I did not reply to individual responses because what they stated are all correct and reasons that I stated and is still trying to get the experts and decision makers to get.
I have been working since 1986 in a leadership role with Traditional Midwives (as we have been calling them in Liberia maybe before I was born).
There is not a delivery that happens in rural areas in in Liberia without more than one TM and sometimes a Trained traditional midwife (TTM) as we also called those who went through the MOH approved program with a process using a curriculum that was developed by the Family Health Division with stakeholders working in this area based on the policy developed by the MOH and supported fully by UNICEF.
During the war years many came to help and brought their own ideas and distorted the program instead of building on it, creating even more challenges. This was also couple with global Maternal health experts making a decision note to support TMs because they causes of maternal mortality could only be managed in hospitals.
In the early 1990s, I wrote an article in the Journal of the West African College of Nursing (WACN) essentially saying the experts had missed the mark because those were direct physical causes and the root causes were not considered as aporopriate training and supervision with the TMs being directly involved were vital for preventing MMR and that the MMR would go up instead of down. Ofcourse being a CNM from Liberia, how can she be an expert. So every opportunity I got national and international I indicated that we had a valuable resource in the TMs and if we worked with them we would be able to reduce the MMR. As a leader in RMNCH, I always insist when ever possible that we would work with TM at community level. Many times I get negative reactions but had to be creative and by the grace of God, managed to convince them to just start on a limited way and those who were negative always became advocates.
I do not know about other countries, but what I said in that article about MMR going up actually happens. In fact with this new thinking that all should deliver at facilities we are now seeing more deaths at the facility than communities. That is mainly due not involving the TMs and the health system at facilities not being prepared and ready for these clients that they are banning from delivering in the communities as stated in the responses.
Presently I will see that now most are again talking about PHC for UHC and engaging communities. However, I am very cautious as I hear people talking about CHWs. Many are not talking about TMs but rather a new cadre and now I find myself again trying to convince experts that TMs are resources at the communities and we need to support them and work with them in an appropriate role that will enhanced their abilities to work as a valuable member of the health team at the community level in not only reducing MMR but in PHC and achieving UHC.
HIFA Profile: Marion Subah works for JHPIEGO in Liberia.
Email: marion.subah AT jhpiego.org