We present the four key themes which emerged from the joint analysis of participants’ perceptions and experiences of trained TBAs’ new role in promoting maternal and newborn health following the intervention supported by HPA in rural contexts in Sierra Leone and Somaliland, and these have been used to structure the results section Theme 1 presents participants’ perspectives on the value of the training received; theme 2 the impact of the trained TBAs new role; theme 3 opportunities to strengthen integration of trained TBAs into the health system and theme 4 the challenges to realizing and sustaining trained TBAs new role. In the results SL is used for shorthand for Sierra Leone and SMLD for Somaliland.
Theme 1: Perspectives on the value of the training received
Providing training to TBAs was considered an important step by all participants. An IDI with a Somaliland MOH staff acknowledged the shortcoming of TBAs in their usual role as providers of maternity care. These two quotes refer to TBAs before they were trained to become MHPs.
“They do provide some advice and do referring if they (pregnant women) are anaemic to the nearest health post, conduct deliveries when the time of delivery is due, if the mother [is] not complicated and they feel any complications they refer to the health centres. That was their primary role but overall it was so that their role had not much helped.” (IDI, MOH representative, SMLD)
During an FGD session, women voiced their reservation about the knowledge and skills of the TBAs.
“[A] TBA doesn't know more than us, she just comes and catches the baby, she only prays to Allah, she doesn't know the danger signs. Mostly they try to do home delivery until it's very late.” (FGD, SMLD)
All trainees interviewed valued their training; which was seen as important in upgrading skills, level and in some cases as a boost to means of livelihood. For example:
“To increase my educational qualification and to give me what I can buy soap with.” (IDI, F, trained TBA, SL)
Some Trained TBAs felt that the process of being engaged in training meant that they had earned more respect from the women and their husbands and were more recognized at the community level and beyond their immediate village.
“This job has made me very popular and I now have a lot of respect in the village, even the people who don’t want to respect me do when I talk to them. Also, the training has exposed me. .. it has made me meet with different people, pregnant women and their husbands and they call me in Kamakwie and Makeni for meeting.” (IDI, F, trained TBA, SL)
A Somaliland TBA reflected on what she has gained from the training which in her view has changed the way she worked significantly.
“Before this project, we were delivering the mothers at home. We were not recognizing the danger signs … we met a lot of complicated cases, even when some mothers were dying at home because we were just waiting for the baby. We would not know…. Just we were thinking that everyone is having a normal delivery. But, after this project and during this we got a lot of trainings, we know danger signs.” (FGD, TBA, SMLD).
Theme 2: Perceptions and experiences of the impact of the training and the new TBA role.
In both countries, the training of TBAs was perceived to have had a positive impact on the communities by increased community sensitization on the need for utilization of health care services, by women and other members of the community and reduction of maternal and child deaths.
In Sierra Leone, pregnant women participating in focus group discussions discussed the benefits of utilizing hospital services and discontinuing deliveries at home. Many of them spoke about the advice trained TBAs had given them about the dangers of delivering at home and the importance of health center utilization.
“Before the training, pregnant women were dying but since this project introduced the MHPS (trained TBAs), they encourage us to go to the clinic. They advise us to come to the hospital because of well body and that if we stay at home maybe we might have sickness in our bodies and we won’t know.” (FGD, Pregnant woman, SL)
Some of the trained TBAs also said that the pregnant women were unaware of the consequences of giving birth at home but now they know because of their training.
“At first plenty pregnant women died because there is no sensitization and plenty go astray, some of them died when there are giving birth and some lost their babies but now it is different.” (IDI, F, trained TBA, SL)
Most pregnant women in Sierra Leone had very positive views about the roles of the trained TBAs and a few even pointed out some deficiencies of TBAs who have not been trained. Most of the women spoke of the roles of the TBAs assigned to their villages and many said the trained TBAs go to their houses regularly to check how they and their babies are doing and ensure they take their medicines.
“The MHP (trained TBA) goes round our houses to check if we are taking the drugs given to us, if you are not taking it she will tell you they are tablets that will help you deliver well so you have to take them. She does this always.” (FGD, Pregnant woman, SL)
In Somaliland, participants also provided similar perspectives. In their view, the training of TBAs has also influenced the health seeking behavior of pregnant women in their community.
“Now, most pregnant women understand to come to the MCH centre and have ANC. There are women who go directly to health facilities. Numbers of home deliveries are reducing in the last 5 years… TBAs can now identify risk cases, can do basic reporting orally… or she asks her child to write.” (IDI, Health worker, SMLD)
Within Sierra Leone, and as part of the post conflict health reconstruction process the Free Health Care initiative was launched in 2010 with the promise of free health care for pregnant and lactating women and under-fives. Analysis of interviews with health workers and Ministry of Health staff in Sierra Leone highlighted that even with the free health care initiative there were still many pregnant women delivering at home but since the training was completed there has been an increase in the utilization of services in the PHUs.
“I say it has changed because before we had a lot of home deliveries more than institutional deliveries, but now we have a form that is filled by the health facility staff…. you know. It contains deliveries conducted, assisted by Trained TBAs and at the end of the month they collate all the data and send them to this office. From these we can see that deliveries conducted in health facilities (are) higher than deliveries conducted in non -health facilities.” (IDI, M, MOH staff, SL)
Most pregnant and newly delivered mothers in Sierra Leone emphasized that trained TBAs had stopped taking deliveries at home and that pregnant woman were utilizing the health centers.
“No more delivery at home, if the MHP (trained TBA) knows you are pregnant she tells you whenever you are ready to deliver to just knock on her door even if it’s at midnight she will take you to the center.” (FGD, F, Pregnant woman, SL)
Different participants discussed similar positive increases in health facility delivery post training Somaliland.
“Before the project, we used to deliver pregnant women at home. Some of them have bleeding and other complications, like convulsions and blood pressure, bleeding and might die at home, but now everything has changed.” (FGD, TBA, SMLD)
“Most deliveries occur in health centres…. TBAs know that home delivery is risky.” (IDI, Health worker, SMLD).
One key informant from Somaliland gave an account of a referral for utilization she witnessed.
“I saw one mother's referral [...] to the MCH and I was at the MCH at that time. She [trained TBA] took one mother, with three babies in her abdomen, and she delivered safely in MCH and if that TBA had not transferred to us maybe the mother [she] would have had some [risk] problem....and the mother and her family, they were very happy.” (IDI, Health worker, SMLD)
With regard to maternal and child deaths, almost every participant in Sierra Leone mentioned that there had been a noticeable reduction in the deaths of pregnant women and their babies compared to what they were experiencing prior to the training of the Trained TBAs.
“It is not easy now to hear that a pregnant woman died and even the babies are no more dying.” (FGD, Lactating mother, SL)
The health center staff said since the training there has been no death recorded at all in the health center.
“The number of pregnant women dying has reduced, in fact since this training no pregnant woman has died here.” (IDI, M, Health worker, SL)
The findings from Somaliland are complemented by the output indicators (proportion of TBAs’ referral and facility delivery rates) from the project documents. During the first six months of the training, 56% of total deliveries were referred, while 72% were referred in second year and 67% in the third year of the project. On the other hand, the desk review of project documents highlighted that total numbers of women received maternity care at the five maternity centers increased from 779 in 2009 to 3296 in 2012. Routine project data elicited that there has been a steady rise in facility-based deliveries from baseline (2009) peaking by mid-2012.The SBAs working at those maternity centers reported that the changing role of TBAs and linking up with the TBA with the facility contributed partly to the increase in skilled deliveries at health facilities.
In Sierra Leone, the research was carried out within the first year of the training hence, and the number of referrals made by MHPs from June 2013–April 2014 which was 28,640 (HPA and Ministry of Health).
The analysis in both contexts highlight how all different participant groups from pregnant women, to trained TBAs to key informants perceive the training has had a positive impact on community sensitization, health center utilization and maternal and child health. Within the Sierra Leonean context, the training and new roles for TBAs coincided with new bylaws that were being enforced by local village chiefs: any woman found delivering outside the health center, and those supporting her (e.g. TBAs trained or untrained) would be made to pay a fine of 50,000 Leones, (approximately USD$10). It was unclear how often this was enforced but it emerged as an issue within the FGDs and is likely to have also had an impact on increased numbers of health center deliveries.
Theme 3: Opportunities to strengthen integration of trained TBAs into the health system.
Within the Sierra Leonean contexts, trained TBAs and key stakeholders mentioned that there were now in an era of a good working relationship between trained TBAs and the health center staff. Trained TBAs felt that there were increasingly cordial relationships between them and health workers. One trained TBA explained that whenever she brings women to the health center, she feels happy because they are given prompt care.
“We (Trained TBAs and health staff) are working well together in unity for the community and when someone wants to give birth or I come with a baby here they attend to them immediately and give them good attention. I feel very good about that.” (IDI, F, Trained TBA, SL)
This improved relationship has also been echoed in Somaliland. TBAs developed relationships with skilled birth attendants, and could call and bring women along to health centres without fear of intimidation. In Sierra Leone, SBAs were sensitized to the new role and some of them were involved in the training of the TBAs to become MHPs. Some TBAs were invited to help in the facilities. Furthermore, TBAs received feedback from SBAs on some of the women they had referred or escorted. One TBA expressed her thoughts on this.
“When accompanying the woman to the health facility, the staff receives us and welcome us very well.” (FGD, TBA, SMLD)
Health workers are beginning to increasingly recognize the role of TBAs in their communities and the value in working with them to reach the community. As one health worker in Somaliland surmised;
“No-one can reach to a community if there's no TBA.” (IDI, Health worker, SMLD)
Theme 4: Challenges to realizing and sustaining trained TBAs new role.
Distance and problems with transportation
Participants from both contexts highlighted the challenge of distance and transportation. In Sierra Leone, most trained TBAs interviewed lived more than 2 miles away from the PHU and either had to walk with heavily pregnant women or find motorbikes if resources were available. In Somaliland, most pregnant women and newly delivered mothers said means of transportation to the health facility was a big challenge. The problem of transportation was not tied to insecurity but related to hard to reach areas in the region especially in Tambakha in Sierra Leone where there are a lot of rivers.
“The biggest obstacle is transport, we know MCH centers are free but you need transport to take (you from) your home, bring you to the health facility…. After that you need someone to bring your lunch, that person also needs transport. Again, I have four young children; three of them are very small. There will be no one if my husband comes to the facility with me.” (FGD, Woman, SMLD)
In both contexts, transport challenges were compounded by the distances to heath facilities. Within Sierra Leone, health staff in one of the chiefdoms pointed out that about 42 villages accessed the health facility and some of these villages are about 25 miles away from the facility.
“One problem is distance and also Tambakha is in the red line in terms of development and index in this country. People stay far away so encouraging them to come to the health facility is a problem because some do walk long distance of 20 miles, 25miles with very rugged roads.” (IDI, M, Health worker, SL)
In Somaliland
“Our health center is quite far for some women which is about 10-20 kilometers.” (IDI, Health worker, SMLD)
Following discussions with MOH and HPA staff, we found that the involvement of the MOH from the planning of the training to its execution was seen as an opportunity to engage MOH as they aim to continue to support the Trained TBAs after the programme ends.
“We are the Ministry of Health and we are here forever and NGOs operate with funds so when the project finishes, they forget about that project but the fact that they involved the Ministry of Health and we are doing everything together. Even when they finish we will step in to make sure we continue to support the health promoters.” (IDI, M, MOH Staff)
Remuneration
The level of incentives given to trained TBAs by HPA (USD$3 per month in SL/USD$5 per month in SMLD) was perceived as insufficient in both contexts. In Sierra Leone, this emerged as a key issue from every participant that was included in the study except the chiefs. For example:
“Really compared to the amount of work the money is small because their number was large and it was out of the money that we removed to give them the group incentive so the amount is reduced. So, they do get only 15,000 Leones every month.” (IDI, F, HPA Staff, SL)
In Somaliland
“It was only USD$5 and you know that USD$5 wouldn’t do anything for you.” (FGD, TBA, SMLD).
“At least it (the incentive) helped…. The TBAs will say that the incentive that is given to them is not matching the standard they expected or the living conditions but still without the incentive, it (the project) would still have been successful as it is today. (Yes) but that needs to be reviewed, we even recommended it during that time. It depends on various conditions and the global recession, economic recession, it may not make that feasible but still it is one aspect of motivation or encouraging the role and active participation of the community and health promoters as well.” (IDI, MOH representative, SMLD)
In both contexts health workers highlighted how being trained and receiving small incentives may actually have reduced the overall livelihoods of TBAs as compared to the time when they delivered at home and received direct payments from families following a successful delivery.
“Imagine that when women were delivering in their homes in a day they get like 20,000 Leones so this 15,000 is too small for them but it will be difficult to sustain the project if we decide to give them a huge amount.” (IDI, M, HPA Staff, SL)
“Before, the TBA, when she delivered at home she would take some amount of money from the mother……. And HPA tried to change that habit and the HPA gave small benefits for TBAs…. TBAs were given USD$5 for each mother.” (IDI, Health worker, SMLD)
Disruption of farm activities and opportunity costs of being a trained TBA
Within Sierra Leone most trained TBAs interviewed complained of disruption of their farm activities since they received the training, as they always must leave their work to accompany pregnant women and their babies to the health center. Those who did not voice complaints about disruption in farm activities were the older ones who preferred to stay at the health centers with the health staff and had probably stopped working on their farms.
“Since after the training I only go to farm sometimes and most times the women call me when I am on the farm so I have to leave my work and follow them to the center.” (IDI, F, MHP, SL)
Within the focus group discussion pregnant/newly delivered mothers confirmed this saying:
“The trained TBAs even leave their farm work to come with us. If someone complains of any problem, they leave their work and take that person to the center.” (FGD, F, Pregnant woman, SL)
Within the Somaliland context disruption of farm activities did not emerge as a concern, trained TBAs were mostly internally displaced people and who did not have access to land and engage in farming. These are cattle rearing people and in this context, this is largely a male role.