Report of TBA Training 5th
and 6th August 2014 in Bulati
Introduction
This
training was planned by WTWT in response to a request from the Traditional
Birth Attendants (TBAs) in Nainokanoka ward, Ngorongoro Conservation Area,
Tanzania. In this area there is severe poverty and hardship exacerbated by
restrictive Conservation Area practice leading to human rights abuses such as
insufficient food due to the banning of practicing agriculture.
It was given
by Dr. Shemaghembe (Medical Officer for Nainokanoka, Alailelai and Naiyobi
wards) Nurse/Midwife Peeiyo (working in the Nainokanoka Health Centre) and
myself, Rachel Blackmore (Midwife from the UK and director of WTWT), with
introductions, conclusions and some translating by and Ponja Tayai and Embapa
Runguna (Tanzanian co-ordinators and employees of WTWT). It was funded by WTWT
UK.
The training
was a two day programme, run twice during the week 5th- 8th
August. It was initially planned for 70 TBA participants in two groups of 35.
The 70 were made up from 5 TBAs from each of the 13 sub villages in Nainokanoka
ward. One training was to be held in Bulati village primary school and the
other in Nainokanoka village primary school. In the event extra TBAs came to
both sessions, so we trained 109 in all. This report covers the training in
Bulati, which was repeated on 7th and 8th August in
Nainokanoka.
Day One 5th August
We staff, with
12 women from Irkeepusi and Nainokanoka villages, travelled by landrover to
Bulati to join another 43 TBAs from Bulati village, more than expected, but all
were welcomed.
We were met and
greeted by the Bulati TBAs with singing, dancing and prayers. All participants
joined in with this during the walk to the classroom.
11:00 Tea and
chapattis were served before the training began and we set up the equipment to
show short films.
11:30 Embapa
opened the training with a prayer, and then we all introduced ourselves.
I (Rachel) welcomed
everyone and Embapa translated:
I said that
I was really pleased that the TBAs had asked for training and that as a midwife
was very happy to be sharing in this with them.
Firstly I
invited them all to give themselves a clap for all the good care they give to
women and babies and for requesting this training. This was received
enthusiastically with all of us clapping.
Then I said
how much I was looking forward to this training, to hearing about their experiences
and ways of practicing. I explained that we wanted them to feel comfortable to
share their experiences and ask questions, so that we could all learn from each
other.
They would
then work out together things they could do to improve the situation themselves
for women and babies. They would be realistic things that they would be able to
afford, or that could be funded.
We would
look at aspects of how bodies work, the help of the films and models, to help
understand why some things are helpful and others are not.
I suggested
the following timetable with flexibility according to how discussions went
Timetable
Day one:
General health and antenatal care
Day two:
Care in labour, delivery and the postnatal period.
A TBA participating
Day
One:
I asked them why they had asked for training. A woman answered that
they knew the traditional ways of doing things but wanted to know the modern
ways.
Antenatal care
I then asked
them why they thought women had problems or died in childbirth. They answered
that women didn't go to clinic and so had diseases that they didn't know about.
I thought this was a good answer, and it gave the opportunity to talk about
diseases and other things which cause problems which can be detected antenatally
and treated, or where delivery needs to be in hospital, such as: anaemia,
preeclampsia, infections, bleeding and malpresentations.
This was a
good lead into two of the films I had brought (Medical Aid Films) ‘Focused
Antenatal Care’ and ‘Warning Signs in Pregnancy’, set in Africa. The
Nurse/Midwife translated them into Maa as they went along and I paused them
when necessary.
Film: Focussed antenatal care
The TBAs
said they found the films helpful in explaining things that could cause
problems and what to look out for. One asked why bleeding occurred antenatally.
I used the doll pelvis and placenta to show visually the different positions
that the placenta could be and how it was a big problem if it lay across the
opening to the uterus. I also showed how sometimes bleeding could come from the
edge of the placenta.
They were
aware of the common problems which arise antenatally, for example headaches,
bleeding, infections and anaemia. When women had headaches first they encourage
the women to drink a lot and take traditional medicine. They admitted that it
doesn’t work and that they then refer them. Now they will refer straight away.
Dr. Shemaghembe advised them not to use traditional medicine during pregnancy
and childbirth, but to refer for problems.
The film covered
signs of infection such as fever and offensive vaginal discharge and stressed
that it was very important to go for treatment in these cases. The pictures
were very clear with diagrams of smelling discharge and women shaking, with a
faster heart beat, sweating and looking hot. The TBAs said they do refer women
to the medical centre for this.
We spoke
about too much fluid, polyhydramnious, and said to refer for this. They said
they had seen this and referred. We spoke about leaking amniotic fluid and Dr.
Shemaghembe said they need to refer and get antibiotics.
The TBAs said
that they, and many of the women, knew that antenatal care was really important,
but said that the problem was the husbands. It is expensive to get transport to
clinic for those far away. The men say their wives should go for traditional
medicine instead. The TBAs suggested solution to this problem was a request for us to train the men too.
WTWT agreed to this and we said it could be included in our planned whole
community health programme to cover a wide range of health issues: HIV/AIDS/other
STDs, FGC, contraception, education before marriage etc.
General health:
We talked about general health being important. I felt that a healthy
diet was a painful subject because being healthy and well nourished is a near
impossible task in these poor areas. I am aware that not only are they without
vegetables due to the ban on growing them and the high cost of buying them in,
but they don't even get much of their nourishing milk for three months during
the dry seasons. Most of the cows and goats are taken far away to graze, perhaps
only leaving one milking cow. This leaves the women and children at home to survive
on watery 'porridge' made from maize meal and just a little milk.
Two plants do grow plentifully in the wild, which the doctor said are
rich in iron, vitamin A and folic acid: African Nightshade (Mnafu in Swahili)
and Wild Amaranthus (Mchicha), so we were able to teach of the importance of
including these in their diets. However even these do not grow in the dry
seasons.
We asked about the tradition of women being discouraged from eating when
they are pregnant in the belief they will have a small baby. They said that
they now know this is not good and that they encourage pregnant women to eat as
well as they can. We talked about a mixed diet with the different food groups that
they can get to eat fairly easily when there is no drought, such as milk, meat,
beans, maize and the wild greens. They
are going to discuss whether their Midwives Forum or newly formed Women’s
Pastoralist group could start a fund for good food for pregnant women.
The TBAs said they felt it was an important role of theirs to encourage
pregnant women to eat as well as they can and to observe what they are eating.
The midwife talked to them about hygiene and the importance of washing
their hands after going to the toilet.
15:30 We ended here for day one, with a meal of rice and meat. We ended
early because the community had prepared a ceremony for us.
After the meal we went outside for the ceremony put on by the community
of Bulati to thank WTWT for their contribution to the completion of their
Medical Centre.
After the thanks with music, dancing, prayers and presenting of gifts,
there were requests for funding of the furniture and solar panels for the
Medical Centre, for microfinance loans and for 2 classrooms towards a school in
the remote village of Irmelili over the hills from the other Bulati villages.
These people are suffering great hardship.
I was able to reassure them that WTWT had already pledged money for most
of these projects and hope to raise enough this year to fulfil their request
for at least one classroom.
Film: warning signs in
pregnancy
Day
2. August 6th
Labour
and birth:
First we
showed the film ’10 steps to a clean delivery’ in a low resource setting. This
covered putting a clean folded cloth under the mother for the birth, hand
washing for the TBA, putting on gloves for the delivery, the importance of
drying the baby quickly and putting it straight onto the mother’s chest and
cutting the cord with a new blade. Our TBAs said they do dry the baby well and put
him/her on the warm mother’s chest straight away, but were interested to hear
about the importance of drying well with one cloth and then wrapping in
another. They discussed the composition of different cloths they use, feeling
that cotton is better for drying, than man-made fibre, such as polyester, which
we agreed with.
Delay in labour
The women
said if labour was prolonged they gave hot sour milk to give the mother and
baby some strength. We said that if labour is prolonged they should transfer to
hospital. Dr. Shemaghembe said they should not use traditional medicine in
childbirth, but refer to hospital for problems.
Cutting
I had heard that the midwives
cut the woman’s vaginal opening with a razor blade during delivery to
facilitate the birth if it is difficult due to FGC scarring. I was able to ask
more about this by drawing a diagram of the female vulva
on the board, marking the anus clearly. I then asked them where they made this
cut. They showed me, by drawing it on the diagram, a very small nick (1cm long)
is sometimes made in the fourchette. I was then able to explain the importance
of protecting the perineum and anus from tearing by applying pressure over the
anus. I asked if they ever had tears down to the anus, they said they did not.
I asked if women were sometime incontinent of faeces after childbirth. Again they said that they didn’t hear of
this. Embapa then told me that these were problems they would not like to admit
to because it would reflect badly on them, so I realised that we need to teach
how to avoid this.
I asked what they
did when women tore. They said that they washed the area with boiled water and
then left it to heal itself. We said that if the tear was big or bleeding they
should transfer her to the clinic where Dr. Shemaghembe could stich it so that
it heals better.
Labour and delivery by TBAs
Next I
started acting as a labouring woman and called out one of the TBAs to help me,
to get them started. She was a wonderful support, massaging my back firmly and
confidently, I felt very reassured.
Observing the drama
A team of 4 TBAs then took over and acted out
the latter stages of labour and delivery showing us the care they would
normally give. The, initially mobile, labouring woman sank onto her hands and
knees, and then put her arms around one of the TBAs neck. The three were giving
wonderful support and encouragement to the vocalising woman. The 'baby' (a doll)
emerged while she was on her knees and the midwife brought it through the
front, to the woman's breast, as the other two helped her back into a sitting
position. They dried the baby thoroughly and then put another clean dry cloth
over the baby on it’s mother’s chest.
They helped the baby to latch on and
suckle. They tied one tie and cut the cord with a razor blade. They told us
that they put ash, milk fat or maize flour on the cord end. They then started
to apply pressure to the woman’s abdomen to deliver the placenta. We all gave
them a big round of applause for their acting ability! This drama gave us a lot
to talk about:
Drama: delivering the baby
Cutting the cord in their drama
on the model baby
I said I
was impressed by their care in labour and delivery, with the back massage,
nurturing of the woman and the good positions she was in. The TBAs said they do
not do VEs, so do not introduce infection that way. The doctor and midwife said
they would provide gloves for delivieries if the TBAs came to clinic for them.
Cutting of the cord
We then went
on to discuss the importance of sterilizing the blade by boiling before using,
if it is not a new blade, which they said they are not at the moment. We then
said there is no need to put anything on the cord, that putting things on can
lead to infection. One woman said that she had seen an infected cord in
hospital, that had nothing put on it. Dr Shemaghembe explained that cords can
get infected anyway and in this case the baby needs to be taken to the medical
centre for treatment. There was a picture of a reddened infected cord base on
the delivery film.
Retained placenta
We asked
what problems they experience with birth. Many of them said retained placenta
was the main problem. We asked what they did in this case. They said they tie a
cloth around the woman's waist to help her to push. One TBA said she follows
the cord up into the uterus with her hand until she can feel the placenta and
then she pulls it way. We advised strongly that she must not do this because
there is a high risk of bleeding and infection, which are life threatening. We
said she should transfer the woman to the medical centre for the doctor to do
this in sterile conditions, where there is IV equipment and oxytocics and
antibiotics available.
Physiological Third Stage
I asked
the question when they did this tying of the cloth to help the woman deliver
the placenta, how soon after delivery? They said they did it immediately, maybe
two minutes after birth after the cord is cut. I explained that the normal
physiological third stage is a process that takes around 20 minutes and so they
don't need to do anything for at least 20 minutes. I talked about the important
effect of the baby suckling contracting the muscle of the uterus, and that
after about 20 minutes you can feel the uterus contract and rise, if you have
your hand gently on the woman’s abdomen. I also said that they would see the
cord lengthen at this time and a trickle of blood from the vagina as the
placenta separates. They were interested to hear this and said they would wait
in future for it to separate naturally.
We also
recommended that they do not rush to cut the cord, but can leave it while it is
pulsing for the child to get a bit of oxygen that way. It was difficult for our
translators translating and explaining all these technical things, they were
always talking for considerably longer than the words we gave!
The TBAs
said that they do palpate and said they are able to feel if the baby is breech,
transverse or if there are twins. They refer for twins and transverse lie, but
generally deliver breech babies without problem. The Doctor demonstrated the manoeuvres
that we use for breech deliveries, and the women said they did the same. He
showed how to bring down the second leg in a footling breech.
Management of PPH
We showed
the film: Management of PPH, in which 3 tablets of Misoprostol are given to the
woman orally if her blood loss soaks a folded kanga. Help is called and the
woman quickly taken to hospital. The women said they did not see it that often,
but that if they did they give Olduai traditional medicine. If it does not stop
they refer to hospital. We stressed that it was important to get to hospital
straight away if the bleeding was heavy. They do not deliver on cloths
currently, but on the leather cowhide that they normally sleep on. I drew an
area of a pool of blood on the cow hide that would be about 250 mls – a pool of
2 foot in diameter. More than this they should be transferring the woman to
hospital after rubbing up a contraction and encouraging her to pass urine. They
were familiar with ‘rubbing up contractions’. We encouraged them to use their
normal dress cloths folded into 4 to deliver on, so that it is easier to assess
the blood loss. If the whole cloth is soaked then the woman should be
transferred to hospital.
Dr. Shemaghembe is going to
start giving 3 tablets of Misoprostol to
pregnant women at their third trimester visit to take orally prophylactically
at delivery. We explained that this would contract the uterus and speed up
the delivery of the placenta a little. We told them of the possible side
effects of nausea, vomiting and shaking, which would be explained to the women
when they are given the tablets in clininc.
Caring for the baby
We showed the film: ‘How to
Care for a Newborn’, which covered drying well at delivery, the importance of
colostrum, and only giving breast milk for 6 months. The doctor also talked
about the importance of giving nothing else. Not only because is it protective
and provides all nourishment needed, but because giving water, cows milk or maize
meal leads to aspirational pneumonia, and he sees this frequently.
Conclusions
and plan:
The end result of our training was that the TBAs are going to encourage
all women and their husbands to attend antenatal care from early in their pregnancies.
They are now aware of the signs which indicate a woman needs referring in
pregnancy, labour and afterwards.
The TBAs will make prompt referrals when there are problems and we will
plan with them and Dr. Shemaghembe to have a vehicle always available to take
labouring women quickly to hospital when there are problems.
They were very grateful for the training and said they had learned a lot.
They stressed that it is really important for them and they want it to continue
on a regular basis. They want 'solidarity with the medical staff and
themselves, to work together' which the medical staff agreed to and are keen to
do.
They want regular updates on the latest information from the medical
staff. They want to form a Women's Forum to address the issues together. They will teach the things
they have learned to other TBAs and so improve maternity care. They will teach parents
the importance of antenatal care and so increase the take up of this service.
I feel
confident that the community will be able to take these things forward, with the
support of the medical staff and WTWT.
WTWT
employee Embapa, speaking at the Bulati Ceremony
Midwife Peeiyo and Dr. Shemaghembe outside the
completed building of Bulati medical Centre
Post script
During
my visit I got some idea about the health care take up by the community:
About
50% of the women currently access antenatal care, though usually this is late
in their pregnancy, between 5 and 8 months. The nurse was keen to encourage
them to come earlier to enable treatment to have more time to work. Very few are
referred to the Health Centre in labour, only about 3 or 4 per month. Most of
these are for retained placenta, which Dr Shemaghembe is generally able to deal
with by manual removal. Sometimes women come with PPH. In this case he gives
Oxytocin, ferrous sulphate, an infusion of saline and a vaginal pack and
transfers them to the hospital in Karatu. He hasn't been aware of any maternal
deaths during the year he has been there. They are aware of 637 births last
year, because those ones came to have a check of the baby after delivery and
register the birth.
The
doctor makes very few referrals to the hospital in the nearest town, Karatu.
Last year it was about 9, some for curetage and some for obstructed labour.
Only about 4 needed a Caesarian Section.
In
discussing these issues with our employee Embapa, he said many women will go
straight to Karatu if they have a problem in labour, so it is difficult to know
things like the CS rate.
Report
written by Rachel Blackmore 19th August 2014
