Achola bridges the gap between TBAs and midwives

Mar 21, 2011

INSIDE the illuminated maternity ward in Tororo Hospital, a mother rests on a raised stool. The last rays of the sun filter through the thick window pane into the ward.

By Daniel Edyegu

INSIDE the illuminated maternity ward in Tororo Hospital, a mother rests on a raised stool. The last rays of the sun filter through the thick window pane into the ward.

Opposite, a cluster of fairly neat sheets are piled up on the white leather delivery bed, just beneath her stare.

The pile occasionally stirs up as though swept over by mild wind – then goes still. The mother smiles reluctantly and watches on with curiosity. From the weary look on her face, she seems lost in thought.

The silence is broken when a midwife arrives to check on the progress of the mother and her newborn baby wrapped in the pile.

“I’m fine, and so is my baby. It’s my first birth. An elderly traditional birth attendant in my village, Amoit Opendi, advised me to come and deliver here. She took me through the difficulties first mothers face during child birth such as hemorrhage and obstructed labour,” beams Lydia Abbo, 24, from Nyakisi village in Rubongi sub-county.

Unknown to Abbo, Roselyne Achola, 37, in charge of training traditional birth attendants (TBAs) about maternal health care and referring them for delivery at the health units, is standing nearby, closely following the conversation.

Achola, a social worker with THETA, a civil organisation promoting the collaboration between traditional and biomedical health systems, coordinates the community-based prevention of mother-to-child transmission of HIV/AIDS (PMTCT) project in Tororo.

The programme, initiated by THETA to promote PMTCT uptake in health units, is funded by the Centre for Disease Control (CDC), a US federal agency under the department of health and human services.

It is an idea that was born out of the dilemma medical personnel had with TBAs. Whereas they possess limited skills to handle complicated child births, the TBAs stood as a stumbling block towards increasing safe births in health units.

Realising how revered TBAs are in the district, Achola sought not to alienate but integrate them into the campaign on maternal health care.

Her start
In 2005, she held a meeting with TBAs within the initial project catchment sub-counties of Mulanda, Nabiyoga, Iyolwa, Nagongera,Petta, Rubongi and Kisoko in West Budama South County.

“The first meeting I had with the TBAs gave me an insight into why women prefer delivering at their hands rather than midwives in health units. They told me midwives were harsh to the expectant mothers and castigated the TBAs. So there was a wide gap between the TBAs and the midwives,” Achola says.

In the subsequent meeting, Achola met the midwives at Tororo hospital, relayed the ideas she had gathered from the TBAs and sought better ways on how to forge a work relationship between the TBAs and midwives to bolster maternal health care in the district.

Despite the initial resistance from some midwives who saw the TBAs as the main cause of the high maternal mortality rate in the district, the meeting brought to the fore issues which, if addressed, would gradually change the face of maternal health care.

A follow up training for the TBAs on how to integrate modern medical practices in their day-to-day chores and demarcation of boundaries on what cases they were to and not to handle is what was required to set the ball rolling.

Except for normal births and emergencies such as sudden labour pains and deliveries late in the night, the TBAs were stopped from handling obstructed births, mothers with HIV/AIDS, twins, had more than five births, with excessive bleeding or mothers who had undergone surgery.

Achola then distributed the referral forms to the TBAs to direct mothers to the hospital for antenatal care and delivery.

For the next six months, Achola combed West Budama sub-county with a few midwives to educate the TBAs on the new strategy and personal hygiene at their homesteads so they could set an example to the mothers who seek their services.

Achola says their focus was on pit latrines, plate stands and general cleanliness. “It wasn’t easy though. It was like picking bread from the mouth of someone and giving it away.

“At first, TBAs were reluctant to refer the mothers because it’s where they earned money, soap and chicken. I kept on explaining to them the advantages of mothers delivering in health units. I also tasked them to hand over to Tororo Hospital the referral forms indicating the number of mothers they had referred,” Achola says.

Programme expansion
With resillience, the efforts paid off. The number of referrals to the main hospitals became overwhelming, prompting CDC to recommend the programme be rolled out throughout the district in 2008.

To absorb more mothers, the district gazzetted Mulanda and Iyolwa health unit as referral centres for mothers. The programme has also expanded to Kumi, Bukedea and Rakai.

This spelt one thing – that Achola had to devise means of taking on the new challenge that came with the additional areas of operation. She trained more TBAs and brought on board the village health teams (VHTs) throughout the sub-counties in Tororo, the municipality and additional district to participate in the programme.

VHTs are community members at village level that aim to improve health status of the people. Each parish was allocated two male and female VHTs to educate the communities on maternal health care.

Achola says whereas the female VHTs are charged with identifying pregnant mothers in the parishes and referring them for antenatal care, the male counterparts comb the social joints such as drinking places, to educate men on how to care for their pregnant wives, voluntary counselling and testing, and family planning.

Challenges
In a district where traditional beliefs pertaining to child delivery are firm among the local communities, the VHTs and TBAs have jointly helped to demystify the stereotype surrounding modern maternal health care and medicines.

Achola says: “Culture here holds that a child is pushed at any time. Elderly women tell young mothers that they pushed their babies in the kitchen. They add that in case a mother prepares for the baby, it won’t come. We tell them that those beliefs are outdated.

“So we advise mothers to engage in income generating activities to earn money that can help them afford transport to the health unit and other basic needs. Labour pains do not telephone or send a message that we are coming,” Achola stresses.

Perhaps where Achola has come face-to-face with the gruelling realities her maternal health care campaign, is mothers who test HIV-positive. As a requirement to accessing antenatal care, all pregnant mothers undergo voluntary testing and counselling.

“When a mother tests positive, at times we withhold the results but counsel her to come along with the husband for the next visit. Then we divulge the results to the couple after thorough counselling. Experience has proved that men don’t accept responsibility of transmitting the disease. Consequently, such marriages usually end up in divorce,” Achola observes.

Achievements
Last year, the district recognised Achola as the woman achiever of the year for her aggressive role in stepping up awareness on maternal health care.

This month, Achola graduated with a doctorate in public health from Uganda Christian University, Mukono, a qualification she says will better her work with the communities.

In Tororo, she has become a household name. All new born babies in the rural areas born in health units are referred to as “Roselyne’s babies” while mothers who deliver in the health units are called “Achola’s women.”

“I derive satisfaction from seeing mothers delivering in the health centres,” Achola says.

And the medical personnel at Tororo Hospital could not have missed the changes the campaign has brought forth. Agnes Onyango, the principal nursing officer at Tororo Hospital, says in last six years, deliveries at the hospital have soared from about 100 to over 200 and 250 per month.

This, Onyango says, has reduced maternal mortality rates.


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