Working with Traditional Midwives
to Save Lives
Home birth is a long-standing tradition in Liberia, with 63% of women delivering outside of the health facility. However, Liberia also has a high rate of maternal mortality—994 deaths per 100,000 live births—due in large part to pregnant women’s inability to get from their homes to a health facility in obstetric emergencies (LDHS 2007). Africare/Liberia, with funding from USAID through the Improved Community Health Project (ICHP) and the Rebuilding Basic Health Services in Liberia Bridging Project (RBHS), has addressed this issue by creating a link between the clinics and the women who make up the front line of maternal health care—traditional midwives (TMs).
Recognizing the culture of home birth and the wealth of cultural, contextual, and traditional knowledge among TMs, the ICHP worked with the American College of Nurse-Midwives (ACNM) and the Ministry of Health and Social Welfare of Liberia (MOHSW) to develop the Home-Based Life-Saving Skills (HBLSS) training. HBLSS makes use of the TMs’ respected roles in their communities and shifts the focus of their work from birthing to encouraging birth preparedness, recognizing and referring complications, and appropriate community-based emergency obstetric care.
Many countries employ with Community Health Workers to provide health care in the home, but an essential part of the HBLSS training that makes it unique is the link that it forms between the TTMs and the local health facilities. Trainers are certified midwives (CMs) who work in community clinics and health centers, and HBLSS training gives them a chance to connect with their TM colleagues and work directly with the community members they support. Collaboration continues after the training, with the CM conducting outreach visits and holding monthly meetings at the clinic to collect reports, share experiences, discuss problems, replenish supplies, and reinforce training. Since the trainings, many TTMs have begun escorting their patients to the clinics for antenatal care, delivery, and post-natal care, and CMs have responded by establishing specific clinic hours for this purpose. This community-clinic link creates a relationship between TTMs and CMs in which they are no longer competitors, but colleagues, forming a team to ensure that women are able to experience motherhood safely.
Ma Garmai Smith, a TTM from Saysayla, Bong County, has increased her referrals since her HBLSS training. In the case of “big belly women” who “are bleeding plenty, have swollen legs and face, have been in prolong labor, have undergone an operation, have a very tiny structure, are teenagers with their first deliveries—these kinds of cases I don’t waste no time but bring the woman in labor to the Salala Clinic quick.” This new knowledge has not only saved lives, but also has been rewarding to Ma Garmai, who says, “a safe delivery brings me satisfaction and joy as a midwife.” Ma Garmai is not alone in her determination to refer women for safe deliveries: in Bong County alone, facility deliveries increased from 9% to 23% over the course of 2008 (RBHS 2009).
The HBLSS training developed by Africare’s ICHP and the ACNM was adapted nationally in December of 2007 in order to aid in Liberia’s goal of reducing maternal mortality by 15% by 2011 (PRS 2007). With the support of the MOHSW, over 2000 TMs have been trained to become TTMs in the past year in 14 counties nationwide, and these individuals have reached over 10,000 community members with live-saving services and messages of safe motherhood. In addition, 10 mater trainers and 20 second-level trainers have been trained from County Health Teams, local NGOs, the MOHSW, and health facilities, ensuring that the training will remain sustainable. USAID will continue to support this successful training intervention under the five-year RBHS project beginning in May 2009. With a strong cadre of trusted TTMs, Liberian women can now begin to face motherhood without fear.The Improved Community Health Project and the Rebuilding Basic Health Services in Liberia Bridging Project are implemented by Africare/Liberia in collaboration with the Johns Hopkins University Center for Communication Programs. This activity is made possible by the generous support of the American people through the United States Agency for International Development (USAID). USAID administers the U.S. foreign assistance program providing economic and humanitarian assistance in more than 120 countries worldwide.