Background
Since adopting the Sustainable Development Goals (adopted by the UN member states in 2015), Sub-Saharan African countries have found it challenging to achieve the related maternal health promotion targets. The global aim is to limit the maternal mortality ratio (MMR) to 70/100,000 live births [
1]. In rural areas of Tanzania, nearly half the women still give birth outside health facilities, so these areas continue to experience a high MMR and raise the national MMR of 556/100,000 live births [
2]. Despite fertility rates being higher in rural areas of Tanzania, health workers and facilities remain concentrated in urban areas. Hence, homebirth rates are much higher in rural parts of the country than in urban areas (urban: 16.8% vs. rural: 56.1%) [
2].
The healthcare system of Tanzania faces difficulties in functioning properly owing to several factors, including increasing population, shortage of healthcare providers and medical materials and facilities, decreasing motivation of healthcare providers, and the double health burdens of communicable and non-communicable diseases [
3]. Although the government has been aiming to increase the number of facilities, the development of human resources in the healthcare field remains a big challenge in the country. The health workforce of Tanzania relies heavily on practitioners who have received brief training courses, with nurses and midwives accounting for 27% of the total national healthcare workforce. This percentage is much lower than that of other African countries (about 50%) [
3].
Regarding strategies to promote universal access to pregnancy and delivery care, the incorporation of traditional birth attendants (TBAs) into the healthcare system alongside formal healthcare providers (i.e., skilled birth attendants [SBAs]) has generally been shown to be an acceptable strategy in the context of low to middle income countries [
4‐
6]. Using the World Health Organization’s definition [
7], a TBA is, “a person who assists the mother during childbirth, and who initially acquired her skills by delivering babies or through an apprenticeship with other TBAs.” The United Nations Population Fund evaluated TBA trainings in 1996. They concluded that, in settings where women-prefer TBAs—such as areas with an insufficient number of SBAs and limited access to healthcare facilities—TBA training may be the only means to optimize the use of community-level heath workers to promote maternal child health. The trainings may also be necessary to improve the quality of care provided by TBAs in such cases [
8]. In a more recent Cochrane review, TBA training was found to be effective in improving outcomes—lowering perinatal death, stillbirth, and neonatal death rates—for cases attended by TBAs. Maternal death rates were also lower, but the differences were not statistically significant compared to cases attended by untrained TBAs [
6].
However, as TBAs are segregated from the formal healthcare system in Tanzania, their potential contributions are limited and not clearly described in the national policy [
9]. This view was corroborated by a study that reported poor linkage between TBAs and the formal health system in Tanzania [
10]. Although research related to the activities of TBAs is limited, we sought out some reports from other countries about the inclusion of TBAs in their health systems. In Kenya [
11] and Somaliland [
12], TBAs receive incentive payments for referrals. In Sierra Leone, Somaliland [
13] and China [
14], they are regarded as connectors between the community and healthcare services. In Bangladesh, they have been reported as breastfeeding supporters [
15]. In such studies, researchers have repeatedly described TBAs as trusted members of the community and remarked on their value for increasing women’s access to national healthcare systems. The relevance of their work in this specific context highlights the need to examine the ongoing activities of TBAs and identify the issues limiting their inclusion in Tanzania’s formal healthcare system. Hence, this study aimed to describe the perceptions of TBAs and SBAs regarding TBAs’ roles and the issues surrounding their inclusion in the formal healthcare system in rural Tanzania.
Methods
Design
We utilized a descriptive cross-sectional design with a qualitative approach. Data were collected through individual interviews with TBAs and focus group discussions with SBAs working in a district hospital in rural Tanzania. To ensure a comprehensive understanding of the studied phenomena, triangulation is recommended for qualitative studies [
16]; therefore, we used triangulation of investigation, methods, and data sources. Investigators included both Japanese and Tanzanian researchers to involve insider and outsider perspectives. We sourced data by exploring the perspectives of both TBAs and SBAs. The different methods were chosen in consideration of the environment where participants would feel comfortable, making it easy for them to talk.
Setting
The study setting was a community in the Korogwe District, which is located in Northeast Tanzania, a rural area of the country. Tanzania comprises 940,000 km
2. In the past four decades, its population has grown by approximately four times (more than 50,000,000), owing to high birth rates and a decrease in mortality rates [
3,
17]. The district of Korogwe is spread over 3756 km
2 and comprises 132 villages [
17]. The main economic activities in the region include agriculture, horticulture (both of which are performed with the natural resources found in the region), and game parks.
In 2012, the Korogwe district had a rural population of 242,038 people and an urban population of 68,308 people [
18]. It has one public and two private hospitals, 59 dispensaries, and three health centers. With the support of a local collaborator, the first and second author conducted interviews with TBAs in one of the villages located in a mountain area; the nearest town is 10 km away from the village. They conducted focus group discussion with SBAs in a private room of a district hospital.
Participants
We used purposeful sampling to identify and collect data from individuals who were information-rich in terms of research purposes. We chose to include both TBAs and SBAs to incorporate the perspectives of both sides. For TBAs, the inclusion criteria were that they must (1) be an active TBA, (2) be able to read and speak Kiswahili, and (3) agree to participate in the study. In our study, SBAs comprised of nurses, midwives, and doctors working in the region. They were invited to participate if they met the inclusion criteria: (1) working in a maternity ward (or working close to this ward), (2) able to speak Kiswahili, and (3) provided consent to participate in the study. For both groups, the exclusion criteria were (1) having never met TBAs, and (2) having no specific perceptions toward this group.
Data collection
To perform the interviews, the second author asked the village leaders to invite TBAs who worked in their communities to participate in this study. Since we had no previous knowledge of the number of TBAs in the area, we had initially planned to interview all TBAs who eventually appeared in the interview site. Owing to TBAs not being publicly recognized as professionals, we considered that performing group interviews would be a difficult and not very suitable task; hence, we planned individual interviews among this group.
The semi-structured interview guide was created by the first author and later analyzed by the third author to determine if any other questions should be included according to the relevant available literature. The English versions of the interview guides for SBAs and TBAs are attached as supplemental files
1 and
2. After completing the development of the interview questions, the second author translated them from English to Kiswahili. When participants arrived at the interview site, we explained the aims and procedures of the study (including how we would record our conversations) and then asked for their permission to record the interviews. The first author led the interviews in English; the second author acted as an interpreter who translated between English and Kiswahili. The finalized semi-structured interview guide included questions related to TBAs’ activities, recently conducted deliveries, the support they provided to pregnant women, referral cases, their perceptions of TBAs’ roles, their lives aside from the TBA work, and their relationships with healthcare personnel and institutions.
TBA participants came to the village by foot or motorbike. Data collection took place in a classroom of a school in the village. All interviews were conducted with assistance from the second author, acted as an interpreter, who translated between English and Kiswahili. Nonetheless, during the interviews, participants would eventually speak in Kisambaa (the local language); however, the second author (interpreter) understands both languages, so translation was not hindered. The interviews were digitally recorded, transcribed into Kiswahili, and translated into English by the same interpreter. Two authors (the first and fifth authors) reviewed all of the translated data.
For SBAs, we planned focus group discussions (FGDs) so that participants could share their perceptions toward maternal & child health and the roles of TBAs working in the community. The first and second authors acted as the facilitator and the interpreter, respectively. The discussion topics included (1) hospital daily maternal care situations and the corresponding issues and solutions, and (2) the possibility of a collaboration with the TBAs working among pregnant women in rural areas. The FGDs were conducted in Kiswahili, recorded with participants’ consent, and transcribed (in the Kiswahili language). The transcription was later translated from Kiswahili into English by the second author; the fifth author and a Tanzanian assistant checked its accuracy and corrected any issues. Data collection took place in December 2015 for the TBA and August 2016 for the SBAs.
Data analysis
The qualitative content analysis was guided by the checklist from Elos and Kyngas’ [
19] to increase trustworthiness. As they suggest, inductive content analysis was used due to the limited number of previous studies dealing with the phenomenon. The authors put the data in the matrix, which was constructed based on interview aims. For TBA interviews, two authors (the first and third authors) discussed the possible categories and ways to summarize them until they achieved consensus. For the focus group discussions, two authors (the first and fourth authors) discussed the categories until consensus was achieved. Then, similar codes were grouped into sub-categories, and similar sub-categories were grouped into categories. After these two analyses were completed, the first author merged and sorted the final categories according to their similarities and differences. The merged results were shared with the research group (all authors) and received agreement.
Ethical consideration
Ethical reviews and approvals were obtained from the 1) Institutional Review Board at St. Luke’s International University, Tokyo, Japan (14–040); 2) Director of the Korogwe District Council; 3) National Institute for Medical Research, Tanzania (NIMR/HQ/R.8/Vol.IX/1604); and 4) Tanzania Commission for Science and Technology (COSTECH) (No.2013–273-NA-2013-101).
Discussion
This study illustrates the continuing contributions of TBAs to maternal-child health in the community in Tanzania, despite their role not being recognized in the formal healthcare system. Additionally, our study highlights the wide range of opinions and perceptions of TBAs and SBAs (who are directly and indirectly affected by TBAs’ work) regarding TBAs’ roles. At the time of data collection, it seemed like there was a gap in the communication between the two groups; nonetheless, both groups seemed willing to collaborate and interact in order to ensure mothers and babies are healthy and to preserve lives.
Until 1999, TBAs did receive training on the outskirts of the village [
20]. Our results showed that, regarding TBAs’ roles, TBAs’ and SBAs’ descriptions did not differ. However, they did differ regarding TBAs’ knowledge and skill levels. TBAs claimed their compliance with the training they had received before, and SBAs repeatedly mentioned TBAs’ lack of training caused interference in SBAs’ practice. However, possibly owing to the international and national policy changes that ended TBA training and support, TBAs may have started to experience a greater lack of resources and the loss of the ability to update their knowledge. They also encounter barriers to collaboration with SBAs in the formal healthcare system. Nonetheless, given that the need for collaboration was not denied by any of the participating groups, the current issue may relate more to the “Hows” that will allow them to achieve such collaborations. We believe that these changes could assist in the promotion of universal healthcare access by reaching even those who are at the most remote places where resources are scarce, and development is direly needed [
21].
Regarding possible practical collaborations between SBAs and TBAs, we acknowledge that these will vary according to the context. The most common approach involves providing TBAs with incentives for bringing pregnant women to health facilities. In Somaliland, a study provided TBAs with a 3-day training, a 1-year follow-up training, and temporary incentives when they brought pregnant women to a healthcare facility [
12]. In this cited study, 75 TBAs participated, and the training improved not only their skills but also their knowledge and scope of practice, improving their ability to identify danger signs more precisely. Additionally, they kept bringing pregnant women to the healthcare facility even after the temporary incentives were no longer provided [
12]. A similar study conducted in Kenya also resulted in an increase in the number of times TBAs brought pregnant women to health facilities when incentives were provided [
11].
Additionally, we would like to highlight other inclusive approaches that were used in previous studies. In East Timor, to improve maternal-child health in the communities, a volunteer leader was chosen for a community. This leader received training on maternal-child health activities and, afterward, was asked to provide health education, home visits to pregnant women, and to accompany pregnant women to a health facility [
22]. In the cited study, TBAs were included as volunteer leaders, and, although they did not receive salaries, they received incentives, continuous training, and material supplies. The results showed that the leaders acted as linking points between the communities and health facilities, hence enabling facility-community collaboration [
22]. In Uganda, TBAs were included in the healthcare team [
23]. Although it was an exceptional approach, they acknowledged that it occurred because TBAs had been contributing to the community for a very long time. Once they were recognized as team members, TBAs started to feel willing to be more compliant with SBAs; moreover, the strong trust that existed between community members and TBAs was beneficial for improving maternal healthcare services [
23].
Given that both groups in our study reported the need for TBAs to receive training and the need for collaboration between SBAs and TBAs, we believe that the next step relates to planning programs that bridge the current gaps in perception described in the findings. In Miller and Smith’s review, it was reported that traditional communities face resistance to changes, and negative attitudes were observed between TBAs and SBAs [
24]. The authors pointed out that a facilitating factor was stakeholder involvement (e.g., decision-makers in the households and community/religious leaders) [
24]. Given that this study found similar negative attitudes between TBAs and SBAs, we believe that a program aimed at bridging the gaps between these groups should be conducted in order to make efforts to involve community leadership. Regarding such involvement, the cited authors suggested that these leaders should be provided with formalized roles and responsibilities, that TBAs should be remunerated, and that SBAs and TBAs should share their knowledge with one another [
24].
Regarding the implementation of such recommendations, a previous study has shown that, to realistically try to implement foreign knowledge in traditional communities, one needs to understand the existing local knowledge and reference the social, political, and cultural context of these communities [
25]. Using traditional practices in Peru from the late 18th to early 19th centuries as examples, Warren [
25] pointed out that, although a French midwife already emphasized external “correct” knowledge and practice at that time, local women, even those highly educated, still sought care from and relied on traditional midwives [
25]. A literature review on Asian traditional beliefs and practices also described that cultural beliefs can influence women’s use of formal maternal healthcare services, and that women’s fear of unnecessary medical interventions was a barrier to institutional births [
26]. In a review of childbirth and postnatal care in rural Africa, the authors found that the influencing factors of people’s preferences regarding formal or traditional healthcare were related to perceived attitudes toward healthcare providers, accessibility to maternal care, and respect for cultural and religious norms [
27]. The study also demonstrated that women across rural Africa prefer to receive childbirth care from caring, considerate, and sympathetic providers, and that this population group sees cruel, insensitive, and degrading attendants as increasing negative maternal experiences and outcomes. A final remark from the cited study highlighted that the trust rural African women have in TBAs influenced the type of healthcare service they sought [
27].
Given these considerations, the World Health Organization published guidelines to promote a positive pregnancy experience based on the fact that women repeatedly report disrespect and abuse during childbirth in health facility [
28,
29]. The accumulated evidence from these systematic review papers showed how increased workload of SBAs due to policy change in 90’s led to the inability to provide a birth environment where the needs of birthing women could be met. The new guidelines include maintaining women’s physical and sociocultural normality, maintaining a healthy pregnancy for both mother and baby (i.e. preventing and treating risk factors, illness and death), providing an effective transition to positive labor and birth, and assisting women in achieving positive motherhood (i.e. maternal self-esteem, competence, and autonomy) [
30]. This shift from focusing on survival to focusing on helping mothers thrive through the enhancement of the mother-practitioner trust relationship shows the expanded potential roles of TBAs. These roles may be included in the “maintaining women’s physical and sociocultural normality” category, as TBAs can serve as their local knowledge providers, hence contributing to women’s sense of normality and health.
Walsh et al. [
31] discussed types of favored and effective traditional leadership using examples from Malawi. When fear and coercion were justified, community leaders often used them to ensure that women delivered at health facilities. Hence, the authors concluded that, although a leadership empowerment model is desirable, it may be unfeasible to implement in highly hierarchical cultures. Conversely, a recent study among Maasai tribes in Tanzania described the need to rebuild trust among SBAs, TBAs, and the community [
32]. That study emphasized that increased sensitivity to women’s cultural preferences could close the gap in the trust between these stakeholders. Therefore, it would be appropriate to try a leadership empowerment model using TBAs’ local knowledge and trust to assist women in the community regarding healthcare.
The next step would be to have a meeting of both sides and discuss what is really needed in the community. The discussion should include how they could work together so that both sides could be cooperative at the time of referral and at the time of maternal education. This can be implemented as an action research so that changes in maternal healthcare service and improvement in maternal health would occur.
Although this study has its strength in design using triangulation, some limitations remain. We did not utilize the member-checking procedure because returning to TBAs for confirmation of analysis was not feasible due to language barriers and a lack of communication methods. We did not seek responses from TBAs based on the SBAs’ opinions. Hence, we do not have information to report on the TBAs’ response to the SBAs’ concerns. However, the first author has been conducting research in Tanzania for more than 10 years and understands the Kiswahili language. Likewise, three of the authors are Tanzanian midwifery researchers who provide local perspectives and cultural understanding. Nevertheless, further research is needed to inform the development of a program that bridges the gaps between TBAs and SBAs in Tanzania.
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