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
