Dissertations / Theses on the topic 'Traditional birth attendants (TBAS)'

Pregnancy and childbirth complications are a leading cause of death and disability among women of reproductive age in developing countries. Worldwide data shows that, by choice or out of necessity, 60 percent of births in the developing world occur outside a health institution and 47 percent are assisted by Traditional Birth Attendants (TBAs), family members, or without any assistance at all. This thesis argues that TBAs in India have the capacity to disseminate knowledge of beneficial maternal practices to the community. Since the 1970s the training of TBAs has been one of the primary single interventions encouraged by World Health Organisation (WHO) to address maternal mortality. However, since the 1990s international funding for TBAs has been reduced and the emphasis has shifted to providing skilled birth attendants for all births due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Researchers have observed that the shift in policy has taken place without adequate evidence of training (in)effectiveness and without an alternative policy in place. This thesis argues further that two main types of birthing knowledge co-exist in India; western biomedicine and traditional knowledge. Feminist, anthropological, and midwifery theorists contend that when two knowledge paradigms exist, western knowledge tends to dominate and claim authority over local ways of knowing. The thesis used such theories, and quantitative and qualitative methods, to assess whether the local TBA training programmes in Ahmednagar District in India have been successful in disseminating biomedical knowledge in relation to the birthing practices of local TBAs and in incorporating local knowledge into the training. The data revealed that some biomedical knowledge had been successfully disseminated and that some traditional practices continue to be practiced in the community. There is a top-down, one-sided imposition of biomedical knowledge on TBAs in the training programme but, at the local level, TBAs and mothers sometimes follow the training instructions and sometime do not, preferring to adapt to the local perceptions and preferences of their community. The thesis reveals the significance of TBA training in the district but queries the effectiveness of not including local TBA practices into the training programmes, arguing this demonstrates the hierarchical authority of biomedicine over local traditional practices. The thesis highlights the significance of community awareness that accompanies TBA training and makes recommendations in order to enhance training outcomes.

Pregnancy and childbirth complications are a leading cause of death and disability among women of reproductive age in developing countries. Worldwide data shows that, by choice or out of necessity, 60 percent of births in the developing world occur outside a health institution and 47 percent are assisted by Traditional Birth Attendants (TBAs), family members, or without any assistance at all. This thesis argues that TBAs in India have the capacity to disseminate knowledge of beneficial maternal practices to the community. Since the 1970s the training of TBAs has been one of the primary single interventions encouraged by World Health Organisation (WHO) to address maternal mortality. However, since the 1990s international funding for TBAs has been reduced and the emphasis has shifted to providing skilled birth attendants for all births due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Researchers have observed that the shift in policy has taken place without adequate evidence of training (in)effectiveness and without an alternative policy in place. This thesis argues further that two main types of birthing knowledge co-exist in India; western biomedicine and traditional knowledge. Feminist, anthropological, and midwifery theorists contend that when two knowledge paradigms exist, western knowledge tends to dominate and claim authority over local ways of knowing. The thesis used such theories, and quantitative and qualitative methods, to assess whether the local TBA training programmes in Ahmednagar District in India have been successful in disseminating biomedical knowledge in relation to the birthing practices of local TBAs and in incorporating local knowledge into the training. The data revealed that some biomedical knowledge had been successfully disseminated and that some traditional practices continue to be practiced in the community. There is a top-down, one-sided imposition of biomedical knowledge on TBAs in the training programme but, at the local level, TBAs and mothers sometimes follow the training instructions and sometime do not, preferring to adapt to the local perceptions and preferences of their community. The thesis reveals the significance of TBA training in the district but queries the effectiveness of not including local TBA practices into the training programmes, arguing this demonstrates the hierarchical authority of biomedicine over local traditional practices. The thesis highlights the significance of community awareness that accompanies TBA training and makes recommendations in order to enhance training outcomes.

The high infant mortality in Zambia is largely attributable to malnutrition. It is exacerbated by the inability of mothers to recognise threats to nutritional status and take corrective action. Advice in ‘Health Centres’ is often inaccessible to mothers. The Traditional Birth Attendants (TBAs) work with pregnant women in local communities, and the purpose of this study was to develop and implement an educationprogram in growth monitoring and nutrition for the TBAs and then to evaluate its effects. Twenty five TBAs from two peri-urban areas of Kitwe were enrolled in this pilot study and eighteen completed the program. The researcher developed and taught a program to the TBAs over ten days. A pretest was given before the teaching program to enable the researcher to obtain information about the knowledge and skills of the TBAs. Following the teaching program the TBAs were re-tested, with the same questionnaire. Focus groups were conducted to enable the TBA to provide information on the teaching materials and the education program. The TBAs then returned to their communities and put into practice the skills and knowledge they had learned for six months. Their practice was monitored by a trained Public Health Nurse. The researcher also surveyed 38 pregnant women about their knowledge of growth monitoring and nutrition before the TBAs went into the field to work with their local communities. The same questionnaire used with the pregnant women was administered to 38 new mothers with children aged 0 to 6 months to gain information of their knowledge and skills following the work of the TBAs. The program was evaluated by assessing the extent to which TBAs knowledge and skills were increased, the knowledge and understanding of a selection of their clients and the rates of malnutrition of infants in the area under study. The results from the research clearly indicated that the teaching program on growth monitoring and nutrition given to the selected group of TBAs had a positive effect on their knowledge and skills. It was found that the teaching developed their knowledge, practical skills, evaluative skills. That they were able to give infants’ mothers sound advice regarding their children’s nutrition was revealed by the mother’s increased knowledge and the decrease in numbers of malnourished children in the study areas at the conclusion of the research. The major outcomes from the study are: that Zambian TBAs can be taught to carry out an expanded role; field experience is a key factor in the teaching program; making advice available in local communities is important; and preliminary data on the Zambian experience were generated. Recommendations are: The pilot program should be expanded with continuing support from the Health Department. Similar educational programs should be introduced into other areas of Zambia with support from the Ministry of Health. That in administering a teaching program: Sufficient time must be allocated to practical work to allow poorly educated women to attain the basic skills needed to master the complex skills required to competently reduce faltering in their communities. The teaching materials to illustrate nutritional principles for feeding programs must be developed to suite locally available foods and conditions. Methods of teaching should suit the local area, for example, using what facilities are locally available. The timing of the teaching program should be suitable for the TBAs to attend. This may vary from area to area, for example it may be necessary to avoid times traditionally given to fetching water or working in the fields. For similar reasons, the venue for the teaching program should be suitable to the TBAs. The teachers should go into the TBAs’ community rather than causing disruption of the TBAs’ day by expecting them to go to the teacher. Data should be collected from a larger group of TBAs and clients to enable sophisticated statistical analysis to complement data from this pilot program. The TBAs should be given recognition for their work and achievement. This is something which they asked for. They do not ask for payment, rather acknowledgment through regular follow up and approbation.

Magister Public Health - MPH
Although the Kenyan government implemented safe motherhood programme two decades ago, available data indicate that prevalence of home delivery is still high among women in Garissa District. The aim of this thesis was to investigate the factors influencing the choice of place of childbirth. Methodology: A descriptive cross-sectional study was carried out among 224 women who delivered babies two years prior to December 2010. Using a statcalc program in Epi Info 3.3.2, with expected frequency of home delivery at 83% +5% and a 95% confidence level, the calculated sample size was 215. Furthermore, with a 95% response rate the adjusted minimum sample size was 226.There were two none-responses hence 224 women were interviewed. Stratified sampling was used. Data were collected using pre-tested structured questionnaires and analyzed using SPSS. Descriptive, bivariate and multivariate analysis was performed. A binary logistic regression analysis using the Enter method was performed to determine independent predictors for use or non-use of healthcare services for childbirth. The threshold for statistical significance was set at 0.05. Results: The result was presented in text and tables. The study found 67% (n=224) women delivered at home and 33% delivered in hospital. The study found low level of education, poverty, none-attendance of ANC, distance, cost of services, poor quality services, negative attitude towards midwives, experience of previous obstetric complications and decision-making to be significant predictors in home delivery at the bivariate level (p<0.05). The study did not find relationship between age, marital status, religion and place of childbirth (p>0.05). At multivariate level, the following variables were still found to be significant predictors of home delivery: no education OR=8.36 (95% CI; 4.12-17.17), no occupation OR=1.43(95% CI; 1.08–5.49) experience of obstetric complications OR=1.38 (95% CI; 1.15-2.12), none-attendance of antenatal clinic OR=1.11 (95% CI; 1.03–1.51), Rude midwives OR=5.60 (95% CI; 2.66-11.96). Conclusions: high prevalence of home delivery was noted due to lack of education, poverty and inaccessible maternity services hence the need to empower women in education and economy to enhance hospital delivery.

Master of Public Health - MPH
Background:Theoutcomeofpregnanciesinmanyinstancesislargelypredicatedon availabilityofSkilledBirthAttendants(SBAs).Despitethisphenomenon,illiteracyand financialdisadvantagehavebeenvariouslycitedastwinfactorspromotingtheinterest andpatronageofTraditionalBirthAttendants(TBAs)bywomenfolk.Itistherefore expected thatwomenhavingtertiarylevelofeducationandpossessing adequate economic resources would naturally prefer to use the SBAs.However,these http://etd.uwc.ac.za/ 9 observationshavenotsignificantlyreflected therealityin thechoiceofmaternal healthcareprovidersinNigeriaandthecityofLagosinparticular.Yet,accessto maternalservicesoftheSBAshasbeenwidelyacceptedasoneoftheleadingwaysof loweringmaternalmortality.Therefore,inordertoimprovethepatronageofSBAsand correspondinglylowermaternaldeathrates,itbecomesimperativetounderstandthe rationalebehindthepreferencefortheTBAs’usebywomenwhoarenotordinarily expectedtodosobyvirtueoftheirhighlevelofeducationandgoodfinancialcapacity. Aim:Theaim ofthisstudywastoexploreandunderstandtheexperiences,perception and beliefsystems influencing well-educated,middle income women and their reasoningfortheuseofTraditionalBirthAttendantsratherthanSkilledBirthAttendants fordeliveryservicesinLagos,Nigeria. Methodology:ThisisaqualitativestudyconductedinAlimoshoLocalGovernmentArea ofLagosinNigeria.Tenwomenwithtertiarylevelofeducationandbelongingtomiddle incomeeconomiccategorieswereenrolledasparticipants.Inaddition,itinvolved3 FocusGroupDiscussionscomprising7TraditionalBirthAttendantspergroup. Results:Behaviouraland attitudinalshortcomings by the SBAs;misconceptions regardingsurgicaldeliverybywomen;bureaucraticdelaysandbottlenecksexperienced attheSBAs’centres;thebeliefbythewomenthatpregnancyisasacredandspiritual eventwhichonlytheTBAshaveabilitytomanage;women’sconfidenceintheTBAsas havingbettercapacitytomanagecertaincoexistingmedicalconditionsinpregnancy; andmisinformationonmanagementmodalitiesforcertainconditionslikeinfertilityand fibroidallcombinetoinfluencepreferenceforutilizationofTBAsbywell-educated, middleincomewomeninthestudyarea.

Despite significant recent improvements, maternal mortality remains high in Malawi. To address this, the Government prioritised strategies promoting skilled birth attendance. However, in a country where 80% of the population resides in rural areas, there are tremendous barriers to institutional deliveries. Historically rural women have been supported in childbirth by Traditional Birth Attendants (TBAs), and by skilled birth attendants (SBAs) at the health facility. In the past, TBAs were trained to help bridge the gaps in provision and accessibility of care but in the 1990’s, the WHO recommended halting their training because it was perceived as ineffective for maternal mortality reduction. In 2007, the Government of Malawi issued Community Guidelines to promote skilled birth attendance and banned TBA utilization for routine deliveries. This grounded theory qualitative study used interviews and focus groups to explore community actors’ perceptions of the 2007 Policy Guidelines and their implementation, and how the Policy affected the decisions and actions of rural women regarding their delivery care. Findings from this study indicate that although all actors may agree that delivering at facilities is safest when complications occur, this does not necessarily ensure their compliance. Women, men and TBAs particularly, perceived the Policy as prescriptive. Furthermore, the implementation of the policy aggravated some of the barriers women already faced. Issues of disrespectful and neglectful care at facilities also partly led women towards non-compliance. Furthermore, a view from the ground demonstrated that the Policy had led to a rupture of linkages between TBAs and SBAs, which have had a detrimental effect on the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation analysis in LICs, by focusing on the perceptions of those at the receiving end of policy change, and on their needs, and aspirations.

Objectivo: A presente revisão sistemática da literatura pretende identificar e compreender melhor, as intervenções implementadas em diversos países, e os respectivos resultados, para aumentar o uso de provedores qualificados, em contextos onde as parteiras tradicionais são os principais provedores de cuidado no parto. Metodologia: Foram pesquisadas 87 bases de dados electrónicas para a obtenção de referências sobre parteiras tradicionais e obstetrícia. Foram também contactados peritos para a obtenção de mais referências neste tópico. Não foi feita qualquer distinção entre países de baixo, médio ou alto rendimento, ou ano ou estado da publicação. Foram utilizados métodos de revisão sistemática narrativa. Resultados: A pesquisa electrónica resultou na obtenção de 16.814 referências em 26 das 87 bases de dados pesquisadas. Após a eliminação de duplicados e da aplicação dos critérios de elegibilidade a todas as referências, tanto as obtidas das bases de dados electrónicas, como as dos peritos, 19 referências foram incluídas para extracção sistemática de dados, e 91 foram inventariadas por tipo de intervenção em cada país. As referências obtidas reflectem as experiências de 38 países. A maioria das intervenções descritas nas 19 referências às quais se fez extracção sistemática de dados foram: melhoria no acesso aos serviços através da eliminação de barreiras geográficas e/ou económicas (n= 10) e desenvolvimento e/ou implantação de recursos humanos (n= 6). Para além destas, 2 referências eram relativas a intervenções de sensibilização da comunidade, e 1 era sobre a adaptação cultural dos partos institucionais. Conclusão: A maioria das referências às quais se fez extracção sistemática de dados relataram estudos que foram considerados de baixa qualidade, com uma variação considerável na qualidade de informação proporcionada. Uma vez que a maioria dos estudos não usou no seu desenho uma distribuição aleatória, foi difícil atribuir com confiança resultados positivos a uma intervenção específica. Contudo, os estudos mostraram resultados positivos para o aumento do uso de atendimento/provedores qualificados e melhorias nos resultados de mortalidade materna, com uma concomitante redução no uso de parteiras tradicionais. No entanto, muitos estudos apontaram uma persistência de desigualdades, e mais atenção precisa de ser dada aos custos de transporte e preferências culturais. As referências analisadas nesta revisão sistemática da literatura apresentam um segmento de tempo/intervenção e local, e seria útil elaborar uma análise aprofundada dos países, para detectar o impacto destas intervenções na redução de mortes maternas.
Objective: The current systematic review intends to identify and better understand the interventions implemented in different countries to increase the use of skilled attendants in contexts where traditional birth attendants are the primary provider of childbirth care, and to summarize the outcomes of the different interventions. Methods: Eighty-seven electronic databases were searched for references on traditional birth attendants and midwifery. Experts in the field were also contacted to request documents related to the topic. No distinction was made between low, middle and high-income countries or publication year or status. Standard narrative systematic review methods were used. Findings: The electronic searches yielded a total of 16,814 references from 26 of the 87 databases. After elimination of dupplicates and the application of the eligibility criteria to all references - from the electronic searches and the experts in the field - 19 references were included for systematic data extraction and 91 references for inventory of the type of intervention and country. These references were from a total of 38 countries. Of the 19 references from which data was systematically extracted, the majority of interventions described were: improvement of access to services by removing geographical and/or financial barriers (n= 10) and human resources development and/or deployment (n= 6). Following these, 2 references were about a community advocacy intervention and 1 reference was about cultural adaptation of institutional childbirths. Conclusion: The majority of the included references for systematic data extraction reported studies which were considered of low quality with considerable variation in the quality of reporting. Since most studies did not use random allocation in their design it was difficult to confidently attribute positive outcomes to an individual intervention itself. Nonetheless, the studies reviewed showed positive results for increased use of skilled attendance/attendants and improved maternal mortality outcomes, with a concomitant reduction in the use of traditional birth attendants. However many studies noted that inequities persist and more attention needs to be given to transport costs and cultural preferences. The references analysed in this systematic review present a snapshot of a time/intervention and place and it would be useful to produce in depth country profiles to see the impact of these interventions on maternal deaths reduction.

Thesis (Dr.P.H)--Boston University PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
Background The Ministry of Health in Zambia is implementing a National Community Health Worker Strategy to improve health care access using a new cadre of community health assistants (CHAs). The strategy does not include traditional birth attendants (TBAs), an existing health care resource in the community. This case study examined how TBAs can work with CHAs to provide prevention of mother-to-child transmission (PMTCT) services to pregnant women and infants in rural areas within this new health worker strategy. Methods Using the case study methodology, this study analyzed multiple sources of data including published and unpublished literature, program documents and key informant interviews. Thirteen semi-structured interviews were conducted with policy makers and community field workers involved with TBAs and community health workers providing PMTCT services in rural Zambia. Methodological triangulation was used to synthesize information and compare themes across different sources to gather various perspectives and provide additional insights into the topic. Results In the absence of trained facility-based health care workers, TBAs often provide antenatal and delivery services. Acknowledging the limited provision of care for pregnant women in the CHA Strategy, respondents pointed to the potential role of CHAs in assisting with deliveries. Emphasis was placed on the importance of TBAs to reduce barriers between the home and the formal health system. TBAs and CHAs have complementary skills that can be used in partnership to provide PMTCT services. Conclusions With standardized trainings, TBAs can play a supportive role in providing PMTCT services within the new community health structure. TBAs and CHAs can assist with deliveries and provide PMTCT services at the health facility and at home. TBAs can accompany CHAs to navigate family and gender dynamics and provide home-based adherence, breastfeeding education and support, and referrals. A new incentives model for TBAs has the potential to increase facility births and engage the volunteer cadre in playing a supportive role to the CHAs. This task-shifting and sharing model, using TBAs and CHAs, can improve maternal health services by strengthening the link between the community and the facility and integrating, rather than excluding the traditional health care system.

Maternal mortality is a global health concern but inequalities in utilization of maternal health care are not clearly understood. Severe morbidity (near-miss) is receiving increased attention due to methodological difficulties in maternal mortality studies. The present thesis seeks to increase understanding of factors that impede utilization of emergency obstetric care (EmOC) in Bolivia and Guatemala. Studies I and IV employed qualitative interviews to explore the role of traditional birth attendants (TBAs) and the care-seeking behaviour of women who arrived at hospital with a near-miss complication. Studies II–III documented maternal mortality and near-miss morbidity at the hospital level and investigated the influence of socio-demographic factors and antenatal care (ANC) on near-miss upon arrival. The studies identified unfamiliarity with EmOC among TBAs and a lack of collaboration with formal care providers. A perception of being dissociated from the health care system and a mistrust of health care providers was common among near-miss women from disadvantaged social backgrounds. In the Bolivian setting, 187 maternal deaths per 100,000 live births and 50 cases of near-miss per 1000 were recorded. Causes of near-miss differed from those of maternal deaths. Most women with near-miss arrived at hospital in critical condition: severe preeclampsia, complications after childbirth at home and abortions were mostly encountered among them. Lack of ANC, low education, and rural residence were interactively associated with near-miss. ANC reduced socio-demographic differentials for near-miss. Complementing maternal mortality reviews with data on near-miss morbidity increases the understanding of priority needs and quality of maternal health care. Additionally, focusing on near-miss upon arrival was found useful in exploring pre-hospital barriers to EmOC. The findings identified subgroups of women who seemed especially vulnerable to pre-hospital barriers. They also underscored the need for initiatives to reduce the effect of social marginalization and to acknowledge the influential role of formal and informal care providers on the utilization of EmOC.
La mortalidad materna es un tema de inquietud global, sin embargo la comprensión de las desigualdades en la utilización de los servicios de salud materna es limitada. La morbilidad obstétrica severa (near-miss) está recibiendo creciente atención, producto de problemas metodológicos en los estudios de mortalidad materna. El objetivo de la presente tesis es aumentar la comprensión de factores que impiden la utilización de la atención obstétrica de emergencia en Bolivia y Guatemala. Los estudios I y IV usaron metodologías cualitativas en un esfuerzo por explorar el rol de las parteras tradicionales y las estrategias de las mujeres que arriban a los hospitales con una morbilidad obstétrica severa. Los estudios II–III documentaron la mortalidad materna y la morbilidad obstétrica severa en el marco hospitalario e investigaron el impacto de los factores socio-demográficos y el control prenatal en la llegada a los establecimientos de salud con complicaciones severas. Los estudios identificaron la falta de familiaridad con atención obstétrica de emergencia entre las parteras tradicionales y la falta de cooperación con los profesionales de salud formales. La sensación de estar distanciadas del sistema de salud y la desconfianza hacia los profesionales de la salud eran aspectos comunes entre las mujeres de sectores marginales con experiencias de complicaciones severas. En el contexto boliviano, 187 muertes maternas por cada 100,000 nacidos vivos y 50 casos de morbilidad obstétrica severa por cada 1000 fueron registradas. Las causas de la morbilidad obstétrica severa y las muertes maternas se distinguieron. La major parte de las mujeres con morbilidad obstétrica severa llegaron al hospital en condiciones críticas: preeclampsia severa, complicaciones después de partos domiciliarios y abortos eran causas más frecuentes en esta categoría. Combinaciones del bajo nivel de educación con la falta de controles prenatales o la residencia en zonas rurales fueron asociadas con la morbilidad obstétrica severa. El control prenatal redujo diferencias socio-demográficas en lo concerniente a la morbilidad obstétrica severa. La complementación de estudios de mortalidad materna con datos sobre morbilidad obstétrica severa aumenta la comprensión de las prioridades y de la calidad en la atención de la salud materna. Además, centrándose en la morbilidad obstétrica severa a la llegada al establicimiento de salud, ha sido útil para investigar las barreras pre-hospitalarias en relación a la atención de emergencia obstétrica. Los resultados permiten identificar categorías específicas de mujeres que parecen ser especialmente vulnerables a las barreras pre-hospitalarias. Los resultados, también subrayan la necesidad de iniciativas que reduzcan los efectos de la marginalización social, y que reconozcan el importante rol que tanto el personal de salud formal como informal cumplen en la utilización de los servicios de atención obstétrica de emergencia.

The purpose of this study was to identify the need for a training programme and to develop the training programme to meet the needs of traditional birth attendants in the management of pregnancy, labour and puerperium. The study was conducted in the Flagstaff district which is one of the districts of the north eastern region (region E) of the Eastern Cape. The target group consisted of all the traditional birth attendants who availed themselves at the residential clinics of Flagstaff district and the number is not known as not all traditional birth attendants who presented themselves are recognized by their communities as traditional birth attendants. The study was a quantitative descriptive design and the data was collected by means of structured interviews using a questionnaire that was designed by the researcher. According to the findings the traditional birth attendants are functioning without being formally trained before. They lack knowledge and skill in the management of pregnancy, labour and puerperium. Some of their practices are reason for concern, for example cephalic versions and not using protective devices. There is a need for the development of the training programme in the Flagstaff district. This programme was developed from the information obtained from the data-analysis and is given as annexure F
Health Sciences
M.A. (Advanced Nursing Sciences)

Magister Public Health - MPH
This is a cross sectional survey study that explored determinant factors contributing to home child delivery and influence of traditional birth attendances on place of delivery in Rungwe District, Tanzania.The study focussed on three main aspects namely factors (socio-economic, cultural and knowledge) that influence women to deliver at health facilities and those who deliver ta home. Reasons/factors associated with the acceptability of health services and influence of traditional birth attendaces on place of delivery and whether accessibility to health services and traditional birth attendants influence women to decide the place of delivery. The study was descriptive cross-sectional in nature where a multistage random sampling procedure was used to select 8 wards and 16 villages. A systematic sampling was used to determine household interval in each village. Only one woman with at least one child was chosen in a household using a random sampling. In case of the absence of a woman with at least one child in a house falling in the interval, then the next house was considered. A total of 400 women with at least one child were selected at random from household cluster sample from all four divisions in Rungwe district. They were interviewed using semi-structured questionnaire. The participation rate was 100 % in both divisions. The age of the women ranged from 19-49 years with the mean age of 31 years (Std dev 7.5). Data entry and analysis were done using the quantitative statistics with Epi Info 2002 software. Results were presented using descriptive statistics, figures and tables, and analytical statistics, using Student’s t-test and chi-square. A total of 400 women were interviewed, among them, it showed that there were good attendance for antenatal care 395 (98.75%) and only 5 (1.25%) did not attend antenatal care. However, 243 (60.8%) of women interviewed had incidence of home delivery and 157 (39.3%) had incidence of health facility delivery. Home deliveries in a surveyed area are commonly assisted by unskilled persons, and consequently carry increased risks to the mother and to the new-born baby. Improvement of quality and accessibility of health care services by the health facility should involve harmonic balance between health service provider and beneficiaries in order to change the attitude towards minimizing the practice of home child delivery in Rungwe district, in Mbeya region, in Tanzania as awhole and elsewhere in the world.

A descriptive quantitative study was undertaken in the Leribe and Butha-buthe northern districts of Lesotho. Thirty-six trained, twenty-four untrained TBAs and nine nurses involved in training TBAs were recruited. In line with research by Clarke and Lephoto (1989:3) the TBAs were elderly females who had children of their own. In contrast with the MOH (1993: 10) where TBAs were found to be illiterate, most (93%) of the TBAs in this study had at least a primary education. The art of primary midwifery was learned through assisting with a delivery and being taught by mothers or mothers-in-law. The public health nurses conduct formal training ofTBAs in Lesotho over a period of two weeks, where subjects like ante-natal care, delivery of the baby and post- natal care are addressed. The majority (78.8%) provide antenatal care at their homes or the home of the mother. This includes palpation, history taking, and abdominal massage and health education. An important role is identifying women at risk. During labour the progress of labour is monitored and care is given to the mother and baby post-natally. Trained TBAs could identify women at risk more readily than untrained TBAs. Cases referred most frequently were prolonged labour and retained placenta. Trained TBAs practiced hygiene more often and gave less herbs than untrained TBAs. The health care system is providing support to the TBAs through training and supervision, but was found to be inadequate. Community leaders are involved in the selection of TBAs for training. Regular meetings are held with the TB As to discuss problems. Communication is one of the problems the TB As have to face, because of the long distances from health care centres. A lack of infrastructure and supplies is also of concern. It can be concluded that TBAs play an important role in maternal health care in Lesotho and are supported to a lesser degree by the health care system, which causes problems for the TBAs in their practices. It is recommended that the ministry of health becomes more aware of the need for training TBAs and that a programme for training should be more appropriate, taking cultural practices into account.
Advanced Nursing Science
D.Lit. et Phil.

The central concern of this study is the social, cultural and political position of traditional birth attendants (TBA), known as yiey maap (grandmother midwives) in Chup Commune (pseudonym). In particular, this study explores strategies yiey maap use to negotiate or bypass Western model health services in an attempt to maintain their personal integrity and cultural capital as birth attendants, and to ensure the physical, emotional, economic and cultural safety of the woman they care for.
This thesis explores traditional maternity knowledges and practices using ethnographic methods to investigate the central issues, concerns and barriers confronting rural woman as they make choices to adapt, resist or negotiate Western maternity care. It is vital to consider historical, political, cultural and economic factors that influence women's decisions in order to understand how and why women hold onto or surrender their traditional childbirth knowledges and practices, including the preservation of yiey maap, their favoured birth attendant.
Safe Motherhood initiatives were introduced into resource-poor countries by the World Health Organization in 1987 with the goal of reducing maternal mortality rates. They were based on the premise that pregnancy, childbirth and postpartum care were safer when provided by skilled birth attendants in a modern health facility. TBAs were not considered skilled birth attendants by Safe Motherhood partner agencies, as training and utilizing TBAs in Safe Motherhood initiatives did not have a measurable impact on maternal mortality rates. Instead, TBAs' roles have been recast, and TBAs are expected to be health promoters and educators, referral agents and information gatherers.
I argue that Khmer women do not engage with the modern health system because it is unfamiliar and expensive, and health personnel provide poor quality care. Instead, in times of obstetric emergencies, women attempt to negotiate their own and their family's safety through personal autonomy and agency.
I conclude by proposing alternative approaches and strategies, including the increased utilisation of yiey maap in Cambodian Safe Motherhood programs. A central question is whether the Ministry of Health, supported by bilateral and multilateral agencies, should train and utilize yiey maap or midwives in maternity care. I argue that both are of equal importance. Until yiey maap are valued for their contribution to, and enjoy equitable inclusion in midwifery care, initiatives that involve yiey maap as program "extras", who undertake peripheral tasks, will not reduce maternal mortality rates.

This study was undertaken to investigate the practice of Traditional Birth Attendants (TBA) during pregnancy, labor, and the postpartum period. The overall goal of this study was to promote safe motherhood. This study was conducted in Abaqulusi, a sub-district of KwaZulu-Natal, Zululand Health District 26, in four rural communities. A descriptive design with structured interview schedule guided the process. A convenient sample of forty-eight actively practicing trained Traditional Birth Attendants and forty-eight mothers attended by these Traditional Birth Attendants were interviewed. Of these 48 TBAs 47 were women, and one interestingly, was a man. Their age range was from 20 to over 70. Fifty percent of the mothers attended by the TBAs were between 15 and 24 years old. This finding is significant because the result shows that most of the mothers who are attended and delivered by TBAs are a high risk group. Data generated was quantitatively and qualitatively analyzed. The study revealed that the TBAs attended the mothers during the pregnancy, labor, and postpartum periods. All TBAs examined mothers with their hands, gave education on the importance of good nutrition, child spacing, and follow up care. The study showed that during labor 100 % of TBAs deliver babies on the floor with an old blanket, in the lithotomy position and encouraged the mother to empty her bladder before and during labor. They wore gloves or plastic bags. They examined mothers before delivery was done. They measured the umbilical cord, tied it with string and cut it. They cleaned the baby's mouth, nose, and eyes with a clean cloth, and wrapped the baby up and put it near the mother. They delivered the placenta, checked it to see if all was out. They washed the mother and put her on her bed. During the postpartum period, 100 % of the TBAs visited the mother at her home for one week to assess and care for the mother and her baby. The TBAs examined the mother, checked the umbilical cord and bathed the baby. They educated the mother about breastfeeding, caring for her breast, and eating balanced meals to produce adequate breast milk. The study revealed that the mothers perceived the TBAs as caring. The mothers loved the TBAs because the TBAs were easily accessible, even at night. The conclusion reached in this study is that TBAs are of great value to the rural communities of South Africa. They need to be supported by the health professionals so thal tbeir practice can be recognized. They form part of the maternal and child health care. Their practice is indispensable.
Thesis (M.N.)-University of Natal,Durban, 2004.

Introduction: In 2007, the Ministry of Health in Malawi issued a directive banning traditional birth attendants (TBAs) from delivering mothers and ordered all mothers to access skilled birth attendants in health facilities (MoH, 2007b). Anecdotal reports showed that the influx of pregnant mothers to the health facilities resulted in mothers delivering on make shift beds on the floor and sometimes without the assistance of the skilled provider. The badly stretched health care system continues to force mothers to deliver with the assistance of TBAs who have gone underground for fear of being fined. Purpose of the study: The purpose of this study was to explore stakeholders’ perceptions of the changing role of TBAs in order to obtain a greater breadth of understanding of the reasons why home births persist in the rural areas of Central West Zone (CWZ), Malawi. Methods: The study employed a mixed method concurrent triangulation design in which 24 health facilities in the districts of Ntcheu, Dedza, Lilongwe and Mchinji, in CWZ, Malawi were included. A non-probability purposive sampling method was used to select 24 health facilities that provide Basic Emergency Obstetric and Neonatal Care (BEmONC) services in rural areas of CWZ. A randomly selected sample was used to collect quantitative data from mothers, using an interview schedule. These were mothers (n=144) who had come to access maternal and neonatal health care but had previously sought the help of a TBA to deliver. A total of 55 nurse midwives who worked in the 24 health facilities and who were available and willing to participate responded to a structured interview schedule. Quantitative data were analyzed using SPSS version 19. Qualitative data were collected using focus group discussions (FGDs) with TBAs (n=4 FGDs, with 6-7 respondents in each discussion group) who lived in the catchment areas of the selected BEmONC sites. Single in- depth interviews were conducted with TBA trainers (n=10) in the districts and health professionals (n=12) from the Ministry of Health and Nurses and Midwives Council of Malawi. Data were analyzed manually. Findings: The findings showed that the moratorium on TBAs was implemented without consultation with the relevant stakeholders and as a result, many mothers in rural areas continued to seek the services of TBAs. Untrained TBAs took advantage of the opportunity and together with some trained TBAs who were afraid of punishment went underground to practice. Maternal and neonatal health care in BEmONC facilities were deficient as the health care system struggled with challenges such as the lack of adequate and humane accommodation for waiting mothers, critical shortages of staff, drugs and supplies and negative health care worker attitudes. In addition, long distances and the lack of empowerment of rural women prevented mothers from seeking skilled birth attendants. The study concluded that even though the government had issued a moratorium on TBAs, the health care system is not coping. Recommendations: It is recommended that having moved away from the TBAs, there is no need to revert to using them since that would mean perpetuating harmful and substandard care for mothers. In addition, TBA services would undermine the government’s efforts to improve skilled birth attendance. However, the system needs to urgently deal with the challenges that rural mothers encounter in trying to access skilled birth attendance.

Namibia has recorded an ascending trend of maternal and neonatal mortality rate from 225 &ndash
449 per 100 000 women from 1992 to 2006, and 38 &ndash
46 per 1000 live births from 2000 to 2006 respectively. Kavango Region in Namibia is one among the top seven regions with high maternal and infant mortality rate. Most pregnant women in peri-urban areas of Rundu District in the Kavango region, where this study was conducted, attend ante-natal care services but do not use public health facilities for delivery. The health records from the public health facilities in Rundu, especially from Nkarapamwe clinic and Rundu Hospital maternity section, reveal that although the pregnant women comply with the required standard policy of a minimum of three visits per pregnancy or more, over 40% of women who attend public ante-natal care clinics do not deliver in the public health facility. The aim of this study was to explore the perceptions of women regarding obstetric care in public health facilities in Kehemu settlement, a peri-urban area of Rundu town. The objectives of the study were to explore the perceptions of women on accessibility and acceptability of maternity services in public health facilities. An explorative qualitative study design using focus group discussion as a data collection method was conducted with three groups of women. A purposeful sampling procedure was used to select participants. Ethical approval was obtained from the High Degree Committee of University of the Western Cape and permission to use data from local facilities was obtained from the Ministry of Health and Social Services. Participants were recruited on their own free will and they signed an agreement on confidentiality. A data reduction process was used for analysis. The study findings indicate that women wish to use public health facilities for deliveries due to perceived benefits, in particular, safety for the mother and the baby and that those services are affordable. However a number of reasons hinder women to access services including the attitudes of health care providers, inability to afford transport at night and cultural influences. The study recommends that delivery services at the local clinic be expanded from eight to twenty-four hours
an information campaign on pregnancy and birth complications as well as the benefits of delivering in a public facility be implemented
refresher training for nurses to improve their caring practices during delivery should be considered and that a similar research be conducted with care providers to ascertain ways to improve maternity services in the public health facility in the area.

博士
臺灣大學
職業醫學與工業衛生研究所
98
Malawi, located in southeastern Africa with an estimated population of 13 million, is among the world''s least developed countries. The life expectancy of Malawian people is only 50.9 years. The high rates of infant and under-five mortality are 83.5 deaths per 1,000 live births and 100 deaths per 1,000 live births, respectively. Although the total fertility rate averages 5.5 children per womon, the maternal mortality rate is as high as 1,100 deaths per 100,000 live births due to poor environmental health and a shortage of medical resources. The leading causes of death in Malawi are infectious diseases such as acquired immunodeficiency syndrome (AIDS), tuberculosis, malaria, pneumonia and diarrhea. The prevalence of AIDS in adults aged 15-49 years is 11.9% and more than 930,000 people were living with AIDS in this country in 2007. In 2000, the Taiwan government built the Mzuzu Central Hospital in the northern region of Malawi in order to compensate the severe shortage of medical resources and dispatched a medical team to assist in managing the Mzuzu Central Hospital. Since July 2002, Pingtung Christian Hospital has taken over the medical team. To face the challenge of high maternal and infant mortality rates, the medical team trained 81 traditional birth attendants (TBAs) during 2004-2006 with support from the Department of Health, Taiwan and totally 1905 babies were delivered until August 2008. The neonatal mortality rate was 13.6 per 1,000 live births, lower than half of the national statistics and the maternal mortality rate was zero. Moreover, the Rainbow Clinic, the first free antiretroviral therapy (ART) clinic has been opened in northern Malawi since 1st July 2004 in order to fight against AIDS, and furthermore a fingerprint identification information system was developed to record patients’ clinical courses and medication history. The United Nations set up eight Millennium Development Goals (MDGs) in 2000. Three of them are related to health issues: MDG4, to reduce child mortality; MDG5, to improve maternal heath; MDG6, to combat HIV/AIDS, malaria and other diseases. These three MDGs, i.e. Maternal and Child Health and AIDS, are the core issues of current international health. This doctoral dissertation also includes these two issues: (1) Maternal and Child Health, evaluating the accessibility of health facilities for pregnant woman and the importance of continuing education for TBAs and their performance; (2) AIDS, analyzing survival rates of AIDS patients on antiretroviral therapy for adults (aged more than 15 years) and children (aged less than 15 years). Summaries of the four dissertations are listed below. The first paper: The distance is the most important concern of women’s choice of delivery places. GPS and Google Earth were used to measure the distance and time needed for pregnant women to reach health facilities. The combination of these two tools helps us to know the resource distribution and the accessibility of delivery services, which may be helpful for public health planning and policy making. The second paper: Through initial training and continuing education, TBAs are able to have a good performance in decreasing the neonatal mortality rate to less than half of the national statistics. Well trained TBAs under regular supervision and continuous support can be a potential human resource for countries lacking medical professionals. We recommended that continuing education should be regularly provided, at least annually. The third paper: The mortality rate was significantly higher in adult males than in adult females with AIDS on ART. This may be associated with the delayed diagnosis, seeking for medical care in a more advanced clinical stage and poorer compliance to therapy in male patients. The gender difference needs to be addressed in scaling up ART programs in Africa. The fourth paper: Severe malnutrition, indicated by BMI &lt;15 kg/m2, may be the most significant prognostic indicator for premature mortality in children on ART. The first three months after starting ART is the golden period of nutrition assessment and intervention, especially for malnourished children. Early and proper nutrition support should be integrated with ART management. From 2000 to 2010, half the MDGs time frame (2015) has passed, but WHO found that the progress of MDGs in some under-developed countries is very slow, mostly due to the shortage of medical professionals. This doctoral dissertation found that TBAs can be a potential human resource, if they can have a proper training and continuing education, under regular supervision and logistic support, and are also well integrated into the current medical system. For example, if we can select good candidates and train them to become TBAs or community health workers, they can do some primary cares such as delivery service, referring high risk pregnancy to health facilities, health education, prevention of maternal-to-child HIV transmission (PMTCT), and nutrition support for malnourished children. They are able to reduce great burden of medical professionals and improve the maternal and child health as well as AIDS control in remote rural areas. Then, there will be an opportunity for us to accomplish MDGs by the end of 2015.

Haiti's political and economy history has led to a maternity care system that lies out of reach, geographically and financially, of most Haitians, resulting in excessively high maternal and infant mortality. The most common birth practitioners are homebirth midwives (matwòns), who attend roughly three-fourths of all births in Haiti (UNICEF), often without the benefit of emergency obstetric services. In this ethnographic study, I examine how matwòns experience caring for mothers and babies in extraordinarily low-resource and high-risk settings. This qualitative research employed a critical approach and feminist research methodologies. In in-depth interviews I asked participants to describe the challenges they find in their work. Then, in an innovative style of group meeting called Open Space, matwòns reflected on those challenges collectively, with an aim to ameliorate their current situations. Data analysis utilized a modified grounded theory approach, which allowed the matwòns' own narratives to determine the categories of analysis. Emergent themes resulting from this analysis revealed four main challenges in the work of matwòns, as well as matwòns' own strategies to mitigate those challenges. The four broad challenges, which include physical risks, social/spiritual threats, a lack of livelihood, and an obligation to practice, are experienced either as episodic hazards or chronic stressors. Matwòns' personal mitigation strategies centered on two broad approaches, providing protection, and offering service. However, the Open Space meeting created an opportunity for matwòns to strategize collective mitigation efforts through professional organization. Based on these findings, I argue that a more nuanced understanding of matwòns' experiences reveals their adaptive skills, which, in part, resemble Davis Floyd's (2007) notion of a postmodern midwife, and offers opportunities for mutual accommodation (Jordan 1997[1978]). Recommendations include support and advocacy for the self-organization of Haitian matwòns, as well as their greater inclusion in efforts to improve maternal and infant health outcomes in post-earthquake Haiti.
Graduation date: 2013

In Uganda, there are an estimated 200,000 women suffering from obstetric fistula, with 1,900 new cases expected annually. These figures, combined with a persistently high maternal mortality rate, have led to an international discourse that claims the solution to improving maternal health outcomes is facility-based delivery with a skilled birth attendant. In accord with this discourse, the Ugandan government criminalized traditional birth attendants in 2010. In this study, I examine the lived experience of traditional birth attendants and women who have suffered from an obstetric fistula in eastern Uganda. Using data collected from open-ended, semi-structured interviews, focus groups, and participant-observation, I describe the biocultural determinants of obstetric fistula. Based on findings, I argue that although emergency obstetric care is critical to prevent obstetric fistula in cases of obstructed labor, the criminalization of the locally constructed system of care, TBAs, serves as yet another layer of structural violence in the lives of rural, poor women. Results demonstrate how political-economic and cultural determinants of obstetric fistula are minimized in favor of a Western prescribed, bio-medical solution, which is heavily resource dependent. This solution is promoted through a political economy of hope fueled by the obstetric imaginary, or the enthusiastic belief in Western-style biomedical obstetric care’s ability to deliver positive health outcomes for women and infants regardless of local context and constraints. Recommendations include increased obstetric fistula treatment facilities with improved communication from medical staff, decriminalization of traditional birth attendants and renewed training programs, and engaging local populations in maternal health discourse to ensure culturally competent programs.
Graduation date: 2013