Traditional birth attendants

7 April, 2019

Citation, abstract and a comment from me below.

CITATION: Weighing the options for delivery care in rural Malawi: community perceptions of a policy promoting exclusive skilled birth attendance and banning traditional birth attendants

Isabelle Uny, Bregje de Kok, Suzanne Fustukian

Health Policy and Planning 2019 [restricted access]


To address its persistently high maternal mortality, the Malawi government has prioritized strategies promoting skilled birth attendance and institutional delivery. However, in a country where 80% of the population resides in rural areas, the barriers to institutional deliveries are considerable. As a response, Malawi issued Community Guidelines in 2007 that both promoted skilled birth attendance and banned the utilization of traditional birth attendants for routine deliveries. This grounded theory study used interviews and focus groups to explore community actors’ perceptions regarding the implementation of this policy and the related affects that arose from its implementation. The results revealed the complexity of decision-making and delivery care-seeking behaviours in rural areas of Malawi in the context of this policy. Although women and other actors seemed to agree that institutional deliveries were safer when complications occurred, this did not necessarily ensure their compliance. Furthermore, implementation of the 2007 Community Policy aggravated some of the barriers women already faced. This innovative bottom-up analysis of policy implementation showed that the policy had further ruptured linkages between community and health facilities, which were ultimately detrimental to the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation in Low and middle income countries (LMICs), by focusing on the perceptions of those at the receiving end of policy change. It highlights the need for globally promoted policies and strategies to take better account of local realities.


- Skilled birth attendance is globally recommended to reduce maternal mortality and Malawi has adopted such policies.

- In 2007, the Malawi government issued a policy promoting exclusive skilled birth attendance and banning the use of traditional birth attendants for routine deliveries.

- A bottom-up analysis of the perceived effects of the implementation of this policy shows that it has aggravated the barriers faced by the poorest rural women weighing their options for delivery care.

- Promoting exclusive skilled birth attendance may be misguided in LMICs contexts and there is a need for more contextualized and socially accountable policymaking.

Comment (NPW): I note from the full text that the 2007 guideline states that TBAs would now be ‘conducting deliveries only in unavoidable circumstances’. This is a recognition that TBAs will continue to be 'in charge' of childbirth in some situations - for example, where they are called to a house and the mother is in uncomplicated 2nd stage of labour and the nearest health facility is hours away. In such situations the mother's safety is best served by the presence of someone who has basic skills in safe management of childbirth. Where there is no trained health professional available, a trained TBA could mean the difference between life and death.

I would be interested to know more about the training of lay health workers (community health workers or trained TBAs - can the latter be legitimised and recognised as trained specialist CHWs?) in managing childbirth in the home, in situations where transport to a health facility is not an option.

Best wishes, Neil

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