Traditional Birth Attendants in Sierra Leone

Traditional Birth Attendants (TBAs) are very popular and influential in rural communities in Sierra Leone. According to Health Poverty Action, in 2008 45% of women in Sierra Leone gave birth with a TBA and in rural areas 77% of women gave birth at home without a skilled birth attendant. This is partly due to socio-cultural reasons but also because of severe shortages of skilled health workers within the public health system. However, without the necessary skills, TBAs can constitute medical risks, particularly during childbirth.In 2010, the Sierra Leonean Government announced that it was illegal for TBAs to assist with deliveries. Many communities have established by-laws so that if a woman delivers at home, the TBA, the woman and her husband are all fined.  Nevertheless, many TBAs continue to practice. The same year, the Government also announced the Free Health Care Initiative (FHCI) which abolished health care costs for pregnant and lactating women as well as children under-five years of age. As a direct result, many more women and children now come to health centers. Although, in principle, this is a positive scenario, there remain challenges for many facilities to be equipped and resourced and able to provide an adequate standard of care. For this reason, currently there is a renewed interest in working with Community Health Workers (CHWs) as potential important actors in bridging the human resource gap, by task shifting, and improving the reach of health services, particularly towards achieving maternal and child mortality related MDGs. It has been estimated that that 41–72% of newborn deaths could be prevented by available interventions, if provided at high coverage, and around half of this reduction would be possible with community based interventions.Within this context, on 28th May 2013, Catholic Relief Services and Concern Worldwide organised a symposium titled “Exploring Roles of Traditional Birth Attendants in Sierra Leone in a Changing Policy Context”. The purpose of the symposium was to review the various interventions targeting TBAs in Sierra Leone and identify good practices portraying the potential of TBAs in the context of the Free Health Care initiative and the newly validated Community Health Worker’s Policy. The symposium brought together high level Ministry of Health and Sanitation (MoHS) personnel including the MoHS Deputy Minister, Chief and Deputy Medical Officers and Director of Reproductive Health, UN Agencies (UNICEF, UNFPA), international NGOs and TBA representatives from the districts.Discussions focused on redefining the role of TBAs on the basis of shared experiences from a range of organizations, which – since the launch of the FHCI - have started re-engaging TBAs by training them in non-delivery community-based roles and simultaneously strengthening relationships between TBAs and Primary Health Unit (PHU) staff. The forum recognized that TBAs are influential and could contribute to better health outcomes. This was reiterated by the Deputy Minister of Health and Sanitation,according to whom the forum should look at best practices within Sierra Leone and other countries when drawing recommendations and conclusions. The Deputy Minister also encouraged participants to deliberate on three critical focus areas for TBAs:

• training for TBAs,
• incentives and
• monitoring and supervision of TBA activities.

According to the Deputy Minister, the redefined roles of TBAs should be aligned with the forthcoming Community Health Workers’ Policy. Due to the role they can play in health promotion to improve health status and access to care, CHWs are an essential part of the continuum of care from the community to the health facility. However, CHWs do not replace the need for quality health care delivery through highly skilled health care workers. Their role should be complementary, intended as a potential link between the community and the formal health system. Amongst CHWs, TBAs are particularly well-placed given the existing trust and status they have within communities.By leveraging these assets, MamaYe believes that this network of respected individuals has the potential to significantly add value to any intervention targeting pregnant women and mothers of young babies, encouraging them to access clinics and building on their existing function in the community but without being involved in a delivery function.