My pride, fame and fortune in this calling[vocation] are not in the mansions that I have built nor in the cars in which I pull, but in the countless many who will point to my tomb and say, we are the reason for which she lived! When my tomb will be cemented, decorated and why not made a monument? That to me is true remembrance and the real value of the services that I am offering to my society ( informal discussion with Mama Tabita, Traditional Birth Attendants (TBA) from Nwa sub-Division of Cameroon, 2011)
The quote above are the words of a TBA and her take on the on the services that she offers to the society. This research explores whether or not, this is a shared view among TBAs. Also, the research seeks to understand if; there is an element of misrecognition in how the services of TBAs are perceived.
As a pre-puberty girl growing up in rural Cameroon, I was one day traumatized by a TBA who called me to assist her in a roadside obstructed labour case in Bafanji village in the North West Region(then province) of Cameroon. This call separated me from the rest of my school mates. I saw myself as a woman who will one day give birth, and the experience shocked me deeply. I could not even give the blade which the TBA asked me to give for her to use in cutting the placenta. As I struggled with my shock and fright, the bleeding woman who had been walking for kilometres to reach the nearest clinic lay helpless, while the TBA who had been called from her farm continually scolded me. This experience aroused mixed emotions in me who ended up being curious to see how a baby was born, as well as having empathy with the bleeding woman.
With these mixed feelings, I left the scene for home where I narrated the experience to my grandmother. However, unusually, she did not listen patiently that day. She instead showed anger saying that, ‘they were spoiling me as a child’. She murmured for hours making very many negative exclamations as to how thoughtless the TBA had been. As though the murmuring was not enough, she left and went to inquire what had happened. To her shock, she met other women busy trying to curb the woman’s bleeding which did not stop until she passed away. She came back weeping as she narrated the story.
In 1996, just three years after the first scare, we as a group of secondary school girls coming back from school were called to stand around another woman giving birth on the roadside in Nchimekone quarter Pinyin, Santa Sub-Division so that, our male mates should not see how the baby was being born. I felt sorry for both the baby and mom, but then wondered what really was wrong with women. However, I grew older; I continued to encounter similar birthing situations and came to realized that, it is a common phenomenon in most parts of rural Cameroon.
In this regards, the present research sought to understand the dynamics of maternal health service provision in rural Cameroon where women are caught between employing the services of TBAs and using health centre/ hospital facilities(here after, ‘formal health care system’). To do this, the rest of this paper is structured as follows. The following part presents the research problem and questions, part three describes the research methodology, part four presents the major research findings, as well as their policy implications for rural maternal and reproductive health service provision. Throughout this research, the term ‘skilled attendants’ (qualified nurses and midwives) will be used to refer to professionals in the ‘formal health care system’. The use of ‘skilled’ in this way has nothing to do with implying that TBAs are unskilled. It is simply for differentiation purposes since both TBAs and midwives have skills.
Problem of study
Prior to the introduction of Western medical practices, women gave birth at home and each society had a way to identify, follow up pregnancy and subsequently attend to delivery through TBAs1. Statistics published in 2004 for rural Cameroon, report that 57.5% of the women who die from a birthing related circumstance die in the house2. Similar statistics in other parts of the developing world have raised a global call for concern about women’s health especially that, 99.6% women who die in childbirth live in places where access the formal health care system is difficult3 and 60% of the births occur outside the formal health care system, assisted only by TBAs, family members, or without any assistance at all4. In this situation therefore, TBAs who cannot handle haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortions which account for 50 to 75% of these deaths5 are criticised for a significant part of high maternal mortality.
View these; mainstream policy has been to train TBAs in biomedicine which is said to be capable of handling haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortions thereby reducing the high rates of maternal mortality3, 6. This has since the 1987 Safe Motherhood Initiative, sparked wide scale research to understand the contribution of training TBAs in the battle to reduce maternal mortality. However, the researches came to quite divergent recommendations. For some, training TBAs can help reduce maternal mortality7, 8 . For others, the training of TBAs is not productive and sponsors should consider alternative health investments9. Nonetheless, some of the researchers still argue that, although governments are being persuaded to ban TBAs10, they are not to blame11 because, majority of the deaths are not defined by the TBAs12.
Following these mixed stances taken by the various researchers in their policy recommendations, policy, at least at the level of implementation, is also mixed when it concerns TBAs in rural Cameroon. In some instances, they are trained7 while in others; they are not trained and have remained the scapegoats blamed for high maternal mortality thereby, making the subject of TBAs and their services an issue of controversy in rural Cameroon. But overall, despite “the actions taken by the government and some of its development partners to reduce maternal mortality23”, there has been no significant reduction in maternal deaths in the country since 199021. Rather, according to the available health statistics for Cameroon, a woman dies almost every hour from complications related to pregnancy and childbirth22 with mortality rates that range between 669 deaths per100.000 deliveries23 and 705 deaths per 100.000 deliveries24. To this effect, the subject of TBAs and their services remain an issue of controversy in rural Cameroon.
Considering this death rate and the tendency to blame it on TBAs2, the present research sought to understand the following: which factors account for the persistent demand and supply of the services of TBAs even in rural areas where there is a formal health care system? Do pregnant women employing their services consider the risks involved? How do TBAs themselves perceive of the services that they are offering to society?
According to Pereza and Tih, the ideal scenario, is when “every woman would give birth in a health facility in the presence of a professional health worker25”. However, considering the socio-cultural and economic contexts of most developing countries, maternal health needs to be tackled as a public-health issue whereby there is a consideration of community interventions as being complementary to care received in health facilities25”. On the same footing, Kamga and others in a 2012 study on “the appreciation of Traditional Birth Attendants’ services in Cameroon in the context of HIV/AIDS in Cameroon26” s how that, out of a total of number of 2566 survey participants, 74.6 % of them living in rural areas showed a satisfactory appreciation of the activities of TBAs.
Connecting this high appreciation of TBAs in rural Cameroon, it could be thought TBAs could play a very important and complementary role in the public health endeavour of reducing maternal mortality in rural Cameroon. Moreover, this qualitative rating of the activities of TBAs in rural Cameroon, rhymes very well with quantitative national statistics which suggest that, of a total number of 4547 rural inhabitants sampled, up to55.6% of them received maternal assistance outside a formal health care system,“ 18.6 % of whom were assisted during delivery by a TBA , 29.7 % assisted by a relative or other and 7.3 % delivering on their own27”. View these, it undeniable that TBAs play a significant role in rural maternal and reproductive health provision. However, what remains unclear is why, rural women continue to highly appreciate their services whereas, most if not all of them cannot handle haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortions which account for majority of maternal deaths 5. To this end, it is important to understand the factors that account for the persistent demand and supply of the services of TBAs. Also, it is important to understand if pregnant women employing their services consider that there risks involved? And finally, how TBAs themselves perceive of the services that they are offering to society and what motivates this perception? This are the questions that the present research sought to answer.
This paper is part of a larger ongoing research on “community responses to maternal deaths: perceptions, causes and interventions”. The findings analysed here in, were collected during a three months research in Cameroon between the months of October to December 2011 using ethnographic methods.
Cameroon is located in the gulf of Guinea and shares boundaries with Nigeria to the west, Chad to the north, Central African Republic to the east, Gabon, Equatorial Guinea and Congo to the south. The country has an estimated population of about 20 million inhabitants33 with 48% living in urban areas and 52% living in rural areas26. In total, 51% of the Cameroonian population are women among whom there is a birth rate of 33births/1000 population, 56% of which occur in rural areas34. The research sites can be seen located on the Country’s Map in Figure 1.
Figure 1: Map of Cameroon with an indication of the research sites
illustration not visible in this excerpt
Source: Copied but adapted from ‘Daniel Dalet/D-maps.com’ by the Author.
As can be seen from Figure 1, this research took place in three (Northwest, West and East) of Cameroon’s ten administrative regions. In the Northwest, the research was conducted in Mezam, Ngohketunjia and Menchum Divisions. In Mezam Division, Mbelluh (including Mudum and Njimbat) in Bali sub-Division, Fingue in Tubah subdivision and Pinyin in Santa subdivision were visited. In Ngohketunjia Divion, the research took place in Bafanji and Bamumkumbit in Balikumbat subdivision. In Menchum Division, Benakuma, Bosung, Benader all in the Menchum Valley subdivision were visited. In the West Region, the villages of Memfung and Bagam in Galim subdivision of Bamboutus Division were visited. In the East Region, Banana in Moloundu of the Boumba et Ngoko Division and Myos, Lossou, and Koumanjab of the Upper Nyong Division were visited.
The choice of these three Regions was based on the following: the East Region is reported to be one of the regions in the country where more deliveries are attended to by TBAs because of poverty and long distances to access health facilities26, 2. The Northwest and West Regions are reported to have relatively fewer women who employ the services of TBAs26. In this light, conducting the research in these regions was perceived to be the best way to find out what is central in the practice of TBA beyond the already well known factors of poverty and lack of access to the formal health care system.
The choice of villages within these regions was determined by differential access to formal health care. Mbelluh, Pinyin and Bafanji fitted into the criteria of choice, and were also villages in which firsthand personal experiences of births outside the formal health care system were encountered in my past.
The research was conducted with TBAs, skilled attendants in both the private and confessional sectors, rural as well as ‘indigenous’ women. The women participants were aged between 23 and 50 years and included the following categories:
- ‘indigenous’ (Mborroros and Baka ‘pygmies’),
- women who were expecting their first babies and had never attended prenatal care, but hoped to rely on the assistance of a TBA to initiate them into the birth process,
- women who never used the services of a skilled attendant for all their births,
- women who started giving birth in the formal health care system but later switched to TBAs,
- women who started to give birth with TBAs but switched to skilled attendants,
- women who switched between TBAs and skilled attendants depending on the necessities (if complicated as indicated by cultural norms, the services of a TBA were sought but if a normal and simple pregnancy, it did not matter), and
- women who had family relationships with TBAs
- 20 in-depth Interviews were conducted with women from all the categories described above.
Five Focus Group Discussions lasting between 90 to 120 minutes were also conducted with;
- women who started giving birth in the formal health care system but later switched to TBAs,
- women who started to give birth with TBAs but switched to skilled medical assistants ,
- Women who switched between TBAs and skilled nurses depending on the style of the child.