be due to the high community patronage of TBAs in low income countries, probably for reasons such as availability, affordability, accessibility and the TBA’s attitude of friendliness and care particularly observed [ 4 , 5 ]. According to World Health Organization, TBAs are customary and autonomous of the health system with no formal training; and are community based providers of care during pregnancy, childbirth and the postpartum period [ 6 ]. In Nigeria, about 80% of the population live in rural conditions and according to Nigeria’s MDG end point report, women residing in rural areas were 77% more likely to give birth at home than in a health facility [ 7 , 8 ]. This may also explain why the use of TBAs remains prevalent across the country despite the availability of skilled birth attendants who are trained and have relatively modern equipment [ 9 ].

It has been reported that, the TBAs when compared to the hospital based skilled attendants are inexpensive, culturally sensitive and compassionate when providing care and therefore, are trusted and respected within the communities [ 10 ]. As a consequence, special relationships develop between the community members and the TBAs. They become an integral part of the communities with wide spread acceptance across social, cultural and religious lines [ 11 ].

The training of TBAs in the conventional maternal health-care delivery systems, has shown to increase the utilization of health facility’s prenatal, antenatal and postnatal care services which invariably improves maternal and neonatal health [ 12 ]. Empowerment, a consequence of effective training is an intentional process, centered in local communities involving active participation, critical reflection, awareness, understanding and control over decisions [ 13 ].

In Nigeria’s Demographic Health Survey of 2018, it was reported that, rural women will give birth to about 1.4 children more than urban women during their reproductive years and are less likely to have received antenatal care from a skilled birth attendant [ 14 ]. This further emphasizes the potential roles that TBAs could play in the promotion of maternal and neonatal immunization when empowered through appropriate training. Therefore, the overall aim of this project is to empower TBAs by increasing knowledge, attitude and willingness to promote immunization through a culturally adapted audio-visual workshop in order to become agents of maternal and neonatal immunization uptake in rural communities.

The project was implemented in Imo State, which is situated in the South Eastern part of Nigeria within longitude 5°29′06“N and latitude 7°02’06”E occupying an area between the lower river Niger and the upper and middle Imo River [ 15 ]. It occupies an area of 5289 km 2 with a total population of 3·93million (2·03 million males and 1·9million females) according to the 2006 census with an annual growth rate of 3·2% [ 16 ]. The State is delineated into 27 Local Government Areas and 305 registrations areas (communities) within three senatorial geopolitical zones; Owerri, Orlu and Okigwe with varying social development, cultural and traditional beliefs.

Study population/sample size

The study population comprise traditional birth attendants practising within the three senatorial geopolitical zones of Imo State. The minimum sample size per zone for a two tailed paired sample T test analysis was calculated using G Power software version 3·1·9·4 where the estimated effect size of 0·5 based on a previous study [ 17 ], α value of 0·05 and a power of 80% was assumed. The minimum sample size calculated was 26 which was increased to 30 to accommodate incomplete or non-responses. A total study sample of 90 participants was enrolled (30 participants per senatorial geopolitical zone).

Study design /sampling technique/selection criteria

The study was a repeated measures design where convenience sampling technique was used to select 90 TBAs. All TBAs practising within the State were invited and as they arrived, were enrolled according to their respective zones of practice until each zone attained a maximum of 30 participants. However, those that had received any formal medical training were excluded and replaced. The TBAs that arrived after enrolment had closed, were registered according to their zones but not enrolled. They formed the pool of TBAs from where replacements were randomly picked in cases of drop out or exclusion. TBAs were also randomly selected from the pool to participate in the pre-testing of the questionnaire.

Workshop intervention/materials

The project commenced 7th January 2020 and was for a duration of 3 months. The workshop activities comprised content communication, health facility linkages and workshop evaluation. Workshop content was communicated through audio visual presentations comprising slide shows on the clinical effects of non-immunization and a drama production depicting the role of TBAs in the promotion of immunization uptake. The audio-visual content was developed by the project team and structured for the target audience by taking into consideration their level of literacy, language barriers, customs and traditions. Health facility linkages were achieved through health-linkage sensitization talks given by health facility immunization focal persons. The accessible health facilities that conduct immunization activities within the three geopolitical zones of the State were identified. Immunization focal persons from these facilities were invited and through health-linkage sensitization talks were engaged with the TBAs. The intention was to establish sustainable communication channels after the programme. The workshop evaluation involved the administration of a semi-structured questionnaire pre and post workshop. See questionnaire supplementary file . The questionnaire was developed by the project team and pretested among the pool of TBAs not enrolled to participate in the workshop. The content validity was established and a reliability coefficient (alpha) of 0·83 was calculated.

Data collection/analysis

Data was collected using a pretested semi-structured interviewer-administered questionnaire. Research assistants were trained on the questionnaire administration and on the appropriate translations in the native language (Igbo). The questionnaire comprised 4 sections: one on socio-demographic characteristics; two on knowledge of maternal and neonatal immunizations; three on attitude towards maternal and neonatal immunizations and four on practices with respect to willingness to encourage clients on immunization uptake.

The level of knowledge was determined by scoring the questions that assessed knowledge. A correct answer was scored 2 and incorrect answer was scored 0. The aggregate knowledge scores for each respondent was assessed against a scale of ≤30 for poor, 31–38 for moderate and 39–46 for good knowledge of immunization. In assessing the level of attitude, an answer connoting a positive attitude was scored 2 and a negative attitude was scored 0 and a “no opinion” attitude was scored 1.The aggregate attitude scores for each respondent was assessed against a scale of ≤8 for poor, 9–10 for moderate and 11–12 for good attitude towards immunization.

Data was cleaned and validated manually then analysed using Software Package for Social Sciences (IBM-SPSS) version 22. Descriptive statistics (frequency tables and summary indices) were generated. Chi square test was done to determine any significant association with the zone of practice. Paired sample t-test analysis was done to determine any significant change in knowledge and attitude towards immunization. A level of significance was set at p  ≤ ·05 with 95% confidence interval.

Ninety copies of the questionnaire pre and post intervention respectively were correctly and completely filled with a response rate of 100%. All respondents were female.

Table  1 shows the sociodemographic characteristics of the respondents. The average age was 46·5 years with a majority within the ages of 41–60 years (57·8%), married (72·2%) and with a secondary level of education (54·4%) being the highest level attained. The average length of time the respondents practiced as TBAs was 16 years with an average of ten birth deliveries per month. There was no statistically significant difference in the distribution between the sociodemographic characteristics of TBAs and the zones they reside and practice ( p  > ·05).

Table 2 shows the number of TBAs in each knowledge level category pre and post intervention. While in the pre intervention period, the majority of the TBAs had a moderate level of immunization knowledge (58·9%), in the post intervention, the majority of the TBAs had a good level of immunization knowledge (71·1%). In the pre intervention period, there was no association ( p  > ·05) between the level of knowledge of the TBAs and the zones they reside and practice but post intervention, there appeared to be an association ( p  = ·027). Okigwe zone had the highest number of TBAs with an increase in knowledge level (Fig.  1 ).

Number of TBAs by zones with “Change-No Change” in the knowledge levels Post Intervention

Table 3 shows the effect of the intervention using a paired sample t test analysis. There was a statistically significant increase in the TBA’s knowledge of immunization overall and across the zones after the workshop intervention ( p  < ·05).

Table 4 shows the number of TBAs in each level of attitude category pre and post intervention. Majority of TBAs in the pre (71·1%) and post (82·2%) intervention periods, had a good level attitude towards immunization. However, in both the pre and post intervention periods, there were no associations ( p  > ·05) between the level of attitude of the TBAs and the zones they reside and practice. Orlu zone had the highest number of TBAs with an increase in attitude levels while Okigwe zone had the highest number of TBAs with no change in attitude levels after the intervention (Fig.  2 ).

Number of TBAs by zones with “Change-No Change” in the attitude levels Post Intervention

Table 5 shows the effect of the intervention on the level of attitude using a paired sample t test analysis. After the intervention, there were statistically significant increases in positive attitude towards immunization among TBAs residing and practicing in Orlu and Okigwe zones. However, overall, the increase in positive attitude was not statistically significant ( p  = ·080). In Fig.  3 , it was observed that, most TBAs in the pre-intervention period, only “sometimes” inform their clients about immunization but in the post intervention period all the TBAs were now willing to “always” inform their clients about immunization.

Frequency of practice and willingness to practice information exchange with clients on Immunization pre and post intervention respectively

This project was designed to assess the effect of a culturally adapted audio-visual workshop intervention to empower traditional birth attendants towards promoting the uptake of maternal and neonatal immunizations.

A number of studies [ 18 , 19 , 20 ] have shown that most TBAs are middle aged or older married women, with experience in child birth and they are highly respected in the rural communities they practice in. This was similarly observed in the present study where the TBAs were all women and the average age was 47 years with an average duration of 16 years practice as a TBA, performing an average of ten birth deliveries per month within their communities.

It was also observed that 72% of the TBAs were married. In the context of culture, especially within the rural communities among the women folk, married women are respected and furthermore, as TBAs, they have a long and consistent history of assisting birth deliveries in a friendly and caring manner that are readily available and affordable. This has endeared them to the community where they practice with wide spread social and cultural acceptance. This acceptance and intimate relationship they have established over the years make them uniquely positioned to act as effective agents to dispel the erroneous cultural and traditional beliefs and misconceptions about immunization which appear to be more evident in rural communities.

In spite of their unique position in the communities, the level of education of the TBAs is a challenge as studies have reported TBAs having no formal education or having some primary or some secondary education [ 18 , 20 ]. In the present study, the majority of the TBAs had either a primary or a secondary education as the highest level attained but it was also observed that up to one quarter of the TBAs had a tertiary education. Similarly, a study in Nigeria [ 17 ] also reported having TBAs with a tertiary level of education. This observation may not be unconnected with the high unemployment rate in Nigeria for graduates of tertiary institutions; and probably, this has forced some of them to relocate to their communities and engage in traditional birthing activities as a means of livelihood. Notwithstanding the proportion of TBAs with a tertiary education, the majority still have either no or incomplete education experience, compounded by differing traditional and cultural beliefs. This poses a challenge in the development of effective communication materials that would impact significant knowledge on a maximum proportion of recipients with differing customs and traditions.

Nevertheless, the present study took into cognizance the level of literacy, language barriers, customs and traditions in the development of the audio-visual communication content but however, in the study’s post intervention period it was observed that there was a statistically significant association between the level of knowledge of the TBAs and the zones they reside and practice; as this, may have been influenced by the differing traditional and cultural beliefs. This further highlights the challenges of developing a uniform communication content for a mix of clusters characterized by low literacy and varying cultural and traditional beliefs.

Despite these challenges of the audio-visual workshop intervention, its effect on knowledge was statistically significant across the zones and in the total population of TBAs. This further emphasizes that, effective training of TBAs with appropriate materials can improve knowledge as similarly reported in other studies with training interventions, where knowledge had resulted in improved maternal and neonatal outcomes [ 12 , 17 , 18 , 21 ].

The knowledge acquired by the TBAs may empower them to be at least willing to effect change as was observed in the present study where all the TBAs post intervention were now willing to encourage the uptake of immunization among their clients.

The study had limitations such as the content of the workshop communication messages. This was developed specifically for the traditional birth attendants by taking into cognizance their varying literacy levels and different cultural and traditional beliefs. However, communicating a unifying message with an appropriate mix of information and clear understanding for this diverse group of participants was still challenging. The resultant less than perfect uniform messaging could have impacted on the degree of knowledge acquisition, positive attitude development and invariably, their willingness to promote immunization. Another limitation was the translation of the questionnaire from English to the native language of Igbo by the interviewers when administering the questionnaire to participants not fluent in English language. This could have introduced interviewer bias in spite of the training conducted for the interviewers before the workshop. The challenge was the lack of equivalent words or concepts for some expressions and this could have impacted on the respondent’s interpretation and understanding and therefore, their knowledge and attitude towards immunization.

It is imperative for traditional birth attendants in resource-limited settings to be knowledgeable about immunization and its benefits, and also be willing to encourage its uptake among their clients and their newborn.

This study highlights the empowerment of TBAs as a complimentary strategy for improving immunization especially in rural areas where they are predominantly involved with pregnant women and the birthing process. Also, it provides some insights for policy makers of the potential roles and impacts TBAs can specifically play in improving immunization uptake and reducing the prevalence of vaccine preventable diseases in our environment when empowered through appropriate training.

Availability of data and materials

The data can be made available from the corresponding author under reasonable request.

Abbreviations

Traditional Birth Attendants

Millennium Development Goals

Tetanus Toxoid

Tuberculosis

Hepatitis B

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Acknowledgments

We thank the team of research assistants from college of medicine, Imo State University who assisted in data collection.

Immunizing pregnant women and infant network (IMPRINT) coordinated by London School of Hygiene and Tropical Medicine that is supported by the GCRF Networks in Vaccines Research and Development, co-funded by the Medical Research Council (MRC) and the Biotechnology and Biological Sciences Research Council (BBSRC). The funders had no role in study design, data collection, analysis, interpretation or manuscript write-up.

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Chinedu Anthony Iwu, Kenechi Uwakwe, Uche Oluoha, Chukwuma Duru & Ernest Nwaigbo

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CAI contributed to the study design, literature review, data acquisition, analysis, and write up of first and final draft. KU and UO contributed to study design, data acquisition, result interpretation, discussions and final draft. While CD and EN contributed to data acquisition, result interpretation, discussions and final draft. All authors read and approved the final article submitted.

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Iwu, C.A., Uwakwe, K., Oluoha, U. et al. Empowering traditional birth attendants as agents of maternal and neonatal immunization uptake in Nigeria: a repeated measures design. BMC Public Health 21 , 287 (2021). https://doi.org/10.1186/s12889-021-10311-z

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Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia

• Christiana R Titaley 1 ,
• Cynthia L Hunter 1 ,
• Michael J Dibley 1 &
• Peter Heywood 2  

BMC Pregnancy and Childbirth volume  10 , Article number:  43 ( 2010 ) Cite this article

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Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province.

A qualitative study using focus group discussions (FGDs) and in-depth interviews was conducted in six villages of three districts in West Java Province from March to July 2009. Twenty FGDs and 165 in-depth interviews were conducted involving a total of 295 participants representing mothers, fathers, health care providers, traditional birth attendants and community leaders. The FGD and in-depth interview guidelines included reasons for using a trained or a traditional birth attendant and reasons for having a home or an institutional delivery.

The use of traditional birth attendants and home delivery were preferable for some community members despite the availability of the village midwife in the village. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries. A number of respondents reported that trained delivery attendants or an institutional delivery were only aimed at women who experienced obstetric complications. The limited availability of health care providers was reported by residents in remote areas. In these settings the village midwife, who was sometimes the only health care provider, frequently travelled out of the village. The community perceived the role of both village midwives and traditional birth attendants as essential for providing maternal and health care services.

Conclusions

A comprehensive strategy to increase the availability, accessibility, and affordability of delivery care services should be considered in these West Java areas. Health education strategies are required to increase community awareness about the importance of health services along with the existing financing mechanisms for the poor communities. Public health strategies involving traditional birth attendants will be beneficial particularly in remote areas where their services are highly utilized.

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Each year around four million newborns die in the first week of life, worldwide [ 1 , 2 ], and an estimated 529,000 mothers die due to pregnancy-related causes [ 2 , 3 ]. In low and middle-income countries many deliveries still occur at home and without the assistance of trained attendants [ 4 – 7 ]. This has generated serious concern, since women who develop life-threatening complications during pregnancy and delivery require appropriate and accessible care. A recent review reported that around 20-30% of neonatal mortality could be reduced by implementing skilled birth care services [ 8 ].

The effort to increase access to trained birth attendants was initiated by the World Health Organization in 1987 in Nairobi, Kenya, through the launching of the Safe Motherhood Initiative, aimed at ensuring women have a safe pregnancy and childbirth [ 9 , 10 ]. Attention to maternal health was demonstrated in 2000 when 147 heads of state and government and 189 nations in total signed the Millennium Declaration, in which the proportion of births assisted by trained birth attendants became an important indicator to measure the progress of improving maternal health (Millennium Development Goal 5) [ 11 , 12 ].

In 1989 the Indonesian Government embraced the concept of the Safe Motherhood Initiative through the implementation of the "Village Midwife" program. This program aimed to place one midwife in every village to ensure a safe pregnancy and delivery for all pregnant women [ 13 – 15 ]. In its initial phase, nurses were trained in a one-year midwifery program to qualify them to become a village midwife. Later, as the pre-services training was claimed to be inadequate, an additional two-week in-service training was carried out for village midwives in the form of classroom-based training as well as clinical training for the management of normal delivery and life-saving skills [ 13 , 15 , 16 ]. By 1996, more than 50,000 village midwives had been placed in villages in Indonesia, and the one-year pre-service training was then replaced by a three-year specialist program for high school graduates [ 13 , 17 ]. Between 1970 and the early 1990s, health personnel were employed in the public sector, and with the implementation of the contract scheme, doctors and midwives, not including nurses, worked for a prescribed time period of around three years for the government and then proceeded to either a private practice or a specialist training [ 18 ]. It has been observed that the distinction between private and public clinical practice in Indonesia remains unclear [ 19 ]. Midwives, including village midwives, employed by the state can also charge private fees for the same services, except for services delivered at health centres.

To encourage the community to contribute to help pregnant women in their own society, in 1998 Indonesia initiated the Siaga (alert) program [ 20 ]. The Desa Siaga (village alert) program embraces the safe motherhood concepts through including community support for pregnant mothers by arranging transport, funds, and access to blood donations. This scheme helps those who have limited financial resources to access health professionals' services through a communal financing mechanism, such as the pregnant mother saving scheme or Tabulin ( Tabungan Ibu Bersalin ), and the social funds for pregnant women or Dasolin ( Dana Sosial Ibu Bersalin ) [ 20 ].

In 2007 a partnership initiative was put forward by involving village midwives and traditional birth attendants through the 'Improving Maternal Health in Indonesia' program [ 21 ]. Under this scheme the midwives and traditional birth attendants were expected to work together. The traditional birth attendants could continue to provide services including herbal drinks or post-delivery care, whereas all medical treatment was to be provided by midwives [ 21 ].

The Indonesian government committed to providing universal health insurance through a mandatory public health insurance scheme called the Health Insurance for the Poor Population or Asuransi Kesehatan Masyarakat Miskin (Askeskin) , as the initial phase of universal coverage in 2004 [ 22 , 23 ]. This scheme evolved into a Health Insurance Scheme for the Population, called Jaminan Kesehatan Masyarakat (Jamkesmas) covering more than 76 million poor and near poor populations [ 22 ]. This scheme aims to provide free health care services, including antenatal, delivery, or postnatal care services for mothers and infants [ 23 ].

The improvement of maternal health care services in Indonesia has been demonstrated by the increased percentage of deliveries assisted by trained delivery attendants - from 43% in 1997 to 79% in 2007 [ 24 , 25 ]. However, the 2007 Indonesia Demographic and Health Survey still reported a large percentage of home deliveries (53%), although the percentage has decreased substantially over the last decade (73% in 1997) [ 24 , 25 ]. The survey also found that 79% of institutional deliveries took place in private facilities such as hospitals, clinics, or private practices of midwives [ 25 ]. Although the Indonesian Ministry of Health set a target to achieve 90% deliveries attended by trained delivery attendants by the year 2010, the percentages of home deliveries and deliveries assisted by traditional birth attendants varies widely across provinces in Indonesia.

West Java is one province on Java Island with a high percentage of utilization of traditional birth attendants (30%) and home deliveries (55%) [ 25 ]. Although health facilities and health professionals in West Java are available at the village level [ 18 , 26 ], the percentage of deliveries assisted by traditional birth attendants and home deliveries was higher compared to East Java Province, where the percentage of deliveries assisted by traditional birth attendants was only 22% and home deliveries was 32%; or in Central Java where the percentages were 17% and 46%, respectively [ 25 ]. These findings indicate the importance of developing strategies at the local level to increase the utilization of delivery care services in this region.

This project is part of a larger study aimed at exploring community members' and health workers' perspectives about antenatal, delivery and postnatal care services in West Java. We present here the results from the analyses of the perspectives of community and health care workers about delivery care services in three districts of West Java. We explored the reasons community members used traditional birth attendants and why they preferred home delivery.

Sampling methods and study sites

This study was conducted from March to July 2009 in West Java Province, the most populous province in Indonesia with more than 39 million people living in 17 districts and nine municipalities [ 27 ]. The majority of the population is from the Sundanese ethnic group who speak Sundanese language. Agriculture and industrial production are the main source of livelihoods for the people in this area.

Using purposive sampling methods, three districts with a low use rate of trained delivery attendants were selected, namely Garut, Ciamis, and Sukabumi [ 28 , 29 ]. In 2008, the population in Garut district was 2,481,471 [ 30 ]; in Ciamis was 1,538,469 [ 31 ] and in Sukabumi was 2,405,777 [ 32 ]. The proportion of deliveries assisted by trained delivery attendants in Garut, Ciamis, and Sukabumi districts was 53%, 67% and 66%, respectively [ 30 – 32 ].

The selection of villages was conducted after consultations between the researchers and the local district health office ( Dinas Kesehatan Kabupaten ) of each district. In all districts, villages in urban areas, as defined by the Statistics Indonesia [ 33 ], have better access to health facilities such as health centres and health clinics compared to their rural counterparts. Based on this information, two villages were selected from each district to represent urban and rural areas. The selected villages were Sukarame (urban) and Sukajaya (rural) villages in Garut district; Benteng (urban) and Panyutran (rural) villages in Ciamis district; and Batu Nunggal (urban) and Limus Nunggal (rural) villages in Sukabumi district.

All the selected villages had road access. However, rural villages are located in mountainous areas and had generally poor road conditions. During the rainy season, some parts of the villages were not accessible by car and, therefore, villagers had to either walk or ride motorcycles to reach health care facilities. The majority of people in our study areas worked as manual labourers in agricultural or industrial production.

Study population

In this study, different groups of participants were selected to provide an overall picture about delivery care services in our study areas from the users' perspectives (i.e. mothers and their husbands, who were assumed to be involved in the decision making process about services), care providers (i.e. health professionals, including midwives and health centre staff and cadres as local community health workers), community leaders, and health authorities (i.e. health office staff). The perspectives of traditional birth attendants were considered important since they reportedly played a prominent role in providing maternal and child services in Indonesia, including in West Java Province [ 34 , 35 ]. A detailed sampling frame is presented in Figure 1 .

Sampling frame for a qualitative study in West Java, Indonesia

A total of 295 participants were recruited in this study. These consisted of 119 mothers of children aged more than 40 days to four months, along with 40 fathers, 26 health professionals including 20 health centre staff (doctors, nurses and health centre midwives) and six village midwives, 20 village cadres (local community health workers), 37 traditional birth attendants or paraji (in Sundanese language), 42 community and religious leaders, and 11 health office staff.

The recruitment of the mothers, fathers and community leaders was assisted by cadres from each village. Health workers participating in this study were the maternal and child health services providers in health centres at sub-district level, i.e. doctors, nurses and health centre midwives, as well as the care providers at village level, i.e. the village midwife. Information about traditional birth attendants in each village was obtained through the local knowledge of community members and they were individually invited to participate. Several health office staff working in maternal and child health program in each district health office were also recruited.

Data collection

In this study, two data collection methods were used, focus group discussions (FGDs) and in-depth interviews. Focus group discussions were used to explore information about the social context and issues which might be necessary to further investigate through in-depth interviews. The interaction between participants and hearing from others in a focus group discussion provides a valuable opportunity to show and discuss the differences among participants [ 36 ]. In-depth interviews were individually focused to investigate personal perspectives.

Six trained interviewers/facilitators and five field assistants were recruited and trained to collect information in the study areas. A total of 20 FGDs and 165 in-depth interviews were conducted across the six villages. Informed consent, including the consent to use recording devices, was obtained from all respondents. No one refused to give consent in this study. FGDs and in-depth interviews were conducted according to the guidelines as shown in Table 1 . Interviews and FGDs were carried out either in Sundanese or Indonesian language.

In each village at least two FGDs were carried out for (1) women assisted by trained attendants during delivery, and (2) women assisted by traditional birth attendants. In some villages, additional FGDs were conducted for traditional birth attendants if there were more than five participants. If fewer participants were available, they were invited only to in-depth interviews. In a village in Ciamis district, an additional FGD was conducted for community leaders who were responsible for the Desa Siaga program since this was the only village in which the program had been successfully conducted. On average, each FGD consisted of around seven participants, in addition to one FGD leader and one observer/assistant. All discussions and interviews were audio recorded. FGDs were conducted either at the community hall or the respondents' house.

In-depth interviews were conducted within a confidential setting, usually at the interviewee's house. At least two respondents from each category (see Figure 1 ) were interviewed by trained interviewers, and all the interviews were audio-recorded. No activity was held in health care-related institutions to avoid any hesitation from respondents who might never have had contact with health care services or personnel.

At the end of each activity, the interviewer or FGD facilitator was requested to fill in an evaluation form to help them evaluate the process and the content of their interviews and discussions. This activity would help them to improve or make adjustments in their next activity. One assistant, a Sundanese speaker, was assigned to each interviewer or FGD facilitator. They acted as an interpreter if respondents could not speak Indonesian language as well as an observer during FGDs and in-depth interviews. A cash payment of 50,000 Indonesian Rupiah (~USD 5) was paid to participants to cover their out-of-pocket expenditure. Information leaflets on maternal and child health care were provided to the mothers, fathers, and traditional birth attendants at the end of each activity.

Framework and definitions

A guideline in the analysis was based on a method previously described in a study of maternal mortality [ 37 ]. Factors affecting the decision to select delivery care attendant and place of delivery were divided into five main groups: economic and pragmatic, trust and tradition, perceived need, access to services and community members' perceptions of providers' expertise (Figure 2 ).

Factors affecting women's decision to use delivery care services

The following standard definitions of delivery attendants based on the Indonesian Ministry of Health and the World Health Organization (WHO) were used. The focus of delivery attendants discussed in this paper is village midwives and traditional birth attendants. Village midwife is defined as "a midwife placed in a village to increase the quality and the coverage of health services of a health centre, with service areas of one or two villages. The village midwife has a role to conduct health services based on the competency and resources in particular delivery services, maternal and child health, and oversee the community in conducting five programs of integrated health posts, which are maternal and children health, family planning, nutrition, immunization, and management of diarrhoea and ARI that includes health promotion" [ 38 ]. The village midwife referred to in this study is different from the village midwife referred to in an earlier study in West Java, which identified village midwives as traditional birth attendants who had been trained for some basic biomedical procedures [ 34 ].

Traditional birth attendants are defined by the WHO as "a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants" [ 39 ]. A trained traditional birth attendant is someone who "has received a short course of training through the modern health care sector to upgrade her skills. The period of actual training is normally not more than one month, although this may be spread over a long time" [ 39 ].

Data analysis

Each participant was de-identified in the data analysis phase and all data was entered into a password-protected computer owned by the researcher. All the audio-recorded interviews and FGD were transcribed in Indonesian language by the research assistants. The transcriptions were cross-checked with the recordings by the research team and then exported to NVivo 8 (qualitative data analysis software). A content and thematic analysis [ 36 , 40 , 41 ] was conducted in the Indonesian language by the lead researcher (CRT). For each transcription, issues relating to the study aims were identified and coded without predefined categories. After the completion of the coding process, themes were developed and classified, guided by the framework previously described. A triangulation of data sources and methods [ 36 , 40 , 41 ] was employed, comparing information from different sources (different categories of respondents), different methods (in-depth interviews and FGDs) using multiple interviewers.

Ethical clearance

Ethical clearance was obtained from the Human Research Ethics Committee (HREC) at the University of Sydney, Australia and from the Ethical Research Commission National Institute of Health Research & Development (NIHRD), Ministry of Health Republic of Indonesia.

Our data exposed a range of issues regarding the use of delivery care services in six villages of West Java Province. Five major topics emerged: (1) Reasons for using the services of traditional birth attendants at childbirth; (2) Reasons for having a home delivery; (3) Reasons for using trained delivery attendants and institutional delivery; (4) The partnership practice between the midwife and traditional birth attendants; and (5) Community perceptions about the village midwife and traditional birth attendant. Topics (1) and (2) are discussed separately since they will provide more information about why some community members still preferred traditional birth attendants and/or home delivery services. A woman might be assisted by trained delivery attendants but preferred to deliver at home.

Reasons for using the service of traditional birth attendants

From 119 mothers participating in this study, more than 40% used traditional birth attendants at childbirth. The participants' reasons for using the services of traditional birth attendants can be classified into five main categories, economic and pragmatic, trust and tradition, perceived need, access to services and community members' perceptions of care providers' knowledge and skills.

Economic and pragmatic reasons

Cost was one of the main reasons stated by participants in all villages for using the services of traditional birth attendants. The average delivery cost for a midwife of IDR 350,000 (~USD 35) was perceived as unaffordable by some community members. In addition, the flexibility of the payment method for traditional birth attendants was more convenient.

We don't have much money. We need to pay around 400 [400,000~USD 40] for a village midwife. For a traditional birth attendant... we can pay around 100 [100,000~USD 10] . Just depends on how much we have. We can even pay them by instalments. (Focus group discussion with mothers, Sukarame, Garut)

I'm struggling with my daily expenses, how can you expect me to pay a village midwife ? (In-depth interview with a mother, Sukajaya, Garut)

Even though some community members had Jamkesmas cards to enable them to access free health care services, the services of traditional birth attendants were still preferred.

There are so many people seeking care from traditional birth attendants. We have already explained that if you have Jamkesmas, you do not have to pay anything to use midwives' services. But then they said they were still afraid that they would be required to pay. One day they also said they were ashamed of using the midwives services without paying anything. (In-depth interview with a cadre, Sukarame, Garut)

Furthermore, misunderstanding about the eligibility of Jamkesmas was also found in the community.

Jamkesmas is only used for the village midwife service. Other than that [e.g. private midwife] you cannot use it. (In-depth interview with a cadre, Batu Nunggal, Sukabumi)

People were afraid that they will be neglected [by a health provider] if they used Jamkesmas . (In-depth interview with a community leader, Panyutran, Ciamis)

Socio-cultural - Trust

Our study found that being part of the community, speaking the local language, living in the community and sharing the same culture meant that traditional birth attendants have developed the feeling of trust in the community.

Traditional birth attendants are much closer to the community. They have been treated as a respected person by the villagers. Sometimes the village midwife could not adapt really well with the surroundings; whereas for traditional birth attendants, they grow together with the community. Psychologically, they trust the traditional birth attendants more. (In-depth interview with health office staff, Garut )

Socio-cultural - Tradition

Another factor that influenced the use of traditional birth attendants was being told by other family members such as the older sister, parents, or husbands to use their services. A long-time tradition in the community of using the service of traditional birth attendants, who had been the only delivery service providers for many years before the National Health System started, was also mentioned as a reason for community members to use their services during childbirth.

Perceived need

Some participants argued that the services of a health professional (a village midwife) are required only for those experiencing obstetric complications. Some community members stated that the midwife's services would be sought only if the condition could not be handled by the traditional birth attendant.

In this village, the first assistant from whom we seek care is the traditional birth attendant. If the delivery starts to be complicated, we then call midwives. (Focus group discussion with fathers, Limus Nunggal, Sukabumi)

They think deliveries assisted by midwives are only for those with delivery complications... If traditional birth attendants cannot manage the deliveries, then they would call us. Otherwise, calling midwives is unnecessary. ( In-depth interview with a village midwife, Sukajaya, Garut)

There are many cases like this, for example an obstructed labour with excessive bleeding, or retained placenta cases. They just wait until the traditional birth attendants could no longer manage it. Sometimes we arrived late and the mother already had severe oedema and was in a very weak condition. (In-depth interview with a health centre midwife, Ciamis)

Access to services

Three reasons related to the issues of accessibility to health care services were physical distance, time constraints, and the availability of a health care provider. In rural areas there was better access to the traditional birth attendants compared to the village midwife. Some rural villages had more than ten traditional birth attendants compared with only one village midwife.

The village midwife service is ... too far away. It is impossible to contact the health personnel at ten o'clock at night. It is impossible. Better to use the services of traditional birth attendants. (In-depth interview with a religious leader, Sukajaya, Garut)

At night time, the major problem is we have a poor road condition...especially during the rainy season. It is difficult to find the midwife by yourself. (In-depth interview with a father, Panyutran, Ciamis)

The delivery was at night and it was an emergency. The baby was already out. The closest was the traditional birth attendant so I just ran to ask for her help. (In-depth interview with a father, Sukajaya, Garut)

Sometimes the midwife was not at home. Sometimes her husband also did not allow her to go out at night. He was afraid something bad might happen along the way. (Focus group discussion with mothers, Sukajaya, Garut)

The traditional birth attendants live closer than the midwife. There is only one village midwife for the whole village, so she also has limited ability to serve the whole community, maybe because she is tired, or needs to travel out of the village. (In-depth interview with a midwife coordinator, Sukaresmi, Garut)

The social distance between the village midwife and the community was also an issue. Some community members were hesitant to seek a midwife's services even if they had received a Jamkesmas card that makes them eligible to use services for free.

The midwife assured me not to worry since I have Jamkesmas. But I feel ashamed for waking her up in the middle of the night. For me it is fine with traditional birth attendants. We are used to them. Yet for the midwife, I feel ashamed for not having any money to pay her. (In-depth interview with a mother, Sukarame, Garut)

Community members' perceptions of care providers' knowledge and skills

For some community members, village midwives were also perceived as too young and inexperienced; whereas traditional birth attendants were more mature, patient and caring compared with the midwife.

They say the traditional birth attendants are more patient. They gently touch your stomach and do not easily feel upset. This attitude is different from midwives. Sometimes after the physical examination, the midwife leaves if she thinks it is not the time for delivery yet. In contrast, the traditional birth attendant will wait patiently and accompany the woman all along. (In-depth interview with a traditional birth attendant, Batu Nunggal, Sukabumi)

Reasons for a home delivery

Almost 80% of mothers participating in this study delivered at home. Similar reasons were given by the participants when asked about home delivery to the ones given for use of a traditional birth attendant at childbirth.

Economic reasons

Particularly among those who did not have the Jamkesmas , cost was one of the major reasons for not having an institutional delivery.

You need around IDR 2 million [~USD 200] to deliver in the hospital. With traditional birth attendants, even 50,000 [~USD 5] is fine. Our husbands only work as manual labours. Where can we get the money to pay the midwife or to deliver in the hospital? (Focus group discussion with mothers, Limus Nunggal, Sukabumi)

I prayed that day, "Lord please do not let my wife deliver our baby in the hospital. We do not have any money." (Focus group discussion with fathers, Benteng, Ciamis)

There is a perception that delivery is a natural rite of passage for women, and thereby home delivery is preferred unless complications occur or someone tells them to deliver at health facilities.

If there were some problems then the mother will be brought to the health centre, otherwise she will deliver at home. (In-depth interview with a community leader, Panyutran, Ciamis)

In addition to the costs, physical distance was an issue for community members living far away from the health facilities and, therefore, home delivery was preferred.

Maybe distance is an obstacle in addition to the costs. You need to ride a motorcycle to reach the health facility. So people prefer having the health professional to come to their houses, especially at night time when it is hard to get transport. (In-depth interview with the head of health centre, Garut)

The midwife's place is too far away. It is too far to go to deliver my baby. (Focus group discussion with mothers, Sukajaya, Garut)

Convenience

The convenience of home delivery related to the responsibilities pregnant women felt towards other family members.

If we delivered at the midwife's place, we automatically needed to stay overnight. Maybe for one or two days. I have two young children at home, 4 and 2 years old. Who will take care of them? I look at it that way. So I better deliver at home. (Focus group discussion with mothers, Cibadak, Sukabumi)

They just said they do not want to bother anyone. Delivery in the midwife's place means someone needs to go and accompany you. At home they can just wait for the delivery time while doing some household chores. (In-depth interview with a cadre, Sukarame, Garut)

Reasons for using trained delivery attendants and institutional delivery

Our study found that delivery complications at childbirth were a main reason for using the service of health workers at childbirth (55% of the mother respondents) and for having institutional delivery (20% of the mother respondents).

Those who seek midwives services are usually those who have difficulties delivering their babies. (In-depth interview with a community leader, Panyutran, Ciamis)

If there is no problem we use traditional birth attendants. But if it looks like the traditional birth attendant could not manage it, we will call a midwife. (In-depth interview with a mother, Cibadak, Sukabumi)

We called the village midwife, and she asked us to bring me to her place. But then she was not able to help me because I had hypertension. So they brought me to the hospital. (Focus group discussion with mothers, Sukarame, Garut)

Some respondents stated that the competency of midwives and better equipment were amongst the reasons for community members to use their childbirth services. Furthermore, advice from midwives was another reason for mothers to have an institutional delivery.

It is better to use the midwife service. It is a guaranteed treatment. (In-depth interview with a father, Sukarame, Garut)

The traditional birth attendant does not have a complete range of equipment in case something happens. If we have the midwife, we do not have to go anywhere anymore. So we just go straight to the midwife. (Focus group discussion with mothers, Limus Nunggal, Sukabumi)

Because I felt pain so I checked with the midwife. She said I was in labour and I was not allowed to go home. (Focus group discussion with mothers, Sukarame, Garut)

The partnership practice between midwife and traditional birth attendants

Health professionals in all six villages were aware of the partnership programs between midwives, traditional birth attendants and cadres. However, the implementation varied across villages. In one village in Ciamis district, the partnership was successfully endorsed by the Desa Siaga program engaging the village midwife, traditional birth attendants and cadres. In fact, in this village a penalty was given by the Desa Siaga officers (mainly the village community leaders from the village) to the delivery attendant if both the village midwife and traditional birth attendants were not present at childbirth (see quotation below).

The delivery should be assisted by both a traditional birth attendant and a midwife. There was an agreement in all sub-districts, if I am not mistaken. You have to pay 500,000 [~USD 50] , divided between traditional birth attendants and village midwife... a penalty will be applied if for example the traditional birth attendant was the only attendant at delivery. (In-depth interview with a cadre, Benteng, Ciamis)

In other villages, the partnership program was not conducted according to the guidelines.

We have disseminated the partnership program to the community... But we still have some problems with traditional birth attendants... maybe the remuneration was too little. We have even had the meeting together with the doctor [from the health centre] , and sub-district office staff... but still it is not working. (In-depth interview with a cadre, Sukajaya, Garut)

The traditional birth attendants have been asked to work together. But it is difficult. They used to say that the baby is already out [they did not call village midwife]. (In-depth interview with a village midwife, Sukarame, Garut)

The implementation of the partnership program was also hindered by the fact that traditional birth attendants in some villages preferred to work independently without the assistance of health professionals, unless perceived necessary.

If it could not be managed, we then called the midwife. Otherwise, we will just manage it ourselves. (Focus group discussion with traditional birth attendants, Limus Nunggal, Sukabumi)

It [partnership program] is difficult here. If something happened then they called the midwife. (In-depth interview with a village midwife, Limus Nunggal, Sukabumi)

Community perceptions of village midwife and traditional birth attendants

The data provided positive feedback about the role of village midwives in the community. They were perceived as diligent, kind, friendly, responsive, alert and willing to provide health services. Nevertheless, the role of traditional birth attendants was considered essential especially in remote areas. Having both a midwife and a traditional birth attendant present at a delivery was perceived important so that the tasks and responsibilities could be shared together.

We prefer having both of them. Before calling the midwife, we called the traditional birth attendant. The traditional birth attendant will gently touch the mother, and have some special prayers for that. For us village people, that is helpful. The midwife can take care of the child; the traditional birth attendant can look after the mother. If only a midwife is available, she might not be able to handle everything. There should be both of them. (Focus group discussion with fathers, Benteng, Ciamis)

Main findings

The use of traditional birth attendants and home delivery were preferable for some community members in spite of the availability of a village midwife in the village. Some major factors for the use of both traditional birth attendants and home delivery were the economic and pragmatic reasons, since delivery costs with a midwife or at health care facility were perceived unaffordable. This was aggravated by the low economic status of the community members in addition to the embarrassment and misunderstanding of the Jamkesmas scheme. Other reasons found were the trust and tradition that traditional birth attendants engendered; they shared the same culture and were long-serving members of the community. The services of trained birth attendants during childbirth or an institutional delivery were perceived important by some community members only during obstetric complications. Furthermore, difficult access to health care personnel and facilities was amongst the major reasons for preferring traditional birth attendants and home delivery. The social distance between the community and village midwife also emerged as an issue. Our study found that home delivery was considered more convenient for some women because of their responsibilities to children or other household members. The implementation of the partnership program between village midwives and traditional birth attendants varied across villages. The roles of village midwives and traditional birth attendants were perceived vital, particularly in rural areas where health care services were sub-optimal.

Issues affecting delivery services utilization

Our study demonstrated that for some community members, assistance by the traditional birth attendants and home delivery were preferable, although data from the 2007 IDHS showed that the use of traditional birth attendants and home delivery in Indonesia has been decreasing over the last decade [ 25 ].

Our findings follow other studies [ 37 , 42 , 43 ], which demonstrated that poverty is a major factor influencing people's decision-making about health services. An analysis of different IDHS data also found a significant association between wealth index and the use of health care services [ 44 , 45 ]. Since most of the population in our study areas worked as manual labourers, such as farmers or industrial workers, and had a low income per capita [ 30 – 32 ], the midwife's services or an institutional delivery were more likely to be unaffordable. A deprived financial situation is often linked to low education levels, which affects one's ability to seek the most appropriate health care services [ 4 , 46 ].

The provision of Jamkesmas to the poor and near-poor households was expected to help disadvantaged communities to access health care services without burden to their pocket. At present the poor community's embarrassment at using Jamkesmas , which enables them to use health service for free, in addition to misinterpretation and misunderstanding about community members' eligibility for Jamkesmas , demonstrate an apparent failure of the Ministry of Health and the local authorities to communicate and explain its use and benefits. As a result, the provision of Jamkesmas does not change the health care seeking behaviour of some women from disadvantaged households. This finding shows that health care professionals should be encouraged to use every opportunity to promote the use and the understanding of Jamkesmas and its benefits to the community. Monitoring and evaluation strategies at the national and local levels for the distribution mechanisms and the effectiveness of Jamkesmas are essential. Strengthening Desa Siaga programs is important to help families who have experienced financial difficulties to access health services through the community-based financing mechanism.

Proximity to health care facilities is an underlying issue for selecting delivery health care services, as also shown in previous literature [ 34 , 37 , 43 ]. Poor road conditions and lack of transportation are associated with increased costs of visits to health care providers. An earlier study from West Java Province mentioned the problem of distance as a reason for a community's use of traditional birth attendants compared to midwives [ 34 ]. This may be aggravated by the unwillingness of a midwife to make a long trip at night [ 34 ]. Reducing the distance by bringing either the community closer to the services or bringing the services closer to the community will be beneficial. Maternal waiting homes where women at the end of their pregnancies can stay and wait for labour have long been advocated to close the physical distance. However, a recent review reported a wide range of views regarding their effectiveness [ 47 ]. Therefore, careful planning that takes into account socio-cultural factors is essential. Women preferred to stay at home for a delivery so that they could take care of family members and manage their daily household chores. This indicates that taking women away from the family, even during labour, might not be the most acceptable and appropriate solution.

The social and psychological distance between community and health professionals is an obstacle in some areas. This can be due to the shortage of health professionals in large and remote areas, a frequently absent midwife, or one who does not live in the village [ 17 , 48 ]. A high rate of absenteeism occurs as village midwives often prefer to live in urban areas. With the current expansion of the private health sector in Indonesia, urban areas are much more appealing for health professionals, including village midwives, to establish a private practice while at the same time also receiving the government subsidy [ 18 ]. Different strategies have been implemented aimed at retaining village midwives in the villages [ 17 ]. However, working in remote areas carries some concerns for midwives and their families, including professional isolation or the pressure of exclusion from a long-established or traditional community [ 13 , 17 ]. Furthermore, if the midwife who is perceived as young, inexperienced, with no children and lacking maturity, is placed in a rural area then the gap may widen further [ 48 ]. This is a real challenge. Partnerships between village midwives, cadres, and the community should be strengthened to overcome these issues.

Our study found a lack of awareness about the importance of trained delivery attendants. For some community members, the assistance of trained delivery attendants during childbirth was perceived as only necessary when obstetric complications occurred. Recognition of the need for health services is important to ensure appropriate health care seeking behaviour. For women, childbirth is often perceived as a normal event and normal work, rather than an event requiring medical attention [ 7 , 37 ]. However, the lack of community members' knowledge about symptoms which require medical care can lead to delays in recognition and treatment of severe complications contributing to maternal deaths [ 3 ]. Therefore, health promotion strategies are important to increase community awareness about the importance of trained delivery attendants. This can be through antenatal care services which are effective in increasing the use of trained delivery attendants during childbirth and institutional delivery [ 49 , 50 ].

The role of traditional birth attendants

Traditional birth attendants have been part of the Indonesian community for a long time, before the Safe Motherhood Initiative was endorsed in Indonesia. This profession has been handed over from one generation to another. Our study showed that their role was still prominent. In all villages, traditional birth attendants outnumbered the village midwives. Considering village midwives' limited ability to reach the community to provide health services due to availability, accessibility and social distance, it was seen as quite acceptable that traditional birth attendants' services would be widely used. Their expertise was valued due to their social and emotional closeness to the community, their long experience in providing services to mothers and infants, and their intimacy with the villagers, which created loyalty and understanding, particularly when other health care services were not accessible. This built the authoritative knowledge conferred on them by the community [ 51 ].

In the past, training programs for traditional birth attendants were conducted and free delivery kits were provided. Unfortunately, this program has been phased out following the Ministry of Health recommendation that training for traditional birth attendants should be stopped in areas where a village midwife is available [ 17 ]. As a result, several traditional birth attendants, particularly the new ones, whose services are being widely used, have not attended any training programs and their ability to conduct a safe delivery remains uncertain.

Previous trials of delivery and postnatal care services involving traditional birth attendants in India and Pakistan demonstrated that engaging traditional birth attendants in the maternal and child health services had a favourable impact on neonatal and perinatal mortality [ 52 , 53 ]. Discontinuing training for the potential traditional birth attendants who are actually capable to provide appropriate care has been claimed to bring more harm than good [ 54 ]. A review of the effectiveness of the training of traditional birth attendants also showed favourable results concerning perinatal and neonatal mortality, although the number of the studies included was considered insufficient [ 55 ]. A well designed and coordinated training of traditional birth attendants might provide a favourable result [ 56 ]. A review of 15 traditional birth attendants and midwife-based interventions aimed at improving delivery assistance skills and recognition as well as referral of complications, demonstrated that both traditional birth attendants and community-based midwives had a role in reducing the maternal mortality ratio [ 57 ]. It is a strategy worth reconsidering in Indonesia, particularly in areas where health care facilities and personnel are still lacking and the utilization of traditional birth attendants is high. Some adjustments to the maternal and child health programs should be conducted, taking into account the traditional values in the community.

The partnership program

Although the partnership program between trained and traditional birth attendants has been endorsed, the implementation of this program varied across villages. In some areas, traditional birth attendants preferred providing services independently and sought midwifery care only if considered necessary. Consequently, adverse delivery outcomes might occur due to the delay of midwives for obstetric emergency conditions. In one village where the partnership program was successfully endorsed, community participation was the key factor in its success. Initiated by local community leaders through the Desa Siaga program, different strategies have been carried out to improve community awareness and utilization of the village midwife in addition to the traditional birth attendant. Efforts to strengthen the partnership program would appear to be a beneficial intervention. Advocacy, dissemination, and monitoring activities should be carried out regularly. Local stakeholders, such as community leaders and traditional birth attendants should be encouraged to develop this program, adjusting and adapting it to local conditions to ensure its sustainability.

Compared to a previous study in West Java [ 34 ], a more positive attitude towards health care professionals was found amongst the traditional birth attendants in all of our study areas. Some traditional birth attendants perceived health professionals as partners in providing maternal and child health services, and their willingness to collaborate provides a valuable opportunity for village midwives to reach the local community. The involvement of local stakeholders, including the traditional birth attendants is essential when planning and implementing public health interventions.

With the emergence of the decentralization program, in which the responsibility of health services has been transferred to the district level, stakeholders at the district, sub-district and village level play a vital role in the improvement of maternal and child health services in their areas [ 58 ]. The identification of resources and constraints to conduct local-based public health strategies is essential. Efforts to implement different approaches adjusting for local conditions should be encouraged and strengthened to increase service uptake.

Significance of the study

The results of this qualitative study demonstrate perspectives on delivery care services in six villages of West Java Province. These findings provide local evidence that will assist the government in achieving the target of 90% deliveries assisted by the trained birth attendants and to develop public health strategies for the improvement of maternal and child health services. In general, our findings showed that no magic bullet solution is available to increase the utilization of delivery care services in Indonesia. Since the adoption of the Safe Motherhood Initiative in 1989, various maternal and child health programs have been implemented, however, continuous and rigorous evaluation and monitoring programs are required to assess the effectiveness of each intervention. Community-based education that targets the disadvantaged community is required. Peer-education programs that have been shown to effectively increase the use of health care providers and institutional delivery should be implemented [ 59 ]. This strategy will increase community awareness about the importance of maternal and children health.

Using a purposive sampling method the results of this study may not be representative of West Java or the Indonesian population; however, using qualitative methods enabled us to explore and understand the perspectives of community members on delivery care services. Triangulation by using different data collection techniques, i.e. in-depth interview and FGD, along with the use of multiple interviewers and different categories of participants increases the validity of the results [ 36 , 41 ].

This study has a number of limitations. We did not differentiate traditional birth attendants who had received biomedical training from those who had not been trained. Although all of the research assistants speak Sundanese and had a role as an interpreter either for the interviewer or respondents, the language issue might have influenced the interaction process during data collection. However, these limitations are unlikely to influence the validity of the results of our study. Further research to examine the extent to which low utilization of these delivery care services might affect maternal and neonatal death could be conducted.

Our findings show the importance of adopting a comprehensive approach to increase the availability and accessibility of maternal and child health care services in the community. The under-served community are the poorest population who are in the greatest need. Poverty alleviation strategies will contribute to improving access and utilization of maternal and child health care services. The provision and the maintenance of infrastructure by the local government will improve access to health care services, especially for communities living in remote areas. The evaluation and monitoring programs for the current insurance scheme, Jamkesmas , are also important to maximise its benefit among poor communities. Health promotion programs to increase community awareness about safe delivery services will benefit the community.

Strengthening the partnership program between village midwives and traditional birth attendants is recommended because of the frequent use of traditional birth attendants in this area. Training of traditional birth attendants would enable them to up-skill their delivery practice under the supervision of health professionals, especially in rural and remote areas. Additionally, local stakeholders' participation plays a major role in the successful implementation of maternal and child health programs.

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Acknowledgements

This project received funding from the Ford Foundation Indonesia and the Australian Health Policy Institute, University of Sydney, Australia. This analysis is a part of the CRT thesis to fulfil the requirement for a PhD in International Public Health at the University of Sydney. We extend our thanks to AusAID for funding CRT PhD Scholarship in International Public Health at the University of Sydney, Australia. We are indebted to the community members and health workers in the six villages, particularly our respondents, and those involved in our study. We are grateful to our local collaborators, Dr Nida P Harahap, and the staff of the District Health Office in Garut, Ciamis and Sukabumi. We are thankful for the researchers from the National Institute of Health Research and Development, Ministry of Health, Indonesia, in alphabetical order, Ms Ida, SKM, Mr Meda Permana, SSos., Dra Soenanti Zalbawi, MM, Ms Tin Afifah, SKM, and Ms Oster Suriani, SKM. We would like to thank the assistants who helped us during the study, in alphabetical order, Ms Anny Hanifah, Ms Asri SR, Mr Dani Ramdhani, Ms Litsa ZA, Ms Nurlela, Ms Santi Hendriyanti, Ms Sintiya AK., and Ms Sri Nanjung. We also would like to thank the staff from the Sydney School of Public Health who supported this study. The funding source had no role in the study design, data collection, data analysis, data interpretation or writing of this paper.

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All authors designed the study. CRT conducted data collection. Under the supervision of CLH, CRT conducted data analysis and wrote the first draft of the manuscript. MJD and PH provided data analysis advice and revision of the final manuscript. All authors read, commented on and approved the final manuscript.

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Titaley, C.R., Hunter, C.L., Dibley, M.J. et al. Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia. BMC Pregnancy Childbirth 10 , 43 (2010). https://doi.org/10.1186/1471-2393-10-43

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Reasons for the utilization of the services of traditional birth attendants during childbirth: A qualitative study in Northern Ghana

Philip teg-nefaah tabong.

1 Department of Social and Behavioural Sciences, School of Public Health, College of Health Sciences, University of Ghana, Legon, Ghana

Joseph Maaminu Kyilleh

2 Nursing and Midwifery Training College, Tamale, Ghana

William Wilberforce Amoah

3 Department of Nursing and Midwifery, Faculty of Health and Allied Sciences, Catholic University College of Ghana, Sunyani, Ghana

Associated Data

Supplemental material, sj-docx-1-whe-10.1177_17455065211002483 for Reasons for the utilization of the services of traditional birth attendants during childbirth: A qualitative study in Northern Ghana by Philip Teg-Nefaah Tabong, Joseph Maaminu Kyilleh and William Wilberforce Amoah in Women’s Health

Background:

Skilled delivery reduces maternal and neonatal mortality. Ghana has put in place measures to reduce geographical and financial access to skilled delivery. Despite this, about 30% of deliveries still occur either at home or are conducted by traditional birth attendants. We, therefore, conducted this study to explore the reasons for the utilization of the services of traditional birth attendants despite the availability of health facilities.

Using a phenomenology study design, we selected 31 women who delivered at facilities of four traditional birth attendants in the Northern region of Ghana. Purposive sampling was used to recruit only women who were resident at a place with a health facility for an in-depth interview. The interviews were recorded and transcribed into Microsoft word document. The transcripts were imported into NVivo 12 for thematic analyses.

The study found that quality of care was the main driver for traditional birth attendant delivery services. Poor attitude of midwives, maltreatment, and fear of caesarean section were barriers to skilled delivery. Community norms dictate that womanhood is linked to vaginal delivery and women who deliver through caesarean section do not receive the same level of respect. Traditional birth attendants were believed to be more experienced and understand the psychosocial needs of women during childbirth, unlike younger midwives. Furthermore, the inability of women to procure all items required for delivery at biomedical facilities emerged as push factors for traditional birth attendant delivery services. Preference for squatting position during childbirth and social support provided to mothers by traditional birth attendants are also an essential consideration for the use of their services.

Conclusion:

The study concludes that health managers should go beyond reducing financial and geographical access to improving quality of care and the birth experience of women. These are necessary to complement the efforts at increasing the availability of health facilities and free delivery services.

About 800 women are reported to die every day from pregnancy and childbirth-related causes. 1 The majority (>90%) of these deaths occur in low- and middle-income countries (LMICs). 1 The lifetime risk of maternal mortality in sub-Saharan Africa is 1 in 38 women compared to 1 in 3700 in developed countries. 1 A key component of the strategy to reduce maternal morbidity and mortality has been to increase rates of skilled birth attendance and facility-based childbirth. 2 While global skilled birth attendance rates rose by 12% in LMICs over the past two decades, almost one-third of women in these regions still deliver without a skilled birth attendant. 2

The importance of skilled attendance at birth lies in the fact that access to and use of maternity care facilities and skilled personnel, particularly skilled attendance at birth is often associated with substantial reductions in mortality and morbidity for the mother over home births. 3 – 7 Despite this recognition, not all women seek skilled care during pregnancy or childbirth. Globally, several factors have been identified as barriers to skilled maternal healthcare access. Studies have shown that delivering in a health facility may be hampered by distance to facilities. 8 – 10 Other studies indicate that structural factors, including lack of financial or economic resources, transportation, and delivery supplies, and lack of coordination of referrals between traditional birth attendants (TBAs) at the community level and facilities prevent women from using facility-based services 11 – 15 Some studies also indicate that client’s negative perceptions of healthcare staff, including reports of unfriendliness at delivery serve as barriers to obtaining skilled care. 11 , 15 – 17

Ghana has expanded its healthcare facilities to reduce geographical access to healthcare and also introduced the Community-based Health Planning and Services (CHPS) strategy in both urban and rural areas to bring healthcare to the doorsteps of communities. 18 – 20 Free maternal and delivery services were also introduced to break financial barriers to antenatal, skilled delivery, and postnatal services in 2008. 21 , 22 Despite this, there is growing concern that many pregnant women still have unskilled delivery. For example, the most recent (2014) demographic and health survey showed that while the percentage of women making the World Health Organization’s (WHO) recommended four antenatal care visits is 87%, skilled attendance at birth is 74%. 23 This implies that 26% of women delivered at home or used the services of traditional birth attendants. Again, a secondary data analysis conducted on the 2017 Ghana Maternal Health Survey showed that approximately 98.7% of maternal deaths completed less than four antenatal visits, and only 38.4% utilized skilled birth attendance during delivery. 24 Unskilled delivery rates are higher in Northern Ghana. 25 An earlier study showed that in the Northern part of Ghana about 39.1% of births occur at TBA facilities. 26 This study was, therefore, conducted to identify the reasons for women’s preference for the service of TBAs when they live in communities with accessible health facilities and free service.

Methods and materials

Study design.

This study adopted the phenomenology approach to qualitative enquiry. 27 In phenomenological research, it is the participants’ perceptions, feelings, and lived experiences that are paramount and that are the object of study. 28 This design was, therefore, deemed appropriate as the study aimed at documenting the lived experiences of women who delivered at TBA facility and the reason for their choice of facility.

We adopted the social–ecological model. This model considers the complex interplay between individual, relationship, community, and societal factors in affecting the phenomenon of interest. 29 The structures at each of the constructs in the model overlap and illustrate how factors at one level influence factors at another level.

The individual constructs in the content of this study refer to the personal-level factors such as age, education, and income that influence individual health-seeking behaviour. 30 The relationship which is the second level examines close relationships that may influence the likelihood of using TBAs for delivery. An individual’s closest social circle peers, partners, and family members influences their behaviour and contribute to their range of experience. The relationship factors also include previous experience with biomedical facilities or TBAs during childbirth. The third level (community) explores the settings, such as health facilities and neighbourhoods, in which social relationships occur and seeks to identify the characteristics of these settings that are associated with health-seeking behaviour 31 during labour. The fourth and final level (societal) looks at the broad societal factors that help create a climate that drives people towards using the services of TBAs ( Figure 1 ).

Social–ecological model showing reasons for the utilization of the services of TBAs.

The study was conducted in Tolon District and Yendi Municipality in the Northern region of Ghana. The Tolon district is divided into three sub-districts for the delivery of healthcare. There are health centres in each of the sub-districts and CHPS compounds in communities in the district. Access to health facilities has been reported to be higher than the regional average. 32 The Yendi municipality has a government hospital located in Yendi and four health centres located at Yendi, Bunbonayili, Ngani, and Adibo. The municipality also has four 7 CHPS compounds at Sunson, Kuni, Kamshegu, Oseido, Montondo, Yimahegu, and Kpasanado. There is also a clinic at Malzeri and a private clinic at the Church of Christ premises in Yendi. 33

The selection of the district was based on information gathered from the Regional Health Directorate and available literature. These two districts are noted for a high number of TBA deliveries in the region despite the availability of health facilities. In Tolon, it has been reported that each community has more than two TBAs. 34 Yendi was also selected because of the number of TBAs in the district and had served as a district for the training of TBAs in the region in the past. As a result, the district has more than 30 TBAs across various communities. 35

Study population and selection of participants

The study population were women who had live birth in the TBA facilities in one selected district and a municipality. Health workers in the selected districts were used to identify the TBAs who have high attendance based on their district report. Their facilities were visited and women who had childbirth with TBA pending their discharge were recruited for the study. An initial screening sheet was used to select eligible women. To be eligible, the person should be residing in a community with a health facility and should be gainfully employed with a monthly income of more than the minimum wage of GHȻ310.00 ($53.13). Financial access and travel distance have been reported as known barriers to skilled delivery. This strategy was, therefore, employed to exclude people who had to use TBA services because of non-availability of a health facility. Higher costs associated with seeking supervised maternity services have been noted as very critical to the uptake of care for many women in Ghana and other developing nations. 5 , 36 Free maternal health service was introduced in Ghana as a pro-poor strategy to reduce the financial barrier to healthcare during pregnancy and childbirth. The free maternal health policy was implemented in Ghana in July 2008 under the National Health Insurance Scheme (NHIS). The policy allows all pregnant women to have free registration with the NHIS after which they would be entitled to free services throughout pregnancy, childbirth, and three months postpartum.

Data collection tool and procedure

An in-depth interview (IDI) topic guide was used for the data collection. The topic guide was designed in English and translated into the local language (Dagbanli). The topic guide was designed according to the four constructs (individual, relationship, community, societal) in the social–ecological framework. For example, we asked questions about the reasons for utilizing the services of the TBA, the various actors in the decision-making process, and their views about the type of services provided by the TBA. For those who indicated they had previous experience with health facility delivery, we asked them to compare the services at the health facility with those rendered by the TBAs (see Supplementary file 1 ). These topic guides were pretested with five women who utilized the services of TBA in another suburb of Tamale. All the interviews were conducted by trained research assistants with previous experience in conducting qualitative interviews. We collected socio-demographic data such as age, education level, religion, and reproductive history at the end of the interview. The interviews for each day were transcribed before proceeding to conduct more interviews. The daily review and coding were useful in determining the point of saturation. 37 Eligible women who refused to participate in the study were replaced. Four women who were eligible and recruited refused to participate for personal reasons. Interviews were conducted between March 2019 and June 2019. Interview sections lasted for 30–40 min.

Reflexivity and bracketing

Reflexivity relates to the degree of influence that the researcher brings to bear on the research either intentionally or unintentionally. 38 Reflexivity enhances the quality of research and also boosts understanding of how the researcher’s own interest could affect the research process. 39 Bracketing, on the contrary, refers to an investigator’s identification of vested interests, personal experience, cultural factors, and assumptions that could influence how he or she views the study’s data. 40 In qualitative research adopting phenomenology, it is important for researchers to disclose their personal biases and measures that were put in place to improve rigour, trustworthiness, and credibility of the research findings. Several strategies were adopted in reflexivity and bracketing.

First, the research team did not have preconceived ideas and interest regarding the outcome of the study findings. The study was mainly informed by available literature that clearly shows that some women still have unskilled delivery despite the expansion of health facilities and introduction of free maternal healthcare policy. Furthermore, the research team and the research assistants were very open to study participants during data elicitation. There was no social or biological relationship between study participants and researchers. Although all the researchers have clinical training and practice, at the point of data collection and the research, none of the researchers was involved in clinical care.

In addition, research assistants with experience in conducting qualitative interviews were recruited and trained by the lead investigator. They were informed on the need to have a neutral mind and behaviour towards study participants during interviews or data collection. They were further told that any biased behaviour, preconceived beliefs, or values could affect the data that would be collected and that could further have a negative effect on the outcome of the study findings.

Recorded interviews were replayed to participants to make inputs and corrections. The interviews were transcribed verbatim. After the data collection and analysis, the findings were shared with some of the participants through a dissemination workshop. This enabled the participant to review and agree with the findings of the study as a form of member checking. 41

In addition, a codebook was developed, reviewed, and accepted by the research team. Double coding of the data was done and compared. The coding trail was reviewed by an independent person for verification. Using the NVivo software, a coding comparison query showed a high level of agreement with a Kappa score of 0.92. 42 , 43

Data analysis

All IDIs were recorded during the interview. The interviews were played to the interviewee after the interview for them to make the necessary corrections and addition. The recordings were transcribed verbatim. The transcripts were reviewed by an independent person who listened to the recordings and compared the content with the transcriptions. Daily interviews were shared with other authors to review and provide feedback on the process. This iterative approach strengthened the data elicitation process. Interviews continued until data saturation was achieved. 44 Hybrid inductive and deductive framework 45 were used in developing the codebook, coding of the transcripts, and developing the themes. Conceptual dimensions of the interview guides guided the preliminary development of the codebook. This was then revised to include the emerging themes from the data. This codebook was discussed and accepted by all authors. The transcripts were imported into QSR NVivo 12 for textual analysis. We used the case classification function in NVivo to identify each respondent and their attributes (socio-demographic and reproductive history). We first read through selected transcripts in NVivo and created nodes from the emerging issues in the data. Both free and free nodes were created during the coding until all the transcripts were coded. During coding, memos were written to key reflection from the data. The memos were linked to both the data sources and the nodes. Coded sections were regrouped into relevant categories and themes for presenting the results. Direct quotations were used, where appropriate, to support the themes. The main themes that depict reasons for patronizing the services of TBAs could basically be divided into biomedical health facility push factors and TBAs pull factors. These factors, which emerged from data, could be put into six sub-themes; good interpersonal relationship and practices by TBAs, post-delivery baby care and provision of special food by TBAs, requirements for labour in biomedical health facilities, preference for vaginal delivery and fear of caesarean section (C/S), perception about poor services in biomedical facilities and inexperienced midwives, and poor attitude of health workers during antenatal care (ANC) and facility delivery.

Ethical approval

The protocol for the study was reviewed and approved by the Ethics Review Committee of Ghana Health Service (GHS-ERC 18/02/2019). All participants signed an informed consent form before participation.

Background information of participants

Fourteen (45.2%) of the participants were between 20 and 30 years with majority of them (74.2%) having attended at least one ANC. Ten women (32.2%) have even delivered in a health facility ( Table 1 ).

Socio-demographic and reproductive history of study participants.

ANC: antenatal care.

Good interpersonal relationship and practices by TBAs

Participants in this study revealed that they patronize the services of TBAs because of their good services and interpersonal relationship. This according to respondents in this study makes them feel confortable at their facilities. They are also able to discuss freely with TBAs their personal feelings and challenges. A participant shared her experience as follows:

I came here to deliver because the woman has a very good interpersonal relationship. When you come, she will welcome you and have time to listen to all your problems. So, we feel very comfortable discussing issues with her. (28 years, para 2)

Interviewees also indicated that TBAs allow women to assume any position of their choice during childbirth. So, individuals who opt to squat are allowed as it is believed this helps in pushing the baby out faster. They juxtaposed the squatting position with the lithotomy position at biomedical facilities which in their opinion gives discomfort. One interviewee revealed,

This woman treats us differently. When you come and you feel comfortable squatting to give birth, she will allow you, and her place is designed to suit that and this position helps to push the baby out faster but in the hospital, I was made to lie down and raise my leg and I could not breathe very well. (30 years, para 2)

Post-delivery baby care and provision of special food by TBAs

Participants in this study indicated one of the reasons for the use of the TBA during labour is the care of the baby after birth. In their opinion, the baby receives a special bath and massage, which is believed to make the baby strong. Moreover, some women patronize the services of TBA because they are served with some special food after delivery. This food in their view promotes lactation. The mothers are also fed on these hot meals until they are discharged from the facility. Two participants shared their experiences as follows:

When you deliver here [TBA facility] you are given special food until you are discharged. Unlike the hospital where nobody cares if you have eaten or not. This special soup is prepared for people who also deliver at home by our mother which helps bring breastmilk. (27 years, para 3) The women (TBAs) are very good. I had my first baby here and she provided us with food and bathed the baby and applied good oil to massage the baby and my boy is very strong. He is the one playing over there. So that is why I have come here again. (29 years, para 2)

Respondents in this study also patronize TBAs because they provide them with some concoctions, which promote lactation and recovery as illustrated:

We can get some herbal preparations which are very good for our health, so it is one of the reasons why we come to her. After delivering you become strong instantly after taking what she gives to you.

Requirements for labour in biomedical health facilities

Furthermore, the inability of some women to acquire items requested for labour in biomedical facilities emerged as one of the reasons for unskilled delivery at TBAs. Participants believed that the list provided to prospective mothers during ANC deter women from going to biomedical health facilities during labour. In their opinion, a pregnant woman in labour who goes to the biomedical health facilities without all the items risk being scolded by midwives. Hence, women prefer to attend ANC at the biomedical health facilities and then go to TBA when labour starts. This concern was mostly raised by women who had previously delivered at a biomedical health facility. The following illustrates this point:

I attended ANC at the health facility where I was given a very long list of items to get for myself and baby and should come to the hospital with those items if I am coming to deliver. I cannot afford those items, so I came here and the woman can manage with what I have. But I am sure if I had gone to the hospital without those items, I will be shouted at. (32 years, para 3) I delivered my first child at the hospital. When I got there in labour instead of the nurses attending to me they were busy checking the items I brought and started shouting at me why I didn’t bring this and that? But here the woman knows that some people cannot afford so whatever you bring the women will make do with it. (29 years, para 2)

Preference for vaginal delivery and fear of C/S

Respondents in this study also utilized the services of TBAs because of what they perceive as unnecessary operations in the hospital. To some of them, when you go to the hospital and there is any delay in labour, C/S is performed. Unlike the TBAs where you may be given some herbal preparations to facilitate vaginal delivery. This was necessary because in their view, motherhood is linked to vaginal delivery and women take pride in their ability to give birth through the vagina. Interviewees were also of the view that babies delivered through the vagina are stronger and more intelligent than those delivered through C/S. The following quotes illustrate these points:

My friend went to the hospital and experience some delay in the baby coming out [being delivered] and they operate on her. She was unhappy so I was afraid that may happen to me too. The woman gave me something to drink and shortly the baby came out. (25 years, para 1) All women prefer vaginal delivery because that makes you a woman and a mother. If they operate you to remove the baby people do not respect you. Children born through the vagina are also stronger and intelligent. (31 years, para 2)

Perception about poor services in biomedical facilities and inexperienced midwives

Interviewees were unanimous of the poor quality of service rendered at biomedical health facilities. Quick service and good medical attention were mentioned as key quality indicators in this study. Generally, respondents were of the opinion that there were always delays at biomedical health facilities. Therefore, they prefer to utilize the services of TBAs who provide their clients better and quick service. A participant shared her experience as follows:

Usually these days when you go to the health centre or the hospital, you spend a lot of time waiting and when it is even time for you to see the doctor or nurses, their services do not meet our expectation. So, for me, I prefer to use TBA. They will listen to you very well and provide you with the best of care. (28 years para 2)

Interviewees also indicated that disrespect at biomedical health facilities is one of the reasons for patronizing the TBAs. To them, TBAs were experienced women, and respect the dignity of womanhood and, therefore, treat women with love and compassion. Interviewees also characterized TBAs as mothers who have gone through labour and, therefore, have a better understanding of the process. In their view, some midwives in biomedical health facilities have not experienced pregnancy and childbirth and, therefore, are less responsive to the psychosocial needs of women. The following quotes support these claims by participants:

I often hear that when you go to the hospital the nurse will be rude towards you and shout at you. So, I decided to come to this woman whom I know she has children and will know what it takes to deliver. (26 years, para 1) TBAs have children and have experienced the process of giving birth better than some of the nurses in the hospital. Some nurses especially the young ones have never given birth and therefore do not appreciate the pain and suffering women go through. (34 years, para 3)

Poor attitude of health workers during ANC and facility delivery

Poor quality of services at the health facilities due to non-availability of midwives, negative experiences with midwives during ANC visits emerged as one of the reasons for women delivering at TBA. Interviews with postnatal women revealed that they were badly treated or had to wait for a longer duration in the hospital before receiving care. Hence, they did not want that to happen to them during labour as that could lead to the death of the baby which they so much desired to have:

. . . If you check my card, you will find that I have attended ANC at [health facility name withheld] but the delays there were just too much. So, I was afraid that may happen to me during childbirth and that can affect my baby or result in the death of my baby. I have been looking for this pregnancy for long. (34 years, para 1)

Also, previous experience of maltreatment during labour was mentioned as a reason for TBA delivery. In the view of such respondents, health workers in labour wards have now become so insensitive to the concerns of women in labour. One shared her experience where she was in distress but was ignored by the midwife on duty. This according to her resulted in stillbirth after an initial ultrasound had shown that the baby was alive:

This is my second delivery. On my first birth, I went to the hospital when I started feeling pain. So, I got to the hospital and was there for some time and was asked to go for a scan which I did and they told me the baby was alive. I spend the whole night in the hospital and when I am in pain and I call the nurse, she will shout at me that it is not time. Until the baby came out and they told me the baby was dead. Since that time, my friend advised me to come to this woman because she is more experienced than the young nurses in the hospital these days. (30 years, para 2)

Another woman narrated how she was neglected during labour while the nurses were busy chatting with people on their phones. She, therefore, called on health managers to ban the use of mobile phones by health workers on duty:

In my case, I went to the hospital and the nurse told me it was too early for me to deliver after examining me. They left me there in very serious pain whilst they were busy chatting and one of them was using WhatsApp. The use of phone should be ban, it has come to increase the neglect that patients receive. The young nurses are always busy chatting with boyfriends whilst on duty. (33 years, para 2)

The poor attitude of midwives emerged as a push factor for facility delivery while encouraging the patronage of TBAs. This finding brings to bear that even though the challenges of accessibility are being addressed by providing more health facilities through the scale-up of the CHPS strategy, there are still significant issues relating to the negative attitude of health workers. It is important to note that the attention given to women by TBAs and quality of care is a motivation for many women to access their services. Quality of care has been defined as the difference between how medical care can optimally be delivered and how it is delivered. 46 Several studies have demonstrated the role of quality care in producing enhanced maternal health outcomes. 46 – 48 To this end, evidence from diverse settings has suggested that increasing facility delivery may not reduce mortality if the quality of care is poor. 49 – 51 For instance, a 2013 analysis of WHO multi-country survey data suggest that coverage with life-saving interventions may be insufficient to reduce maternal deaths without overall improvements in the quality of maternal healthcare. 52 There is, therefore, the need to put in place measures to improve the quality of care and birth experiences of women. Customer care can also be incorporated into the training of health workers.

Participants in this study were of the view that TBAs have an in-depth understanding of labour and have a better sense of urgency to act and willing to support mothers. These attributes led to expectant mothers’ preference for their service. In contrast, services at hospitals were seen as poor with health workers treating the expectant mother with discontent. These negative attitudes prevented women from utilizing skilled delivery. Similarly, a study in Northern Ghana has shown that women refused to patronize facility-based delivery because of poor quality and maltreatment during labour. 34 The findings of this study underscore the need for nurses to change their attitude towards clients that seek healthcare.

The study found squatting position as one of the reasons for the use of TBA facilities. Another reason cited for delivery at TBA facilities is the use of herbs, which is believed to be effective and facilitate the labour process. As found in some studies, women’s preference for TBAs during pregnancy and labour, compared to the healthcare facilities, was due to the use of herbal medications, which was preferred to the drugs and vaccines administered at the ANC clinics. 53 In light of these, health education offered to women during ANC visits should highlight the necessity for the continuum of care that includes skilled attendance at birth and postnatal care. Again studies have reported that even women who attend ANC still go to deliver at TBA facilities. 54 As more than 65% of maternal deaths occur during delivery, the importance of having a skilled attendant in a facility with adequate healthcare services during the time of birth cannot be overemphasized. 55 Furthermore, orthodox healthcare providers are guided by procedures that may be at variance with the cultural inclinations of pregnant women. 56 – 58 It is, therefore, critical for health facilities to identify some of the good practices of the TBAs and incorporate them into biomedical healthcare services. Collaboration between TBAs and health workers in biomedical facilities can provide an opportunity for the training of TBAs on danger signs during labour and encouraging them to refer such cases to avert complications.

Another barrier to utilization of skilled delivery was the fear of C/S section and perceived belief of the high incidence of C/S. This fear is related to community beliefs that motherhood was generally related to vagina delivery. Hence women who give birth through C/S did not receive the same recognition as those who deliver through the vagina. However, since the TBAs did not have expertise in performing C/S, respondents were of the view that using their outlet was an assurance that one could avoid C/S outcome. An earlier study showed Ghanaian women’s preference for vaginal delivery, 59 but our study highlights the reasons for their preference. An earlier study has shown that women generally prefer vaginal delivery with about 11.6% of C/S deliveries refusing this mode of delivery in developing countries. 60 Low preference for C/S has been reported across the world in a systematic and meta-analysis of observational studies. 61 Per the WHO standards, C/S rates are generally reported to be higher than the expected 5%–15% of all births. 62 C/S rates in Ghana have been reported to vary between 3.3 in rural poor women to 10.8 in urban richer women. A study conducted at the University of Cape Coast Teaching Hospital found a C/S rate of 26.9%. 63 Though there is inconsistency in the rate of C/S, it is clear the rates are relatively high. Moving forward there is, therefore, the need to do case reviews of C/S conducted in different hospitals to inform policy.

Limitations of the study

Even though this study provides useful insights and reasons for the continuous patronage of the services of the TBAs, it is important to note a few limitations. One weakness in qualitative studies is the inability to generalize the findings. 27 Nonetheless, we employed maximum variation sampling technique involving women from different communities and TBAs operating at different locations to strengthen the findings of the study while increasing the credibility, dependability, and trustworthiness 64 of the evidence from the study.

In addition, some of the interviews were conducted in the local languages and translated into English, hence some words could have lost their original meanings as a result of the translation. To minimize the effects of possible distortions due to translations, each translation was done by two people and the research team reviewed the translations from the local languages. Nevertheless, given the limitations of such a procedure, little weight was placed on the specific wording or phrasing of responses but on the overarching themes from the data.

The study concludes that health managers should go beyond reducing financial and geographical access to improving the quality of care and birth experience of women. Financial and geographical access is necessary but not sufficient to guarantee skilled delivery. Quality of care is necessary to complement the efforts at increasing the availability of health facilities and free delivery services. Accepting harmless social practices during labour will improve trust and cater for community’s worldview about childbirth.

Supplemental Material

Acknowledgments.

We thank all study participants for accepting to be part of the study.

Author contributions: P.T.-N.T. was involved in the conceptualization, methodology, data collection, formal analysis, and writing – original draft of the article. J.M.K. also was involved in the conceptualization of the article. J.M.K. and W.W.A. were involved in the methodology, data collection, writing – review and editing of the article.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material: Supplemental material for this article is available online.

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Establishing partnership with traditional birth attendants for improved maternal and newborn health: a review of factors influencing implementation

Affiliations.

• 1 Department of Social Sciences, Oxford Brookes University, Oxford, OX3 0BP, UK. [email protected].
• 2 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, L3 5QA, Liverpool, UK.
• PMID: 29052533
• PMCID: PMC5649078
• DOI: 10.1186/s12884-017-1534-y

Background: Recent World Health Organization recommendations recognize the important role Traditional Birth Attendants (TBAs) can play in supporting the health of women and newborns. This paper provides an analysis of key factors that affect the implementation of interventions to develop partnerships with TBAs to promote improved access to skilled care at birth.

Methods: We conducted a secondary analysis of 20 papers identified through two systematic reviews that examined the effectiveness of interventions to find new roles for TBAs on maternal and newborn health outcomes, as well as papers identified through a systematic mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and implementation barriers and facilitators, as well as other contextual issues.

Results: This analysis identified countries that have implemented interventions to support the transition from birth with a TBA to birth with a skilled birth attendant. Drawing on the experiences of these countries, the analysis highlights factors that are important to consider when designing and implementing such interventions. Barriers to implementation included resistance to change in more traditional communities, negative attitudes between TBAs and skilled attendants and TBAs concerns about the financial implications of assuming new roles. Facilitating factors included stakeholder involvement in devising and implementing interventions, knowledge sharing between TBAs and skilled birth attendants, and formalised roles and responsibilities and remuneration for TBAs.

Conclusions: The implementation barriers identified in this analysis could, if not addressed, prevent or discourage TBAs from carrying out newly defined roles supporting women in pregnancy and childbirth and linking them to the formal health system. This paper also identifies the factors that seem critical to success, which new programmes could consider adopting from the outset. In most cases a multi-faceted approach is needed to prepare TBAs and others for new roles, including the training of TBAs to strengthen their knowledge and skills to enable them to be able to assume new roles, alongside the sensitization of healthcare providers, communities, women and their families. Further research is required to map the transition process and stakeholder experiences in more detailed ways and to provide longer-term monitoring of existing interventions.

Keywords: Implementation; Maternal health; New roles; Newborn health; Partnership; Traditional birth attendant (TBA).

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The authors declare that they have no competing interests.

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