Training birth anendants in the Sahel K L. Dehne, J. Wacker, &J. Cowley A small-scale training programme for birth attendants in a remote area of Burkina Faso was evaluated two years after it had been started. The evaluation methods included interviews with trained birth attendants and the analysis of health service statistics and survey data. The findings showed that the programme had been moderately successful in imparting knowledge and overcoming cultural inhibitions about assisted deliveries. However, the effectiveness of the programme was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport. In deprived areas such as the Sahel, it is probably the health centre, the hospital and the referral system that should be the first priority for improvement, rather than grass-roots practices.
Outside the industrialized countries it is still common for babies to be delivered by village birth attendants or family members. The shift towards primary health care in the 1970s stressed the benefits of home deliveries and led to the introduction of training courses for traditional birth attendants in most developing countries, with variable results. This evaluation of a small training programme for birth attendants in a remote area of Burkina Faso gives an idea of some of the factors involved. The department of Sebba, in the Sahelian north of Burkina Faso, is one of the world's least developed areas. It has a population of about 100 000 who belong to several ethnic
groups, of which the Fulani, the Rimaibe (former Fulani slaves) and the Gurmance are the most important. The area is served by two clinics and one medical centre. The regional hospital, where caesarean section and blood transfusions can be performed, is about 100 km away. An important feature of the behavioural code for the Fulanis is selfdiscipline and the avoidance of expressions of emotion or pain (1). Pregnancies are kept secret for as long as possible, and traditionally the mother delivers alone or calls a relative, often her own mother, to cut the cord.
The training programme In 1990, Save the Children Fund, in collaboration with the provincial health authorities, provided birth attendant training for 18 women, each from a different Fulani or Rimaibe village. The villages themselves made the selection, and most of them chose someone from the Gurmance or another ethnic minority. Only three of the participants were Fulani or Rimaibe. Owing to the lack of experienced candidates, some villages selected women who had never attended a delivery. 415
Dr Dehne was Coordinator of the Save the Children Fund (UK) primary health care programme in Burkina Faso and is now with the Global Programme on AIDS, World Health Organization, 1211 Geneva 27, Switzerland. Dr Wacker was the gynaecologist at the Centre hospitalier regional in Dori, Burkina Faso, and is now at the University Hospital in Heidelberg, Germany. Ms Cowley, a midwife, was Technical Assistant for the Save the Children programme in Burkina Faso, and is now at Keele University, England.
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All the participants were illiterate. The curriculum included the detection and referral of high-risk pregnancies, the procedure for cutting the cord cleanly, the administration of anti-malaria and iron tablets, and the prevention and management of postpartum haemorrhage. For the latter, three simple techniques were taught: massaging the uterus to induce contractions, putting the baby to the breast as soon as possible after birth (which, in addition to its other benefits, may have the same effect), and referral. The teaching methods consisted mainly of group discussions, practical demonstrations and role playing. A pictorial "statistics" form was introduced, for the birth attendants to use for recording antenatal examinations, deliveries and referrals. Each participant was provided with a simple maternity kit, and a revolving fund was established at the medical centre so that the kits could be replenished. An ambulance was available for emergency referrals.
vey sample comprised 296 women of childbearing age from 21 villages, five of which had been part of the birth attendant programme.
Delivery survey Out of 397live deliveries during the 5 years preceding the survey, 366 (92%) had occurred in the respondents' or their mothers' compounds, and 27 had taken place at one of the two clinics or at Sebba medical centre (for the remaining four the place was not recorded). No deliveries took place at the provincial hospital. Forty-seven (12%) mothers had given birth without any assistance; 157 (39%) had been assisted by a close female relative (usually her mother but also mother-in-law, sister-in-law, grandmother-in-law etc.); 94 (24%) had been attended by old women living in the same compound or in the neighbourhood; 72 (19%) had been attended by trained or untrained village birth attendants (accoucheuse villageoise) and 27 (7%) by health personnel. Most of the Fulani mothers had delivered alone or accepted help from their mothers, while most of the Gurmance mothers had delivered with the assistance of in-laws. Many of the Rimaibe deliveries had been attended by an old woman or a village birth attendant. Three Fulani women indicated that they had been attended by a (Rimaibe) servant.
Evaluation Two years later, the training programme was evaluated. Seventeen of the 18 trained birth attendants were interviewed (the remaining one was living outside the area at the time
Knowledge and practice survey The results of the survey are shown in the table. Most of the 17 trained birth attendants interviewed had retained a reasonable amount of the knowledge they had been taught. Eleven correctly quoted the common reasons for risk pregnancies and said they would refer them to the medical centre, and 14 correctly described hygienic deliveries. All17 knew that chloroquine was the drug of choice for
of the evaluation), and their answers were checked against information from two of their clients. Health service statistics were analysed, and questions on delivery practices were included in a health survey that took place in the department at that time. The sur416
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Traditional birth attendants in the Sahel
Summary of birth auendant knowledge and practice survey Village Bagnaba Bambari Baundore Dambini Denga Diagata Dari Yagha Gataugau Gauntaure Guissangau Habanga lbbal Kaurari Nyaptana Sam bag au Sal han Tiekanibi Ethnicity of birth attendant Sanrai Fulani Rimaibe Gurmance Gurmance Gurmance Fulani Gurmance Massi Gurmance Gurmance Sanrai Bella Gurmance Massi Gurmance Sanrai Age in 1992 Presence in village +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++
Knowledge ++ ++ ++ ++ ++ +++ ++ ++ +++ ++ +++ ++ +++ (+) ++ +++ +
Maternity kit ++ ++ + + ++ + + ++ +++ + ++ + ++ ++ + + ++
Utilization of service + + (+) + ++ (+) (+) + ++ (+) + + ++ + ++ ++ +
49 41 57 40 54 34 47 35 55 64 44 64 58 55 56 72
56
Key:+++ excellent,++ satisfactory,+ unsatisfactory,(+) poor or non-existent.
malaria prophylaxis, and 12 still knew that the recommended dosage was three tablets a week. Their knowledge of how to manage postpartum haemorrhage was less satisfactory. Twelve of them said they would refer the woman to the health centre, only six said they would "rub up a contraction" and only one said she would put the baby to the breast. The majority of birth attendants had been present in their villages throughout the twoyear period, but on the whole, little use had been made of their services. In seven villages they were well accepted and had been regularly called during labour, but in the others they had usually been called only after the delivery, and had performed few or no deliveries outside their immediate family. This was true for all three of the Fulani birth attendants and for the younger ones. Significant numbers of antenatal examinations were reported from only five villages. All birth attendants were found to have a stock of new World Health Forum • Volume 16 • 1995
razor blades (readily available at the village markets), but in most cases the original stock of other items in the maternity kit, such as chloroquine tablets and alcohol, had either not been used up or not been replenished. On the positive side, three birth attendants had correctly attended 35-50% of all the births that had taken place in their villages. Most of them had been conscientious about filling in the monthly reports and sending them to the medical centre. During 1991,
··llfllitlcattt'flflm/1Brs ~~ ~~~••ral ~Jt.smlfl.. stions were reptJrtBd from rJB/f fiVB rlllsges. 13 of them had referred a total of 36 women to Sebba medical centre, six for prolonged labour and the remainder for various pregnancy conditions.
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Health service statistics
For various reasons, probably not connected with the project, the number of deliveries _at Sebba medical centre decreased from 229 m 1989 to 212 in 1990 and 184 in 1991. Fifty-one (about 8%) of these 625 deliveri~s ~esulted in a stillbirth or a neonatal death withm 48 hours after delivery. Six maternal deaths were recorded. Each year, 5-11 women had been referred to the provincial hospital. There was no record of how many had previously been referred. At the provincial hospital, 25 out of 286 women referred from the surrounding clinics and medical centres died during or shortly after delivery. Thus the maternal mortality rate for referrals was 9%.
However, future courses could be muc? more effective if stricter criteria for the selection of villages and candidates were used. In Fulani/ Rimaibe villages, older women and those belonging to ethnic minorities appear to have fewer cultural inhibitions about attending births and are more likely to be consulted than ;oung Fulani women. In Gurmance villages, there is little evidence of a tradition ?f delivery by specialized bir::h attend~nts. S~nce it is not usually cost-effective to tram family birth attendants, Gurmance villages should probably not be included in the programme. Recognizing the limited role played by birth attendants in this area in comparison with other parts of Africa such as Nigeria, Sierra Leone and Zimbabwe, the curriculum had deliberately been kept very simple. It foc_used mainly on the detection and referral of highrisk pregnancies, ma!ari~ prophylaxis, ~d cutting the cord hygiemcally. All had hfesaving potential, and had been found manageable by traditional birth attendants elsewhere. Findings in Malawi in 1989 (2) suggested that training birth attendants t? enco~rage suckling immediately after dehvery did not reduce postpartum haemorrhage: an? it may no~ b_e worth retaining this practice m future trammg courses as a means of reducing haemorrhage. In Sebba most birth attendants had forgotten about "rubbing the uterus", a method which may well be effective, can do n? har~ and costs nothing. It should be retamed m future training programmes unless it is_ proved to be ineffective. The use of ergometnne or oxytocin to induce contractions was not included in this programme, in contrast to some others, as it did not appear to be possible to ensure supplies and proper use. The course had been in many respects successful in that most participants had retained an acceptable level of th~ knowledge t~~ght. This confirms the effectiVeness of participaWorld Health Forum • Volume 16 • 1995
Strengths and weaknesses of the programme In deciding to organize the training; co~~s~ in Sebba it was assumed that cultural mhibltlons about accepting help from professional birth attendants could be overcome, and that beneficial changes could be introduced. The subsequent survey of delivery prac~ices confirmed that both these assumptions were to a large extent correct. Only a minority of women in the area, mainly Fulanis, deliver without any assistance. Most Rimaibes accept help from the husband's relatives or from old
women, and would probably accept assistance from trained village birth attendants as well if such services were available. In several villa~es the newly trained birth attendants did attend a large number of the births which occurred.
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tory methods such as role-play and demonstrations in the training of middle-aged illiterate birth attendants. As in neighbouring Mali (3 ), the women had no great difficulty in learning how to fill in simple pictorial forms, although illiteracy often includes unfamiliarity with the idea of representing things with pictures. However, there is little evidence to suggest that the programme had a significant impact on health indicators, with the possible exception of a reduction in tetanus mortality due to clean cutting of the cord. Malaria and anaemia prophylaxis were irregular, as iron tablets and antimalarials were frequently out of stock. Importantly, a higher number of referred high-risk pregnancies did not result in an increase in the number of deliveries supervised by skilled personnel. The Sebba centre continued to assist few deliveries, with poor outcome. Very few women were referred to the provincial hospital. As is often the case in training projects of this kind, it was structural deficits in the health system, rather than the training course itself or cultural barriers, that prevented the Sebba programme from succeeding. Although obviously needed, and in fact originally planned, no skilled midwife had been transferred to the medical centre. Infrequent supervision of village birth attendants together with irregular supplies resulted in the poor functioning of the revolving fund. Women referred by the birth attendants were prob-
ably either sent back to their villages without a clear diagnosis or treatment, or encouraged to go to the provincial hospital, which was too far away and too expensive. Even those who could afford it were probably reluctant to accept referral because of the hospital's reputation as "a place where people go to die". Thus the vicious circle of late referral, high hospital mortality and deeper reluctance to go to the hospital remains unbroken. We may conclude that without significant improvements in the support systems, especially in skilled staff, supervision and transport, the training of birth attendants in Sebba will not yield significant benefits, however well it succeeds in overcoming cultural barriers and selecting suitable candidates for training. In deprived areas such as the Sahel, efforts by health planners and obstetricians should concentrate on assuring an acceptable level of maternity care at the clinic and hospital, before setting up new grass-roots structures. • References 1. Kirk-Greene AHM. Survival and symbiosis. In: Adamu M, Kirk-Greene AHM, eds. Pastoralists of the West African savannah, Manchester, Manchester University Press, 1986. 2. Bullough CH, Msuku RS, Karonde L. Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants, Lancet, 1989, 2: 522-525. 3. Chabot HT, Rutten AM. Use of antenatal cards for literate health personnel and illiterate traditional birth attendants. Tropical doctor, 1990, 20: 21-24.
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