Formal health facilities are often inaccessible. For some people, the closest health centre is 30 kilometres away and entirely unreachable in the rainy season. For others, the costs of healthcare are too high. For the women that do manage to get to a healthcare centre, they often find it to be dysfunctional, with some facilities having no skilled staff. In Chad, the odds are against you. Some pregnant women do not have access to a delivery kit they wash with after the birth.
According to Souat Ahmat Ramadan, a Chadian midwife: “A traditional birth attendant usually doesn’t have the training or the tools. She delivers the baby on the ground in the woman’s house. With a razor blade, she cuts the umbilical cord without disinfectant. She closes the cord with woollen strings or anything she can find.” [Image: Noor Cornelissen].
Introducing Traditional Birth Attendants
After listening to the struggles women in the communities of Sila face, our Doctors Without Borders (MSF) teams collaborated with them to pilot a traditional birth attendants (TBAs) project to try address some of the most urgent needs. TBAs are women, usually between the ages of 25 and 60, who provide help with childbirth, breastfeeding and other related matters.
The World Health Organization (WHO) estimates that community health workers in maternal health roles fulfil 17 trillion dollars’ worth of healthcare services a year. They are mostly women, almost always unpaid.
According to UNICEF, in Chad, only two out of five births take place in the presence of a skilled birth attendant such as a midwife or doctor. In the Koukou district in Sila province, only three out of 11 health centres have a skilled birth attendant. And as health centres are inaccessible to many, it is clear that TBAs have an invaluable role to play.
Each village elected a TBA to participate in our project. Most TBAs have had no formal education in midwifery; they are simply courageous women who have delivered children themselves after their mothers or grandmothers showed them how.
Souat Ahmat Ramadan, a Chadian midwife, explains, “A traditional birth attendant usually doesn’t have the training or the tools. She delivers the baby on the ground in the woman’s house. With a razor blade, she cuts the umbilical cord without disinfectant. She closes the cord with woollen strings or anything she can find.”
For the 31 elected TBAs, MSF designed a training programme to sharpen their skills in areas like recognising the signs of danger before, during and after a delivery.
Results from the project
After a few months, the first signs of impact are clear. Antenatal care consultations have increased substantially along with referrals to health centres for complicated deliveries. TBAs also report that their skills and confidence are growing.
“This is a worthwhile project. After decades of working in this field, I have not yet worked with such an approach,” says Augustine Nsiloulou, an MSF midwife activity manager in Chad. “We face big challenges. None of the TBAs can read or write. We are limited in what they and we can do. But this approach is sustainable.”
“We listened to the communities, and it led us to a new path,” says Noor Cornelissen, MSF project coordinator. “We are aware that our approach requires careful evaluation and needs to be accompanied by an advocacy strategy targeting structural public health deficits. In the future, MSF would like to train the TBAs on community pre-natal care, sexual violence, family planning and other topics.”
