A ban on traditional birth assistants (TBAs), which has been in place since 2007, was effectively lifted by Malawi's President Bingu wa Mutharika on return from a recent UN Summit on Millennium Development Goals in New York.
The lifting of the 2007 ban on TBAs still requires Ministry of Health approval, the issuing of guidelines, and consultation with stakeholders, but according to health practitioners, the president's pronouncement "will now allow them [TBAs] to come back and operate openly."
A 2004 Malawi Demographic and Health Survey said the maternal and infant mortality rate was 984 per 100,000 live births, translating into 6,000 maternal deaths each year. The current estimate, collated from inter-agency projections, was 510 maternal deaths per 100,000 live births.
Mutharika said on arrival: "We need to train traditional birth attendants in safer delivery methods. We should not completely stop them because their work is very important. We should train them to assist us in addressing the health challenges that we are facing."
The rationale for the 2007 ban was that low-skilled TBAs were unable to identify obstetric emergency cases early enough. Delays caused by poor transport infrastructure and the paucity of medical facilities contributed to the high incidence of maternal deaths.
It was hoped that by preventing TBAs from practising, mothers would utilize the country's medical facilities, but nearly half of all deliveries still occur outside medical facilities.
Dorothy Ngoma, executive director of the National Organization of Nurses and Midwives in Malawi, said TBAs continued to exist because the health system failed to provide services.
She told the national daily newspaper The Nation: "They [TBAs] never really stopped... What happened is that they went underground for fear of being fined a goat. So, in terms of statistics, we were losing out, as deaths and births from these people were not recorded."
|They [TBAs] never really stopped... What happened is that they went underground for fear of being fined|
Ngoma said a system should be established for a two-year training course for midwives, and then the work of TBAs would wither as people recognized the benefits and availability of qualified medical personnel.
The World Health Organization estimates there are about two doctors and 59 nurses for every 100,000 people and that in 2006 the vacancy rate for nurses stood at about 65 percent. About 59 percent of Malawi-born physicians were practising outside the country.
The statistics further mask the skewed distribution of health infrastructure which is concentrated in urban areas, even though about 70 percent of the 15 million population live in rural areas in one of the world's poorest countries.
Two weeks training
Victor Chinyama, Malawi spokesman for the UN Children’s Fund, told IRIN TBAs had about "two weeks training, probably less", when ideally training should be for about three months, "so they [TBAs] are able to recognize at an early stage any [birth] complications".
He said the linkages between TBAs and health services had to be strengthened, and communications improved with clinics so they were able to respond to emergencies, for example by using motorcycle ambulances - a motorcycle fitted with a stretcher on a sidecar.
Chinyama said in Malawi about 90 percent of women attend the first ante-natal clinic at three months, and "after that you never see most of them again".
Adamson Muula, a lecturer in community health at the Malawi College of Medicine in the country's second city Blantyre, said: "If government plans not to use TBAs any more, then a safe alternative must be identified. In many cases, not all women, even if they wanted to, would end up delivering at hospital. Again, if just 70 percent of all pregnant women were to deliver at hospital, the hospital system would not cope."
Ernest Mngoni Mahwayo, a resident in the capital Lilongwe, said TBAs were part of Malawian society. "Not many families can afford to have babies delivered in good hospitals. Those that make it to hospitals have to stay for days, and that means they have to fend for themselves. These women find it cheaper to deliver in their villages where a TBA will attend to them."
Miriam Chimbalanga, a mother of two living in Chiradzulu, a town near Blantyre, said: "It was a TBA who helped me deliver my second child. I know of several women who have delivered all their children with the assistance of TBAs. It’s good to hear that they can now practice without fearing anyone."
Constance Milanzi, a mother of three living Lilongwe, told IRIN: "There should be a deliberate policy to force every TBA to undergo training. More women are dying because they find themselves in the hands of people who do not know the basics of safe motherhood."