Malawi is planning to change the role of Traditional Birth Attendants (TBAs) in an attempt to reduce one of the world's highest rates of maternal and infant deaths.

A 2004 Malawi Demographic and Health Survey said the maternal and infant mortality rate was 984 out of every 100,000 live births, translating to 6,000 maternal deaths each year.

But such a move, observers say, does not take into account the already overburdened public health system, which would be overwhelmed if TBAs were removed.
Adamson Muula, a lecturer in community health at the Malawi College of Medicine, in the commercial capital of Blantyre, said less than half the women in Malawi delivered their babies at recommended hospitals, "yet the system is overtaxed."

"If government plans not to use TBAs anymore, then a safe alternative must be identified. In many cases, not all women, even if they wanted, would end up
delivering at the hospital. Again, if just 70 percent of all pregnant women were to deliver at the hospital, the hospital system would not cope," he said.

Birth attendants shoulder the blame

Sabinna Mlusu, the District Nursing Officer in Blantyre, said the reason for government ending the practice of licensing TBAs was the discovery "that most maternal and infant deaths are caused by delays in arranging transport from homes of TBAs to clinics, and then to referral hospitals. Such delays ended up complicating cases which TBAs could not treat."

She said the majority of deaths were a consequence of such complications as internal bleeding and high blood pressure, which required emergency medical attention only available at public and private clinics.

Diana Khonje, neonatal health officer at the Reproductive Health Department in Malawi's Ministry of Health, said government would not completely discard the TBAs, but that they would no longer perform the duties of midwives.

"They have been given a new roles. One of them will be to arrange transport for expectant women to clinics and teach lactating mothers the importance of breast feeding," Khonje said.

She dismissed concerns that removing TBAs from the loop would exert an added burden on public health facilities. "There is enough capacity in our hospitals to handle maternity cases. The problem is that most women are ill-informed ... [often] by the same TBAs who were getting paid for the services rendered."

She said the process for switching the TBAs from handling expectant mothers would be gradual. "We believe in their new roles the TBAs will help government to reach out to the rural poor who are ... [mostly] ill-informed about childbirth and breast feeding."

Chimota Phiri, the Blantyre District Health Officer, told IRIN that the government was also using traditional leaders to convince people to stop using TBAs. "People tend to listen much more to what their traditional leaders tell them than anyone else. Chiefs must therefore tell people the importance of coming to hospitals with problems affecting their health."

He said the country's high maternal and infant mortality rate was a consequence of home births. "Such unsafe conditions cause infections to both the mother and the baby, which, in most cases, lead to death."

But not all traditional leaders accepted that the high rate of maternal and infant deaths could be attributed to TBAs. Chief Kabunduli, from northern Malawi, said government should also shoulder some of the blame. "Experience has shown that most maternal and child deaths occur in houses of TBAs, but it is government that accredits these people."

Charles Munthali, a health official from the same region, said in one district only 4,000 of the about 10,000 expectant mothers had visited a hospital for antenatal services. "Maternal and newborn deaths are avoidable, but most women prefer to go for deliveries by unskilled TBAs."

Challenges and strategies

The United Kingdom Department for International Development (DFID), which has donated about US140 million to Malawi for 2006/07 - including $40 million for budget support, another $40 million for health and HIV/AIDS, and $14 million for education - said there were evident challenges in the health sector, as the maternal mortality rate had risen by more than 50 percent since 1992.

However, at the same time, the under-five mortality rate had declined to 133 deaths per 1,000 live births in 2004 - a 43 percent reduction in 12 years - and was on target to reach the 2015 Millennium Development Goal in this category.

The UN Children's Fund (UNICEF) estimates that almost half of all births in developing countries occur without a skilled birth attendant present. Globally, 529,000 women die every year in pregnancy or birth, according to the World Health Organisation (WHO).