Aimable Twahirwa

KIGALI, Sep 30 2010 (IPS) – Two years spent training traditional birth attendants in remote rural areas has allowed Rwanda to reduce the country s maternal mortality rate, says the country s health department.
In Rwanda, where almost half of all women give birth at home, the majority of traditional birth attendants (TBAs) are non-professional practitioners who rely on skills passed on to them by elder women in the community. Many of them use un-sterilised equipment, sometimes causing mother and baby more harm than good.

Yet poverty-stricken, expecting mothers largely rely on TBAs because they lack access to public health services since they don t have the means to pay for transport to the nearest clinic or hospital.

Laetitia Mureshyankwano, a 42-year-old mother of two who lives in the mountainous southern district of Gisagara, says she gave birth to five children with the help of TBAs, but only two babies survived the delivery.

Like Mureshyankwano, many rural women say they have gone through a lot of suffering when they had complications with their pregnancy, while others tell of fear of being infected with HIV due to insufficient safety precautions and sanitation.

Although they put on gloves and aprons for the delivery process, we don t feel safe because we don t know how clean their tools are, explains Mureshyankwano. She believes government s TBA training programme has been a good initiative towards improving the situation of pregnant women who live in remote areas.
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According to statistics from the United Nations Children s Fund, in 2008, Rwanda reported a maternal mortality rate of 750 deaths per 100,000. The national health department is confident that the next report, due in 2011, will show a strong improvement over this baseline.

At the United Nations Millennium Development Goal (MDG) summit in New York City in September, Rwanda was applauded for the significant progress it has made towards achieving MDG 5 of improving maternal health.

Government is committed to reach a target of zero deaths because no woman should die during child birth, notes Ministry of Health permanent secretary Agnes Binagwaho, adding that though the TBA training programme, this commitment has become a reality because communities are better served.

To reduce maternal and child deaths, the Rwanda Ministry of Health launched a training programme for TBAs in August 2008 that teaches them basic nursing and midwifery skills. Through the programme, the health ministry also hopes to address the country s general shortage of health workers, particularly in rural areas.

Rwanda has less than one midwife per 10,000 people, according to department s statistics.

Traditional birth attendants who have not gone through the training programme are officially prohibited from delivering babies and instead help to monitor pregnancies, encourage women to get regular antenatal care and educate them about potential problems.

To further assist the newly trained TBAs, the Department of Health also provided mobile phones to 432 community health workers (CHWs), who are responsible for maternal health on district level. Through them, TBAs can now report difficult cases, complications or emergencies to the nearest clinic or hospital.

Government also purchased 67 ambulances, one for each district hospital, to make sure pregnant women in remote areas can access emergency care.

Health department officials said they were unable to disclose the budget made available for the TBA training programme and related initiatives.

The health department acknowledges that it will have to continue to invest in maternal health care. Other maternal and sexual health-related services, such as family planning, will also need a boost.

To make the TBA programme sustainable in the long-term, it will be crucial that trained TBAs receive a level of remuneration that will encourage them to keep working in rural areas instead of seeking jobs at urban hospitals and clinics like many skilled health workers have done in the past.

Marie Rose Mujawamariya from Kamonyi district, an hour south of Rwanda s capital Kigali, is one of the TBAs who recently participated in the health department s training programme.

She doesn t receive a salary from the health ministry as yet, but says she hopes the training will help her create a better source of income for herself.

Where her clients previously negotiated a fee for her services, Mujawamariya plans to charge $10 per delivery based on her new skill set.

While Mujawamariya used to assist women to give birth based on what she learned from her grandmother, she now proudly talks about her new midwifery skills, such as checking up on the position of the unborn to make sure a natural birth can take place or gauging when medical assistance is necessary.

I can now help women to deliver safely, she declares.

Says Mujawamariya: This move [to provide TBA training] gives hope that mother and child health will be taken care of.