Traditional Birth Attendants: Are we burying our heads in the sand?

Traditional Birth Attendants: Are we burying our heads in the sand?

Doris KwesigaOne of the major global health issues currently under discussion is the high rate of preterm births, whose complications are responsible for many of the deaths among newborn babies. The situation is worse in developing countries like Uganda, where an estimated 226,000 babies are born preterm each year. About 38% of the nation’s 39,000 annual newborn deaths are linked to prematurity difficulties.

With the 2016 Uganda Demographic and Health Survey showing barely any change in the neonatal mortality rate in the country (death within the first month of life), it is important to think about the key providers of care for mothers and babies within this critical time. A critical group in Uganda are the Traditional Birth Attendants (TBAs). These are women who provide assistance to mothers during delivery (as well as before and after). They often work from their own homes or may go to the home of the mother. TBAs in Uganda are rarely qualified health workers, but rather tend to have learned their skills as apprentices to their mothers or other TBAs. Previously, when they were still formally recognised by the Government, a number of them were trained by the government and other non-governmental organisations and given knowledge and a toolbox to help them carry out safer deliveries, understand the basics of newborn care, refer mothers in trouble, etcetera. However, the Government later “banned” them and is focused on encouraging health facility deliveries.

Nevertheless, many women continue to deliver with the help of TBAs, rather than go to health facilities, especially in the rural areas. While conducting research on Kangaroo Mother Care (KMC) in Busoga region in December 2016, we had the opportunity to visit various TBAs. All of them continue to conduct deliveries, albeit “under cover”. For example, one TBA had conducted 77 deliveries at her home in the month of November 2016, and by mid-December she had already done 24 (with 3 women waiting to deliver on the day we visited). This TBA lives very close to a health center IV and a hospital. Therefore, they are an important group in the provision of not only maternal, but also newborn care. The discussions we had with the TBAs revolved around their care for preterms and KMC. Some of what we learned includes:

  • All of them could identify a preterm baby at birth, using different signs like the appearance of the skin, their crying, breathing, etc
  • Some of the older TBAs were part of the group earlier trained, so they had some basic knowledge on caring for preterms. However, the knowledge on preterm care was mostly inadequate, outdated, or totally wrong for all of them. A few mentioned the need to keep the baby warm, wrap it up and not bathe it, observe strict hygiene, as well as to refer them to hospital immediately. On the other hand, others stated that they cared for them by keeping preterms in cotton wool, rubbing oil on them, mixing milk with hot water to feed the baby, and other practices. Although a few mentioned the need for “skin-to skin” care, they said that a cloth must first be put on the mother, with no direct contact between her and the baby.
  • None of the TBAs had heard about KMC. Only one had seen it being practiced when she followed up one of the mothers she had referred to hospital and found her doing it.
  • They mentioned the fear to ask health workers out rightly about any challenges they had, because of animosity between the two groups since TBAs continue to operate “illegally.”

What we do…..what I do as a person….I am meant to be with a hot water bottle-  they are the ones that  keep the baby warm so that they are well. I also have my cotton wool, I first put on that baby after mopping it very well. I first put cotton wool on the body, then wrap the baby very well in its baby cloth… I tell them to bring a towel, wrap the jerry cans [of hot water] which I put on both sides, then it sleeps in the middle…(One of the TBAs describing how to look after a preterm)

Such emerging gaps in knowledge lead to incorrect practices that could be partly responsible for the stagnant number of neonatal deaths in the country.

TBA Maternity Ward_Jinja copyRather than burying our heads in the sand about TBAs, pretending that they are not working, I suggest that we find a middle ground for the meantime, which could play a role in improving care for preterms (and indeed all newborns). Most of the TBAs we spoke to were eager to learn about KMC and how to ensure that mothers practiced it. Infact, some of them wanted to start telling mothers with preterms to do it as soon as they got one, basing on the basic information they had received from the interviewers. Therefore, training them on proper newborn care and recognition of danger signs, as well as the need to refer such cases could be one of the avenues by which we can improve their knowledge and skills to the advantage of mothers and babies. Furthermore, mothers and all community members need to be taught beforehand about caring for preterms through practices like KMC, so that if they get a preterm baby they are not taken by surprise.

At the same time, we should continue to sensitise mothers about the importance of giving birth in health facilities, with skilled health workers, but also improve on the quality of care that these facilities offer. We need a holistic approach that includes everybody involved in the child birth and newborn care process.

***Blog by Doris Kwesiga, a Researcher at Makerere University School of Public Health.


  • Thank you, Doris, for this blog. Actually, the estimated proportion of Low Birth weight babies is 11-14%. Moreover, an estimated proportion of newborns (22%) do not always have their weight was taken, which is closer to the births of unskilled assistance. Besides, we know what happens at the health facilities in terms of quality maternal and newborn services. In fact, looking at the picture you have provided, it seems this TBA is more organized than some of the facilities in addition to the good client relationship, trust they already have with the community. In some of the studies, we have not seen any newborn difference between facility and community delivery. Of course, there are many reasons ranging from demand and supply side challenges.
    Over to you Doris, do you think the TBAs should be given basic skills contrary to the government position?

    Kananura Reply
    • Thanks Kananura, a lot of good information you give there. Good client relationship is one of the reasons the TBA gave for many mothers coming to her to deliver. This TBA is organised, she weighs the babies and records their weight and state. However, in some cases she writes ‘good’ and yet the baby is of low birth weight. Nevertheless, most of the TBAs we met were passionate about the mothers and keen to learn new things. I therefore agree that we should look at them as partners and give them basic skills, so they know things like who a low birth weight baby actually is and the fact that they may need to refer them. Let us utilize this opportunity. We should not ‘throw out the baby with the bath water’.

      Doris Reply
  • Dear Doris, thank you so much for this interesting blog! I have been visiting Uganda since 2005, did fieldwork for my PhD here, within ethnobotany, and have taken part in several community Projects together With local collegues, mainly in Mbarara District. Among others we have been working on nutrition, mother and child Health. Late 2016 and early 2017 we were running a training progrm in Mother and Child Health Care for voluntary Health workers in Nyakayojo division of Mbarara. TBAs, Village Health teams and local leaders were invited. In forehand we had had searched for advice from Dr. Mihayo Placid at MOH, who told us it was OK to give training following the program for Village Health Teams. The training was faciitated by Bishop Stuart University, Mbarara, and in cooperaton With the District Health Authorities, Health center and hospital. The trainers were mainly midwifes and doctors. 69 persons (TBAs, VHTs, LC1s) got a 4 day training which included danger signs during pregnancy, delivery and newborns. All the participants were happy about the training. So it is possible to give training to TBAs, as long as you Train them to become VHT. I agree With you; to improve situation for pregnant and delivering mothers and newborns, training should be given to TBAs!

    Torunn Stangeland Reply

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