ETD Collection

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    Stakeholders' perceptions of the changing role of traditional birth attendants in the rural areas of central Wets zone, Malawi: a mixed methods study
    (2014-03-28) Banda, Evelyn Chitsa
    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.
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    Self referral of women in labour at Chris Hani Baragwanath Hospital after the introduction of a triage down referral system
    (2013-01-25) Dlakavu, Welekazi Fuziwe
    Background and objectives There has been a steady annual increase in the number of deliveries performed at Chris Hani Baragwanath Hospital in recent years. A 2004 audit found that approximately one third of deliveries conducted at the hospital were of women who had referred themselves and were low risk and as such did not require delivery at a specialist centre. A triage down-referral system back to midwife obstetric units was implemented in 2008 to address the problem of low-risk self-referrals at the hospital. This study was conducted after the establishment of the triage system to find out whether the establishment of the triage system had been accompanied by a decrease in the proportion of self-referred women presenting to Chris Hani Baragwanath Hospital in labour, and to assess delivery outcomes in these patients. Literature review The literature review was conducted using Pubmed and MDConsult using the key words self referral, triage, gatekeeper, low-risk pregnancy, maternity / labour and referral systems. Relevant references were accessed via the University of the Witwatersrand eJournal portal. Appropriate articles cited by other authors were also reviewed. Appropriate websites were also used and referenced. Methods This was a retrospective descriptive study which included all women presenting in labour to the hospital maternity admissions area. The study population was clinical case-files of all births that were admitted in labour from 1 May to 31 May 2010. A simple random sample of these files was drawn. Results One hundred and eighty two intra-partum admissions were sampled. Thirty-five (19%) of these women were self-referred. Seven out of the 35 (20%) required caesarean sections. Five more (14%) needed oxytocin augmentation of labour, and one more (3%) had a vacuum delivery. Twenty women (57%) did not develop any complications during labour and could have been delivered at their midwife obstetrics units. During the month of the study, the triage down-referral system attended to 171 women and down-referred 83 (49%). Conclusion The establishment of a triage down- referral system has been accompanied by a curtailment in the number of low-risk pregnancies presenting self-referred at the referral hospital labour ward, compared with the audit in 2004.