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African Health Sciences
Makerere University Medical School
ISSN: 1680-6905 EISSN: 1729-0503
Vol. 10, Num. 1, 2010, pp. 75-81
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African Health Sciences, Vol. 10, No. 1, March, 2010, pp. 75-81
Referral practices and perceived barriers to timely obstetric
care among Ugandan traditional birth attendants (TBA)
Keri L1, Kaye
D2, Sibylle K 1
1 Department of Epidemiology, University of Alabama at Birmingham [UAB],
USA 2 Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
* Corresponding author: Keri Lawrence, UAB, Department of Epidemiology, RPHB, 1530, 3rd Ave South Birmingham AL
35294-0022 Email: keri.deanna.lawrence@uab.edu Phone: 423-653-9967 Fax: 205-934-7154
Code Number: hs10014
Abstract
Objectives: To assess current beliefs, knowledge and practices of Ugandan traditional birth attendants (TBAs) and
their pregnant patients regarding referral of obstructed labors and fistula cases.
Methods: Six focus groups were held in rural areas surrounding Kampala, the capital city of Uganda.
Results: While TBAs, particularly those with previous training, appear willing to refer problematic pregnancies and
labors, more serious problems exist that could lessen any positive effects of training. These problems include reported abuse
by doctors and nurses, and seeing fistula as a disease caused by hospitals.
Conclusions: Training of TBAs can be helpful to standardize knowledge about and encourage timely emergency
obstetric referrals, as well as increase knowledge about the causes and preventions of obstetric fistula. However, for full
efficacy, trainingmust be accompanied by greater collaboration between biomedical and traditional health personnel, and
increased infrastructure to prevent mistreatment of pregnant patients by medical staff.
Key words: Obstetric fistula, Uganda, TBA, qualitative methods, training
Introduction
Obstetric fistula (OF) is an unnatural hole
between the birth canal and the bladder and/or the
rectum, causing fecal and urinary incontinence, as well as
a host of other physical ailments, labeled the
"obstetric fistula complex"1. In rural Uganda, OF is
usually caused by obstetric trauma, particularly
unrelieved obstructed labor, where the pressure of the
fetal head on the area around the birth canal causes
loss of circulation to these delicate tissues, which
later die and rot away2. Fistula rates are highest in
areas where women are married very young
(sometimes before menarche), where women are small and
thin because of malnutrition, illness or genetics, or
where women have little or no bargaining power in
financial or health care decisions3,4. This injury can
be prevented by recognition of potentially
obstructed labors and trained medical assistance before,
during, or directly after an obstructed
labor5. In East Africa, fistula surgeries have a 75% cure rate, although
up to 80% of women with fistula never seek
treatment, primarily because of lack of knowledge of
such surgery or of the location of fistula
clinics1,8.
Rural Sub-Saharan Africa currently stands as the location of the highest obstetric fistula
prevalence globally2. The incidence of obstetric fistula in
this region has been estimated to be about 124 cases
per 100,000 deliveries2. The incidence rate could be
as high as 200 500 cases per 100,000 deliveries in
the most rural areas4. The UNPF and Engender
Health Organization estimate that 2 million women are
living with O.F. worldwide, most of them in
Sub-Saharan Africa. This estimate is generally regarded a
great underestimation, due to the problematic
collection of epidemiological data in rural areas, which
are usually the areas of highest
incidence6. The lifetime risk that a women will die as a direct result
of complications during pregnancy and delivery in
Africa is estimated at 1:16 mothers compared to 1 in
8700, in North America or Europe7.
Uganda specifically has a very high
maternal mortality rate (880/100,000) 8.
Around 80% of Uganda is considered rural, where there is little
or no access to emergency obstetric
care9. Around 60% of childbirth is handled by traditional birth
attendants (TBA), relatives, and
friends9, although only 20% of births to mothers with little education or money
were attended by a trained or skilled birth
attendant8. With 80% of the population below the poverty line,
and a female literacy rate of roughly
59%1, many rural Ugandan women are either ignorant about
proper maternal care, or are unable to visit a hospital
during an obstructed labor due to poverty.
A vital tool in fighting fistula in sub-Saharan
Africa is the traditional birth attendant, as they
outnumber biomedical health practitioners by a
hundred-fold or more10. Previous studies of TBA
practices, knowledge and beliefs showed high rates
of dangerous vaginal cutting (which can lead to
fistula) and lack of knowledge of when obstructed
or dangerous labors should be referred to nearby
health clinics, as well as low rates of referral in
practice2-4. This study used qualitative focus groups
with Ugandan traditional birth attendants to
research current beliefs, knowledge and practices of
TBAs and their pregnant patients regarding referral
of obstructed labors and fistula cases. This study
also researched existing barriers to a quality
recognition and referral system, and suggested interventions
that may increase referral occurrence and efficacy.
Methods
Study setting
Our study was held in the Wakiso and
Mukono Districts, which surround Ugandan's capital city
of Kampala. Wakiso District, the second largest
district in Uganda, has a population of 950,000 people
and lies to the west of Kampala. Mukono District lies
to the east of Kampala and has a population of
808,000 (according to the 2002 census). These districts
are primarily rural outside of the Kampala city
limits. These areas were chosen because of their
proximity to Mulago Hospital in Kampala, where
emergency obstetric cases could be referred.
Study design
Qualitative methods were used in this study
to capture and understand beliefs, attitudes and practices of birth attendants about referral
of obstetric cases. We also were interested in the
attitudes and opinions of birth attendants' pregnant clients
in their community. Using a focus group method allowed participants to engage each other
with examples from their own experience, and is particularly helpful when attempting to discover
and analyze underlying factors that affect
behaviors, beliefs, and motivations11. A focus group guide
was developed that included 27 questions regarding common types of problems seen during
pregnancy and labor, any formal training received,
experiences with obstructed labors and fistula, and their
own referral practice of problematic pregnancies
and labors. These questions attempted to give a
broad qualitative picture of the TBA's recognition
and referrals of labor problems, particularly obstructed labor, and attitudes, knowledge, and practices of TBAs and their clients that may prevent
proper referral of cases that lead to obstetric fistula.
Each TBA was asked to sign a written informed
consent form before the start of the focus group discussion.
Recruitment: TBA participants were recruited
using two local district mobilizers who worked for
the Ugandan government and had some previous organized contact with local TBAs. Mobilizers
invited TBA in their area to attend focus groups and
gave information about the meeting times and
locations of the focus groups.
Data collection
Basic demographic data such as age and number
of years working as a TBA, were collected from
each study participant before the start of each
focus group. All focus groups were held in Luganda,
the local language familiar to all research
participants. The six focus groups, which ranged in size from
5 to 12 participants, were held in secluded
outdoor settings at locations that were central for local
TBAs, including near district administrative offices
and midwife training centers. Study participants
were compensated $3 (5,000 UgS) for travel and
time, and snacks were provided for everyone. The
focus groups lasted about two hours each; they were
tape-recorded with the participants' consent, and conversations were guided using a focus group
guide. Two local research assistants moderated the
focus group discussions and used open ended
questions and probes to encourage all participants to contribute.
Data management and analysis
The resulting data was translated from Luganda
to English and transcribed verbatim using tape
recorded data and supplemented by field notes. Data in
the transcripts was analyzed by weighting data
using several factors. These factors included frequency themes that were commonly mentioned
throughout and between each focus group, specificity comments where specific examples were used to provide
details, emotion comments where participants
exhibited passion, enthusiasm or intensity, and extensiveness how many different people mentioned the
same idea11. After looking at responses to each
question separately, we compared and contrasted
common responses and themes across all areas.
Results
Socio-demographic data
61 TBAs participated in our study. Of these, 27
were from the Wakiso District and 34 from the
Mukono District. All participants were current TBA in
their communities. The length of time they had
spent working as TBA ranged from 1 year to over 50 years. All participants were female, with ages
ranging from 23 to over 80. No participants reported
having any formal medical training as a clinician, nurse
or midwife.
Problems commonly seen during pregnancy
and labor
The participants listed several problems that
they commonly identified among their pregnant
patients. The most common of these included: vomiting,
pain, anemia, malaria, high blood pressure, fever,
vaginal itching and vaginal bleeding. When asked
about problems reported during labor, the two most common were related to obstructed labor.
These were mostly due to poor or breech positioning
of the baby and the mother's pelvis being too
small. Other common problems included "too
much bleeding," the placenta coming too early or not
at all, maternal fever, and umbilical cord around
the fetal neck.
Believed causes of obstructed labor
TBAs were asked what they believed were the
causes of, or the risk factors for delayed or obstructed
labor. The most common responses included young women whose pelvis was too small,
women pregnant with their first child, those with
anemia, those with a genetic history of
problematic pregnancies, and women who did not take
"pelvic bone weakening" herbs.
Referral practices/criteria for referral
When asked about their referral practices,
participants listed a large number of symptoms or situations
in which they would refer pregnant women to health facilities. The most commonly reported
situations included when labor is delayed or contractions
are too far apart or too close together and
contractions occurred without the water breaking.
Other problems in labor that participants saw as
needed to be referred included poorly positioned
fetuses and twins.
Risk factors where birth attendants referred
mothers included when the fetus' head was too big or
the pelvis too small, or when the pregnant woman was very young or pregnant with her first child. Other risk factors listed by participants included
pregnant women with high blood pressure, those who
had had a caesarean section in the past, the epileptic,
the "mad," the lame, and women who have had
many births. Several participants mentioned that
they encouraged their pregnant clients to attend
prenatal sessions at a local health clinic or hospital. One
stated, "We should make sure that the women who
come to us here have attended antenatal at least three
times. At the hospital they will have learnt a lot and this
will ease our work."
Several participants mentioned how they
had been taught in previous trainings to refer if
they sensed any problems. TBAs with some previous training were more likely to suggest referral of
both pregnant women with many risk factors (high
blood pressure, epileptic, previous C-section, etc.)
and women during problematic labors to health
clinics. Some mentioned previous training where
dangerous practices, such as vaginal cutting to relieve
obstructed labor, were discouraged "We were told that
if that part is tightening, get a warm cloth and wet
the place instead of cutting." However, there were
still several mentions of vaginal cutting as a method
to relieve obstructed labor. One older woman said, "Me, I just cut and get out the baby I can't kill
the mother and the baby."
Practices for referring obstructed labors
varied between participants. One TBA said, "We get
them, but only give them two days in labor, if more
than two days, we send them to health centers."
Another said "Me, when I get one at night, I only help
during the night, if by morning she has not delivered, I
refer to the health centre."
Attitudes of local pregnant women
about medical doctors or clinics
Participants were asked about the attitudes of
local pregnant women towards medical doctors or
clinics. Their responses were for the most part, very
negative. Some reported that pregnant patients had experienced verbal and physical abuse from
doctors and nurses. One birth attendant stated, "The
health workers are abusiveand arrogant; they shout
at mothers to go and bring their husbands who made them pregnant." Another said, "They [health
workers] at times slap these mothers, for them they
prefer protecting their jobs than people's lives."
Some referred to nepotism in hospitals - "You find
that the director has recruited only his relatives and these cannot manage the situation most of the time."
Two birth attendants stated that when they took a
mother for delivery at a health center, they themselves
were verbally abused by health workers and the
mother eventually died.
Several participants reported that
pregnant women were unwilling to be referred to health
clinics or hospitals because they were nervous
about learning their HIV status. "We have discovered
that mothers who have been tested and found
positive don't go back to health centers but resort to
TBAs," stated one birth attendants.
A consistent theme among responses was
that pregnant mothers found the care of TBAs to be
of higher quality than at the health center. Some
birth attendants mentioned that they provided some
food and drink for their clients, as well as some
clothes and massages something not provided in
the hospitals. Local pregnant women preferred the personal knowledge and treatment provided by
the TBA, as well as their location in the community
and cheaper price, as compared with hospitals. One
birth attended stated, "Our working relationship with
the mothers is so good, to the extent that when we
refer mothers, they refuse to go."
Other reported barriers of pregnant
women to go to local health clinics include lack of
money, both for surgery and the necessary supplies, such
as gloves, cotton, etc. Women feel shame about a
lack of supplies or clothing such as underwear, and
are unwilling to go to health clinics without these. A
birth attendant said, "A mother came in to deliver in
a skirt and blouse and nothing else for the baby.
Such a situation cannot be tolerated at the health
center." A few participants mentioned that husbands
of expectant mothers were not willing to give
their wives the money for health clinics or the
supplies they needed, and sent them to birth attendants
to save money. One focus group agreed that when referring complicated cases, transportation was a
big problem, particularly making husbands pay for transportation.
Believed causes of obstetric fistula
Almost all TBAs personally knew someone who
had had a fistula; interestingly, most TBAs saw
obstetric surgery or labor at the hospital as one of the
primary causes of obstetric fistula, rather than a means
to prevent fistula. One participant said that
"Most people {who go to hospitals for labor} get
scratched on the bladder in hospitals and that result in
fistula (at times the baby dies)." Another said, when asked about what she believed was the cause of fistula, "At times, we the TBAs delay some mothers.
But even the doctors take long to operate the
mothers and it has been found that most women who go
to the [surgical] theater end up failing to hold
urine." One participant stated, "[Fistula] usually happens
to women who deliver from health centers," and
said it was due to the use of metal forceps to pull
out the baby, and nurses' carelessness, particularly
those with long fingernails. Another said that fistula
"usually happens to women who deliver in hospitals and
are operated."
The second most common believed cause
of fistula was pregnant women having full bladders during labor. Several mentioned cases they knew
of full bladders or rectums being pushed against
during birth, which resulted in a tear and urinary and
fecal incontinence. One participant said, "As a TBA, it
is our responsibility to encourage mothers to pass
out urine most of the times during labor."
Another referred to a previous training where she was
taught to "endeavor to have the bladder and rectum
[of their pregnant clients] emptied."
Other common believed causes of
fistula included the long nails of birth attendants,
and someone assisting the birth without gloves,
resulting in an injured bladder. Participants also believed
that large babies can cause problems. "When a
woman has a big baby and in case of failure to push,
they are usually forced out, and the baby can injure
the bladder," stated one participant.
Beliefs about whether fistula can be fixed
Participants had mixed responses about
whether fistula could be fixed or healed. Some mentioned
a quick referral to a hospital as a way to prevent or
fix fistula. Others mentioned a radio ad for the
fistula clinic at Mulago Hospital in Kampala. About
half of participants who spoke about the clinic at
Mulago said that they knew people who went and were
not helped. One woman noted that the cost of
fistula surgery at Mulago was 60,000 USh (~$40), a
large price for many rural women. A few
participants mentioned alternative methods, including prayers
and herbs, as having healed fistula in the past.
Most participants said that they were unsure
whether fistula could be healed, partially because they
didn't see enough cases in their communities to know
for sure.
Interest in future training sessions for TBAs
All participants in our study expressed a strong
interest in receiving more skills training. Reasons for
their interest included desiring to renew their memory
of techniques, desiring to learn new things, such as
how to deal with fistula, HIV, and lack of spousal
support during pregnancy, and needing to know what
to teach the mothers in their community. Birth attendants also wanted to learn more
modern methods and skills and learn from other
birth attendants.
When asked what methods of training they
would find acceptable and helpful, participants
mentioned training that was facilitated with
transportation, organized at the parish or sub-county level
(versus the district level), and training that is very
hands-on and practice oriented (versus lectures).
Several attendants wanted the chance for clinical
observation and practice at local health centers, and
several mentioned certificates and community
recognition at the end of training.
Other requests by participants included
more supplies, as scales, bikes for transportation,
gloves and other tools for assisting labors in a clean
manner. Because attendants can spend some time
without any clients, they asked for some kind of
consistent financial support from the government. In
addition to community wide recognition after training,
several birth attendants in our study mentioned
wanting improved relationships between medical
personnel and birth attendants. One stated, "If we can
be helped here at the health center and the
midwife cooperates with us it would save many lives."
Discussion
One of the most important findings of our
study was the verbal and physical abuse reportedly
suffered by both TBAs and pregnant women at the
hands of local doctors and nurses. Other serious
problems reported by this study included health
personnel negligence and inexperienced care. Another
study in the Wakiso District reportedthat pregnant adolescents found health workers harsh and
abusive, and used blame and
intimidation12. After experiencing such negative treatment, the pregnant teenagers
were more likely to avoid health services, and sought
care instead from untrained TBAs12. A study set in
the Rakai district of Uganda reported that
pregnant women found midwives or health workers at
public hospitals or clinics sometime "rude, proud,
negligent and vulgar," and sometimes verbally abusive
of pregnant women, while in comparison TBAs were reportedly much kinder and flexible about
payment13. Clearly, these factors might
discourage pregnant women from visiting a health care
facility, and could potentially be the last straw for a
woman already dealing with day-to day difficulties such
as high cost of transportation, lack of supplies,
lack of finances, lack of food, and lack of
spousal support.
However, Amooti-Kaguna and
Nuwanda found that pregnant women in their study saw
health care workers as more knowledgeable about how
to deal with problematic pregnancies and
labor13. The pregnant women in this study also
reported problems with the quality of care offered by
TBAs, such as late referrals, lack of knowledge about
how to deal with some deliveries, and the
development of fistula after being assisted by some
TBAs13. These views, which would not have been reported by
the TBAs in our study, also play an important role in
a pregnant woman's decision about where to deliver her child.
Our research found that another
major detractor to proper referral practices to
prevent fistula is the TBA's belief that hospital deliveries
were one of the primary causes of obstetric fistula,
rather than a means to prevent them. These beliefs
and perceptions are a significant barrier to TBAs
naturally encouraging timely referrals, and could
potentially exacerbate already present tendencies to deliver
high-risk cases themselves. Naturally, these beliefs
would also have a strong negative role in pregnant
women's desire to be referred to clinics or hospitals, and
their subsequent compliance with referrals.
In this same line, of the TBAs that
mentioned that fistulas could be healed at the local
hospital, about half mentioned that they had known
women with fistula who had not been helped at these
"fistula clinics". This lack of confidence in the
established system could significantly discourage
women suffering from fistula from seeking curative care
at the local hospital, particularly in the light of
other existing barriers such as lack of transportation
and money for fistula curative surgery.
Even in light of these negative attitudes
and beliefs about the Ugandan health care system,
the majority of our participants seemed very willing
to refer cases they felt were too high-risk or
challenging to manage. Our TBA study participants
appeared to have a fairly good and broad understanding
of when pregnancies or labors were high-risk. This
is compelling in light of the fact that our participants seemed relatively willing to admit areas in which
they lacked knowledge.
The focus group design proved to be
strength for our study because participants, who were
all TBAs, felt comfortable to share their
impressions and attitudes about this particular topic. It has
been shown that people in focus groups are more
willing to disclose information or feelings when they
are with others who have something in
common11. Our study had a 100% participation rate, and
this eagerness translated into a high willingness
among TBAs to talk, as well as a large amount of
enthusiasm about the study.
However, within the focus group design,
there remain several negative factors that could
detract from the validity of our findings. When
one participant's opinion or role isoverwhelming,
other participants may not have enough time to speak,
or may be swayed or biased into changing their
opinion11 . Our study attempted to counteract this situation
by using research assistants who had not only
worked with TBAs previously, but also had
experience moderating large focus groups of birth
attendants. Secondly, there was a potential that the presence
of the American researcher would distort answers,
if participants felt that there were certain answers
they were expected to give. To ensure that this was not
a confounder, the researcher did not attend one
focus group, and there no difference was found in
the results from this group. Finally, as some of our
focus groups contained more than 10 TBAs, there
was the possibility that not all participants had
enough time to express their opinions. This risk
was controlled for by holding the focus group for
over two hours, thus allowing enough time for
everyone to speak. As with all research methods based in
self-reporting of practices, there was the risk
that participants were not honest about what their
true activities were.
In conclusion, our study found that
TBA training about referral is helpful, particularly
for standardizing knowledge about what is
considered a high risk pregnancy or labor, and under
which circumstances and time periods to refer
pregnant women. These results agree with a recent
meta-analysis about the efficacy of TBA
training14,15. This study by Sibley and Sipe showed that
training produced small yet significant increases in
women's use of antenatal care and emergency obstetric
care16.
However, our results also showed that
there are larger and more serious health care
problems that could potentially lessen or even neutralize any positive effects due to TBA training. These
include abuse of patients and TBAs by health care
personnel, and lack of infrastructure to ensure quality and
timely treatment of emergency obstetric cases.
To ensure that the full positive effects of
TBA training on referral rates are reached, a holistic
focus should be on developing more collaboration between TBAs and biomedical health
professionals with the ultimate goal of reducing maternal and
child mortality. A study from rural Cambodia shows
that training of traditional health workers is most
effective when included in a "chain of survival"
of complicated deliveries, which included not only TBAs, but also midwives, paramedics, and
the existing emergency obstetric network at nearby hospitals or health care
clinics17. This method treats each rural delivery as a potential trauma, and
merges midwives and TBAs with an already present
and successful rural trauma rescue system.
References
- United Nations Population Fund
and EngenderHealth. Obstetric fistula needs assessment report: Findings from nine
African countries. 2003. Available at http://www.unfpa.org/fistula/docs. Accessed October 10, 2006.
- Lewis G, de Bernis L. Obstetric fistula:
Guiding Principles for clinical management and programme development. WHO Integrated Management of Pregnancy and
Childbirth. 2006. Available at http://www.who.int/making_pregnancy_safer/publications
/obstetric_fistula.pdf. Accessed October 2, 2006.
- Wall LL, Karshima JA, Kirschner
C, Arrowsmith SD. The Obstetric Vesicovaginal Fistula: Characteristics of 899 patients from
Jos, Nigeria. American Journal of Obstetrics
and Gynecology 2004; 190: 1011-9.
- Donnay F, Ramsey K. Eliminating
obstetric fistula: Progress in partnerships. International Journal of Gynecology and Obstetrics 2006; 94: 254-261.
- Miller S, Lester F, Webster M, Cowan
B. Obstetric Fistula: A Preventable Tragedy. Journal of Midwifery & Women's Health 2005; 50: 4.
- Lassey AT, Ghosh TS. Vesico-vaginal fistula
in Ghana. Unpublished report for the Ministry
of Health of Ghana and non-governmental organizations interested in the care of women in Ghana. 1993.
- Walley RL, Kelly J, Matthews KM,
Pilkington B. Obstetric fistulae: A practical review. Reviews in Gynaecological Practice 2004; 4: 73-81.
- World Health Organization. Core
Health Indicators for Uganda. 2004. Available at
http://www3.who.int/whosis/core/core_select_process.cfm. Accessed November 11, 2006.
- Koomson G. Telemedicine in rural
Uganda. Africa Recovery Online 1999; 13: 4.
- Homsy J, King R, Balaba D, and Kabatesi D.
Traditional health practitioners are key to
scaling up comprehensive care for HIV/AIDS in sub-Saharan Africa. AIDS 2004; 18: 1723-1725.
- Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. California: Sage Publications, Inc; 2000.
- Atuyambe L, Mirembe F, Johanasson
A, Kirumira E, Faxelid E. Experiences of pregnant adolescents voices from
Wakiso district, Uganda. African Health
Sciences 2005; 5: 304-309.
- Amooti-Kaguna, B ,Nuwaha F.
Factors influencing choice of delivery sites in Rakai district of Uganda. Social Science and
Medicine 2000; 50: 203-213.
- Akpala CO. An evaluation of the
knowledge and practices of trained traditional birth
attendants in Bodinga, Sokoto State, Nigeria. Tropical Medicine and Hygiene 1994; 97: 46-50.
- de Vaate A, Coleman R, Manneh H,
Walraven G. Knowledge, attitudes and practices of trained traditional birth attendants in
the Gambia in the prevention, recognition and management of postpartum
hemorrhage. Midwifery 2002; 18: 3-11.
- Sibley LM, Sipe, TA. Transition to Skilled
Birth Attendance: Is There a Future Role for
Trained Traditional Birth Attendants? Journal of
Health, Population and Nutrition 2006; 24: 472-478.
- Chandy H, MidwifCert, Steinholt
M, Husum, H. Delivery Life Support: A preliminary report on the chain of survival
for complicated deliveries in rural Cambodia. Nursing and Health Sciences 2007; 9: 263-269.
- Holme A, Breen M, MacArthur C.
Obstetric fistulae: a study of women managed at
the Monze Mission Hospital, Zambia. BJOG. 2007;114:1010-1017.
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