Source: IPS
When the ban on traditional birth attendants was lifted last year, pregnant women quickly appeared at Dorothy Chirwa's door in Malombe village in Mangochi, a district on the southern shores of Lake Malawi. Chirwa was among the thousands of TBAs banned from providing women with care in 2007.

The Ministry of Health imposed the ban, attributing the country's high maternal mortality rate to a lack of skills on the part of traditional birth attendants. TBAs, the ministry said, were not capable of quickly recognising obstetric emergencies cases and were failing to provide measures to prevent transmission of HIV from mothers to their newborn children.

During the three years that TBAs were banned, cases of life-threatening complications, such as a ruptured uterus or bladder, declined according to the president of the Association of Gynecologists, Dr Frank Taulo.

Imperfect solution

The ban seemed to be having a positive effect. In 2007, Malawi's maternal mortality rate stood at 807 women per 100,000 live births. According to figures released at the U.N. Millennium Development Goal Review in September 2010, it had fallen to 510 women per 100,000.

But behind the improving figures, a badly-stretched public health system meant that many women continued to turn to TBAs during the ban, according to Dorothy Ngoma, executive director of the National Organisation of Nurses and Midwives in Malawi.

"What happened is that [traditional birth attendants] went underground for fear of being fined. So, in terms of statistics, we were losing out, as deaths and births from these people were not recorded."

Taulo acknowledges that pregnant women do not, as a rule, enjoy adequate access to care. The association has long recommended that the government increase the number of health centres, train more people and recall retired nurses to make up the shortfall in skilled birth attendants instead of involving unskilled people.

Two out of three positions in Malawi's public health system is unfilled, according to current statistics from the Ministry of Health.

Ban lifted

On his return from the MDG summit in September, Malawi president Bingu wa Mutharika caught everyone by surprise when he reversed the decision to ban TBAs.

"Traditional birth attendants should not be stopped from practicing. Instead they should be trained in safer methods of delivery," Mutharika said.

The ban was immediately lifted. "Women in labour started knocking on my door right away demanding that I assist them in giving birth," Chirwa told IPS.

Chirwa's home area, Malombe, perfectly illustrates the demand for birth attendants' services: it is about 70 kilometres to Mangochi District Hospital, the nearest health facility which provides maternity care.

"I cannot turn the women away. I know a number of women who have given birth right on the road on their way to the hospital. Many pregnant women find it difficult to travel the long distance. The road has so many rivers and streams, passing right through it. It is difficult for many women in labour to cross over and some give birth on the river banks," she said.

Chirwa admitted that the service she and other traditional attendants provide in communities across the country is not perfect.

"There are some complications which I cannot handle. I was comfortable with the ban but I cannot refuse to render services to the women who are so much in need," she said.


But the gynecologists' association is not impressed. "We are puzzled that Malawi is going back to a policy of allowing TBAs to deliver babies. How will TBAs help in case of pregnancy complications in the absence of a medical facility?" asked Taulo.

The unbanning also provoked concern in several communities. In Pitala Village in Mchinji, Central Malawi, the village had established various task forces and committees on safe motherhood, under the leadership of the village chief.

"We adopted by-laws that stopped traditional birth attendants from delivering babies and also prohibited women from giving birth at a TBA's house. Offenders would pay fines to the chief and the payment ranged from a chicken to a goat," said 59-year-old Pitala resident Margret Dambe.

Dambe, whose 25-year-old daughter died in labour in 2005 while being cared for by a traditional birth attendant, told IPS that she sees no merit in bringing back the unskilled TBAs.

"It is not safe to be attended to by a TBA. My daughter died because she lost a lot of blood while giving birth and the TBA could not carry out a blood transfusion," said Dambe.

The National Organisation of Nurses and Midwives in Malawi insists that the long-term solution must be to increase the number of trained midwives to fill the gap imperfectly filled by traditional birth attendants.


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