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Traditional Birth Attendants in Rural Northern

Uganda: Policy, Practice, and Ethics

Sarah Rudrum

To cite this article: Sarah Rudrum (2015): Traditional Birth Attendants in Rural Northern
Uganda: Policy, Practice, and Ethics, Health Care for Women International, DOI:
10.1080/07399332.2015.1020539

To link to this article: http://dx.doi.org/10.1080/07399332.2015.1020539

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 Health Care for Women International, 00:1–20, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399332.2015.1020539

Traditional Birth Attendants in Rural Northern

Uganda: Policy, Practice, and Ethics

SARAH RUDRUM
Institute for Gender, Race, Sexuality and Social Justice, Vancouver, British Columbia,
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Canada

The current emphasis on skilled attendants as a means to reduce

maternal mortality contributes to a discouraging policy environ-
ment for traditional birth attendants (TBAs). They continue to at-
tend a significant number of births, however, such that their role
and the policies and practices affecting their work remain impor-
tant to understanding maternity health care and maternal health
in the global South. In this article, I examine the policies and
practices governing community elders practicing as TBAs in ru-
ral northern Uganda. This discussion is relevant to health workers
in developing countries and to scholars in fields such as women’s
studies, sociology, and public health.

BACKGROUND

In this article, I discuss the role of TBAs in a rural northern Uganda commu-
nity. This discussion is relevant to an international audience of practitioners
and scholars of health care, and particularly maternity health care, in the
global south. The issue of how global health policies are implemented in
various local contexts is of concern to scholars in disciplines including an-
thropology, sociology, women’s and gender studies, international develop-
ment, and public health.
Since the United Nations’ announcement of the Millennial Development
Goals (MDGs) in 2000, maternal health has been an identified priority. Cur-
rent global approaches to maternal health emphasize delivery with skilled

Received 4 November 2013; accepted 14 February 2015.

Address correspondence to Sarah Rudrum, Institute for Gender, Race, Sexuality and
Social Justice, 038-2080 West Mall, Vancouver, BC, Canada V6T 1Z2. E-mail: sarahrudrum@
gmail.com

1
 2 S. Rudrum

attendants over the training of TBAs. Skilled attendants are defined as those
who are formally trained (Campbell & Graham, 2006; Say & Raine, 2007;
World Health Organization [WHO], 2007). The implementation of MDG 5, to
reduce maternal mortality, focuses on increasing the number of deliveries at-
tended by skilled attendants. This strategy is based on evidence that indicates
an increase in deliveries by such attendants will save lives. It nevertheless
also affects the status of TBAs, who assist large numbers of women in many
of the countries targeted by the MDGs. Due to the major role TBAs have in
providing care, policies and practices regarding their inclusion or exclusion
or otherwise affecting their work continue to be important issues in mater-
nity care provision, despite this increasing emphasis on skilled attendants.
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In this article, I examine the role of TBAs in the current policy environment
in a rural, postconflict area of northern Uganda, and identify the need for
improvements in how TBAs are incorporated into maternity care. Key issues
include how denying support to TBAs affects safety at TBA-attended births as
well as how limiting the role of TBAs impacts childbearing women’s choice,
autonomy, and control regarding approaches to care.
Traditional birth attendants (TBAs) play an important yet contentious
role in maternity care in Uganda. In sub-Saharan Africa, approximately 58%
of women delivered their first child outside of a health facility (Rogo, Oucho,
& Mwalahi, 2006). Many of these births are attended by a TBA. In Uganda,
Grace Kyomuhendo’s (2003) study in a rural area of Western Uganda also
found that 58% of women gave birth outside a health facility, yet TBAs have
an increasingly precarious status in Uganda. I begin my discussion with a
definition of a TBA, attending to both international and local understand-
ings. I then identify the policies governing TBAs’ role, focusing on global
and local approaches and their interrelation. I examine the practices of lo-
cal formal health care providers in relation to TBAs in northern Uganda,
and the practices of TBAs themselves, describing how these practices ex-
emplify a working around of current policy approaches. I go on to identify
ethical considerations raised by the current situation, including how cur-
rent approaches to TBAs in this setting may impede safety at TBA-attended
births, and how the current approach impacts childbearing women’s choice,
autonomy, and control regarding approaches to care. While situated in a
context-specific case, the issues I raise concerning policies and practices of
TBAs are relevant to other areas where TBAs continue to practice.

METHODS

As part of an institutional ethnography of maternity care and childbirth in a

small rural community in northern Uganda, Amuru, I undertook 8 months of
fieldwork while living with my family at a rural health center. Institutional
ethnography (IE), an approach to social research developed by the Canadian
 Traditional Birth Attendants in Uganda 3

sociologist Dorothy Smith, focuses on the processes of social organization

by learning more about people’s everyday actions and experiences and how
they are coordinated via institutional processes (Smith, 1987, 2005). Begin-
ning from the standpoint of birthing women, this critical ethnographic study
examined the social constitution of maternity care and birth. I understood
approaches to maternity care and to birth to be situated within social, as
well as medical, institutions. As part of this fieldwork, I spoke with mothers
of children under age 2 in 35 interviews and two focus groups, with a total
of 45 participants in this stage. In a second stage, I conducted interviews
and focus groups with 22 health care workers, including TBAs. Here, I draw
on material and knowledge from that period of research, but I focus on
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one complex element of local maternity care: the role of TBAs in providing
care within Amuru subcounty, northern Uganda, and how it is shaped by
international and local policies and practices.

Study Setting
Understanding the context in which the childbearing women of Amuru dis-
trict of rural northern Uganda live and seek care helps to situate this discus-
sion of TBAs and their work. Local people have returned to their villages
from Internal Displacement Camps after a protracted and brutal conflict in-
volving the Lord’s Resistance Army and Uganda’s People’s Defense Force
(UPDF). This conflict was characterized by widespread abductions, notably
including the abductions of children, as well as by mass displacement. Since
2007, people have begun the process of rebuilding their homes, gardens,
and their lives after two decades of violent armed conflict and displacement.
(See Dolan, 2009; Finnström, 2008; or Branch, 2011, for discussions of this
conflict and its social impacts.) The majority of people in Amuru are subsis-
tence farmers with little income. Their small household groupings are often
remote, in terms of being far from each other, the road, and any trading
center. Local infrastructure, including roads, remains worse than in many
other areas of the country, although while I was conducting fieldwork, an
often-impassable major north–south route was being upgraded and power-
lines were being extended to the administrative headquarters of the district.
While there are several health centers within the subcounty, only one was,
at the time of fieldwork, fully operational when it came to providing an-
tenatal care and support for normal deliveries. Accessing formal maternity
care, therefore, is difficult, given people’s remote location, their widespread
poverty, the poor roads, and lack of operational health facilities. These prob-
lems of lack of investment and poor infrastructure affect the whole country,
but they are exacerbated in the north, both by the years of conflict and by
lack of investment. In addition to these sociopolitical contexts, it is important
to recognize that women in this area have large families: in rural areas of
Uganda, the average number of children born to each woman is 6.7 (Uganda
 4 S. Rudrum

Bureau of Statistics, 2011). Family size reflects both the value placed on
a large family and unmet demand for family planning services (Mbonye,
Asimwe, Kabarangira, Nanda, & Orinda, 2007). Maternity care and child-
birth are vitally important to women’s lives in this area. It is in this context
that TBAs continue their work of supporting birthing women throughout
pregnancy and particularly at the time of delivery.

Health Service Delivery in Uganda

In Uganda, health services are identified by levels that correspond to local
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political entities. A Health Centre I (HCI) corresponds to the village level and
is comprised solely of Village Health Team members. These are volunteer lay
community members who disseminate basic health information, liaise with
formal health workers to coordinate outreach, and deliver drugs. A Health
Centre II (HCII) is the lowest level of health center to have a physical facility
and should have an enrolled nurse and a midwife, as well as more junior
health workers. It corresponds to a parish level. At the subcounty level, a
Health Centre III (HCIII), like the one where I lived during fieldwork, is re-
quired to have a senior clinical officer and a laboratory in addition to the staff
an HCII would have. A Health Centre IV (HCIV) also has a doctor and an
operating theater and corresponds to the district level. Beyond that, there are
hospitals, which in addition to the basic care provided at health centers, offer
specialist and consultant services. This formal health system is comprised of
government- as well as non-governmental organization (NGO)-operated fa-
cilities. Not all health centers, however, are fully operational to their defined
levels, an important consideration. In Amuru, shortages of staff including
midwives, as well as a lack of appropriate facilities, made some HCIIs and
HCIIIs unacceptable locations for maternity care and birth (from the per-
spective of both childbearing women and health administrators). Alongside
the formal health system, traditional health practitioners, including herbalists
and TBAs, continue to practice. The TBAs have been required to join the
Village Health Team: as such, they are part of the formal health system, yet
their role in attending births in villages is being actively discouraged.

DISCUSSION
What Is a Traditional Birth Attendant (TBA)?
The World Health Organization (WHO) defines a TBA as “a person who
assists the mother during childbirth, and who initially acquired her skills
by delivering babies herself or through an apprenticeship to other TBAs”
(WHO, 1992, cited in Sibley et al., 2007). This definition certainly applies
to the women who practiced as TBAs in Amuru. I learned about their roles
and practice from childbearing women, from other health providers and
 Traditional Birth Attendants in Uganda 5

administrators, as well as from TBAs themselves during focus group dis-

cussions. All women in their fifties and sixties, the TBAs told me they had
learned through experience, by necessity, and by taking courage. Since life
expectancy for women in Uganda is 54 (Index Mundi, 2013), these women
are elders in their communities. In previous generations, TBAs explained, all
older women would have been expected to be able to assist at birth.
To explain the process of becoming a TBA, Dorota (all participants are
referred to by pseudonyms) simply told me: “Me, I first saw it from big
people (elders) and felt it is all courage. And then I felt that I should also
have that courage and help pregnant women.” Another, Amaya, told the
story of the first birth at which she had assisted. She recalled that it was
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before she had given birth to any child of her own, meaning that she was
still a girl:

One time I found a woman knelt down, next to a house, so I went

and knelt near her, and when the child came, I waited and received the
baby. There were two babies. I waited and received the second one too,
and also then I removed the placenta. I went to the big people (elders)
and said that the woman who knelt there had delivered twins. So that
courage, I have had it forever now.

This story was her response to how she had learned to be a TBA. The
TBAs I spoke with had all participated in organized training (funded by
NGOs and often delivered via health centers) at various points over the last
three decades. In each case, however, they identified local and informal
experience as the way they originally became TBAs, often by telling a story.
While the WHO definition has considerable overlap with local under-
standings of the term, there are some issues with the term TBA and the way
it is understood. With its potential to evoke the past or bygone practices,
the term “traditional” is one that asks us to ignore or look past the clinical
skills that these women do in fact practice and pass on to one another. Stacy
Pigg (1995) has discussed the term “traditional birth attendant” as part of a
universalizing and objectifying discourse. She writes: “The concept of the
‘traditional’ is necessary to create a position from which development can
emanate. At the same time, the inclusion of the local that is ostensibly sought
in such formulations is rendered impossible, at another level, by a discourse
that effaces the differences among localities with a blanket concept of ‘the
traditional”’ (p. 49). In addition to acting to universalize diverse groups of
practitioners in diverse places, the term traditional birth attendants is often
deployed in contrast to skilled attendants (defined as those with formal train-
ing). This can be misleading, first, because TBAs certainly have birth skills,
often including skills useful in a difficult labor such as a breech or multiple
delivery, and second because not all of those providing formal antenatal care
(ANC) and delivery care in health centers entirely fit the official definition
 6 S. Rudrum

of skilled birth attendants (SBAs). For example, those who work as nurse
aides are often, like TBAs, lay people. They have been hired from within
the community without formal qualifications and are trained on the job to
perform health work including attending births. (In contrast to TBAs, the
nurse aides who I encountered were younger and literate, having completed
all or most of a secondary school education. They performed broad duties
at the health center.) This often is overlooked in the dichotomy between
“traditional” and “skilled” health workers. While the term “village midwife”
is occasionally used in Uganda, the term traditional birth attendant is more
prevalent, and despite its shortcomings, it is the term I use throughout my
work.
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The International Policy Context

The current international policy approach to TBAs can be summarized as a
shift away from training TBAs and toward a focus on skilled attendants in
health facilities. Starting around the 1970s, there was a widespread focus on
training TBAs as a means of prevention of maternal mortality. The WHO,
for example, promoted training of TBAs between the 1970s and 1990s (Sib-
ley et al., 2007). As described by de Brouwere and Van Lerberghe (2001),
the authors of “Reducing Maternal Mortality in a Context of Poverty,” an
initial enthusiasm for training TBAs gradually gave way to skepticism. They
summarize this as follows:

The resistance (or inability) to change of TBAs, their lack of credibility in

the eyes of the health professionals, the de facto impossibility to organise
effective and affordable supervision, all have discredited training of TBAs.
Whatever its other merits, it is now considered an ineffective strategy to
reduce maternal mortality.

With regard to merits, Bergström and Goodburn (2000) suggest that the
agreed-upon benefits TBAs provide are in the areas of “empathy, cultural
competence, and psychosocial support” (p. 96). Training for TBAs did not
help in the reduction of maternal mortality rates as programmers had hoped
it would (de Brouwere & Van Lerberghe, 2001), and despite some successes
with the reduction of perinatal deaths of infants (de Brouwere & Van Ler-
berghe, 2001), support for TBA training has declined.
Instead of the training of TBAs, promoting skilled attendance at birth
has been identified as the primary means of reducing maternal mortality (Say
& Raine, 2007, Wirth et al., 2008; WHO, 2007). The majority of interventions
currently focus on promoting births at health facilities with trained medical
staff. “Skilled attendants” are defined as those with formal medical training
(Campbell & Graham, 2006; Say & Raine, 2007; WHO, 2007).
 Traditional Birth Attendants in Uganda 7

The concept of “skilled attendance” emphasizes that in addition to the

presence of staff members trained in midwifery skills, an “enabling environ-
ment” is required to support safe birth. Such an environment provides the
resources required to deliver care, including “facilities, supplies, transport
and professionals to provide emergency obstetric care when it is needed”
(UNFPA ). Without such an environment, providing emergency obstetric care
(EmOC, 2013) is not possible.
The focus on setting as well as staff recognizes an important factor in
a safe birth, and one with implications for the role of TBAs. Many formal
health care facilities may not meet these criteria of having adequate supplies,
facilities, staff, or transport. For example, only one health center in the sub-
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county in which this research was situated, Amuru, had adequate transport
to a hospital (which nevertheless required calling an ambulance from that
hospital, approximately 50 kilometers away). Other health centers either had
no vehicle or were limited by mechanical failures or constant shortages of
fuel (which is costly and not locally available). A study evaluating EmOC in
Uganda found the following:

Over 86% of health facilities expected to offer basic EmOC were not able
to provide emergency care to pregnant women at the time of the study.
Consequently most maternal deaths that occurred in the health facilities
were due to inadequate care, especially lack of blood transfusion, inade-
quate skills to perform assisted vaginal deliveries and removal of retained
products. (Mbonye et al., 2007, p. 224)

Such findings were consistent with an evaluation of the abilities of so-

called “skilled attendants”: “Our findings appear to confirm this conclusion: a
woman who delivers at a formal health facility assisted by a so-called ‘skilled’
attendant cannot necessarily assume she will receive competent care” (Har-
vey et al., 2007). For Ugandan women, then, presenting at a health center is
far from a guarantee of appropriately skilled care, a factor potentially con-
tributing to the continued acceptance of TBAs among many childbearing
women.
While there has been an overall shift in the research, funding, and
policy environment away from the practice of training TBAs as an approach
to reduction in maternal mortality, it is important to note that despite this
shift, training for TBAs and support for their role does continue to a limited
extent. During fieldwork, I saw that TBAs were still being trained at health
centers. For example, training in neonatal resuscitation was provided (though
the goal was identified as overlapping with their role in referring women to
the hospital, described in greater detail below). One-off programs also relied
on training TBAs for provision of maternity services as a mode of facility-
based delivery: this was the case at a birth center run by an NGO in Atiak
(town), in the district where this research was conducted but in another
 8 S. Rudrum

subcounty, bordering South Sudan. This center has included TBAs in their
care team, an unusual approach and one that prioritizes the ongoing role
of elders and their knowledge in birth. Founded by American midwives,
the center, Ot Nywal Me Kuc, had recently received some funding for this
training work. While the training of TBAs still continues, major decision-
making bodies in global health, such as the WHO or the UNFPA, no longer
consider such training to be the way forward. The approaches of such large
organizations are significant in shaping the actions taken by ministries of
health and other decision-making bodies within countries relying on external
support, including Uganda.
The international policy approach is reflected in the policy approaches
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in Amuru and in Uganda generally, in that there is a focus on increasing

the number of facility-based deliveries. In rural northern Uganda (as in other
locations within sub-Saharan Africa), however, the policy preference for
skilled attendants comes up against the difficulty of accessing health facilities
where such attendants work, as well as the prevalence of TBAs and women
for whom their assistance is acceptable or preferable. Locally policy and
practice contexts are examined in detail below.

Ugandan Policy Context

Due to shifts in approaches and informal policy pronouncements, identifying
the current Ugandan policy approach to TBAs is challenging. While major
Ugandan newspapers, The Monitor and The New Vision, as well as the British
paper, The Guardian, had reported a 2009 ban on TBAs,1 such a ban was
not formally implemented through policy. As described to me by local health
administrators, the situation governing TBAs was, in fact, unclear. There had
never been an official written policy banning TBAs, but there had been a
number of speeches or documents referring to a ban. A strong anti-TBA
stance on the part of the government, coupled with lack of any concrete
guidelines, presented a challenge to administrators working in communities
where TBAs practice.
In our interview, the clinical officer in charge at the health center ex-
plained the situation as follows:

Actually what transpired in the past that they, the TBAs, should not
conduct deliveries, it was not a policy, it was not a law, neither was it a
bylaw, but it was a statement just from the president that came out after
[a] woman died in labour in eastern Uganda. So the president said, ‘this
was done, she died in the hand of a TBA, so with immediately effect, all
TBAs must not conduct deliveries.’ So this was just a statement, there was
no documentation. That was why it became very difficult to implement
such a statement, to start working.
 Traditional Birth Attendants in Uganda 9

Despite this difficulty, the health center worked to discourage TBAs from
assisting at births, encouraging instead a referral role. Writing before the
time of this presidential statement against TBAs, Kyomugisha states: “Caught
between tolerating the need for their service and seeing it as illegal, the
government occasionally openly discourages it” (2008, p. 21). The Uganda
Ministry of Health, for example, had circulated an edict to NGOs, asking
them to stop training TBAs.2 The lack of a clear policy governing the role of
TBAs in health care provision makes it difficult and at times confusing for
both local health care administrators and TBAs to know how to proceed.
This ban, then, was framed in the context of maternal mortality.
Uganda’s maternal mortality is estimated at between 435 and 500 deaths
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per hundred thousand births nationwide, and 662 deaths per hundred thou-
sand in rural areas (Uganda Bureau of Statistics, 2011). As such, Uganda
has one of the highest rates of maternal mortality in the world. By contrast,
Canada’s sits at between 7 and 8 maternal deaths per hundred thousand
births. The regional disparity within Uganda is shaped by lack of infrastruc-
ture, the recently ended conflict, and the challenge of providing care to a
rural population.

HIV/AIDS as an Additional Context Shaping Approaches to TBAs

As well as the prevention of maternal and infant mortality, another possi-
ble reason for a semiofficial ban on TBA training is the concern over HIV
transmission. For example, one TBA told me, “They had stopped us from
delivering women from home because of the sickness which is rampant
(HIV/AIDS) and (told us) that when labor begins we should bring them to
the hospital.” The clinical officer, Jonas, explained that when speaking to
TBAs he cites the risk of HIV infection as a reason to refer women to a
health center. The public health officer, William, referred to HIV/AIDS as the
main reason village delivery was discouraged, saying, “In fact, in the past,
before this rampant disease AIDS, they were allowed to deliver from the
villages.” His language demonstrates how talk of a ban, even when the ban
has no formal documentation, can influence what is seen as permissible.
Both the prevention of maternal mortality and the prevention of trans-
mission of HIV were important reasons why women were being encouraged
to attend ANC and deliver in a health center—and in so doing, to shift their
practices away from giving birth under the care of TBAs as their mothers had
and as they may have in previous pregnancies. Attending formal care was
encouraged through public notices, through outreach, and through health
talks. A further incentive was a “mama kit” consisting of basic baby care
items, such as towels, a washing basin, and soap, which was distributed at
the time of delivery in a Health Centre. Offered by NGOs, the intent of the kit
 10 S. Rudrum

was to help vulnerable women, but, in practice, it also acted as an incentive

to health center delivery.

Local Practices Regarding Traditional Birth Attendants and Delivery

At the level of practice, a “ban” on TBAs never took place in Amuru. More-
over, as health officials describe the situation, it never could have occurred.
The clinical officer in charge, Jonas, said it was difficult to comply with the
statement that TBAs should stop practicing because no guidelines were ever
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issued and because there was no way of preventing them from doing their
work in their own home villages. The district health officer also emphasized
that because of their location in the villages, TBAs were “everywhere” while
health centers had a limited reach: “To enforce the policy directly, we will
fail. The health centers are not everywhere.. .. But the traditional birth atten-
dants.. .. They are everywhere! They are the closest contact to these mothers.”
While this was a disadvantage in terms of trying to govern their practices,
he also saw it as an advantage if health authorities could work with TBAs,
because they had direct access to birthing women in their communities.
Leveraging this advantage, the strategy in the subcounty since 2010 has
been directed at bringing TBAs closer to health facilities and their staff, par-
ticularly by asking them to refer pregnant women (Peter and Jonas, personal
communication). The Public Health Officer, William, described the close
relationship the health center has fostered with TBAs: “When we started
working with them, they were fearing us, they were running away from
us. . .. So we used to follow them and then convince them to come to us.
Now they are so free. . .. They interact with us, look at us as fellow staff
now.” This sense of collegiality, which I also observed in the warm interac-
tions between staff and visiting TBAs, was formalized by requiring TBAs to
join the Village Health Team (VHT), a voluntary group administered through
the Ministry of Health and locally by health center staff. The TBAs were
also required to keep a record of births attended in the village and women
referred to a health center. Because the TBAs were often illiterate, other
VHT members, who were male or younger and thus had had better access
to education, acted as their record-keepers. These numbers identifying TBA-
attended births and TBA referrals were recorded at the health center. Their
age, rural location, and illiteracy are factors that would prevent TBAs from
pursuing formal education as registered nurses or midwives. The shift to
skilled attendance is more likely to mean these elders lose their role in birth,
rather than gain new credentials. This role loss is seldom addressed in the
literature recommending a policy shift to formal care, but it was recognized
by local health administrators who worked to ensure that TBAs continued to
have some role in their communities as supporters to pregnant women.
 Traditional Birth Attendants in Uganda 11

Staff members at the health center reported to me that they encourage

TBAs to refer all pregnant and birthing mothers to a health center, or to
accompany them. Encouraging referral was both a way to promote health
center delivery for women and a way to ensure that TBAs could still play
a role in supporting pregnant women. While a focus on referral meant a
diminished role for TBAs, administrators felt it was a way to value their
work. In their talks with TBAs, health workers emphasize that the risk of
HIV infection, or of losing a mother or baby and being blamed, should be
a disincentive to attending births in the village. If a TBA was recording rela-
tively few referrals in comparison with many births attended in the village, a
health center representative would speak to her to encourage better referral
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practices. Through such measures, TBAs were encouraged to refer pregnant

women to a facility for ANC and for delivery.

Ethical Considerations With Current Approach

Locally, introducing referral as a main role for TBAs was relatively noncon-
tentious. The approach recognized TBAs’ important role, yet it avoided an
emphasis on deliveries occurring at which TBAs are the sole attendants and
may not have the skills or tools to deal with complications or to prevent in-
fection (such as HIV and other infections). The TBAs understood the threat
of HIV, and they mentioned referral as a practice associated with a decrease
in maternal mortality.
There are also evident shortcomings to this approach, however, includ-
ing a lag time or period of confusion, in which the care available to women
was shifting in unpredictable ways. On a more ongoing basis, it is clear that
births in the villages with TBAs attending will continue, but less clear is how
current policies and practices support safety at such births. The emphasis
on skilled attendants, in this context, represents a policy shift that is more
idealistic than pragmatic. Further, the current approach appears to curtail
childbearing women’s ability to exercise their own preferences with regard
to provider type and location of birth, as well as other aspects of controlling
health care decisions in pregnancy and birth.
Confusion over policy was evidenced by TBAs who told me that, af-
ter hearing the message from the president to stop working, they did stop,
for fear of what might happen to them otherwise. With no one to assist
at village births, they recalled, there were instances in which women who
could not reach a health facility faced labor complications alone, and died
as a result. Just as they had initially become TBAs through necessity, the
evident ongoing necessity of their work led them to continue or return to
their practice. While the TBAs described the time in which they stopped
attending births as a short period in the past, in one out of the six vil-
lages I travelled to for interviews, childbearing women stated that TBAs
 12 S. Rudrum

would not attend a birth under any circumstance. One mother informed me:
“They would not accept to help because they fear being imprisoned.” Thus,
the announcement of a TBA ban had lasting impacts on the work TBAs
were willing to carry out, as well as on childbearing women’s perceptions
of TBAs’ role. The announced ban diminished the delivery care options
available to women living in remote areas, meaning that the goal of pre-
venting substandard care might result in women giving birth with no care at
all.
Even with referral as the agreed-upon role for TBAs, births in the village
will continue to happen, and TBAs will continue to attend. Precipitous labor
was one reason women might not reach a health center. Others included
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distance to an operational health facility, poor access to transportation, bad

roads, and the related problems of darkness or heavy rain. Often, these
factors interacted to make access difficult. For example, for an individual
woman, access to transportation might have been possible during the day,
despite bad roads and the cost, but it was not possible either at night or
during a heavy rain, at which times a boda-boda (motorcycle taxi) driver
might either be hard to find or refuse to travel for safety concerns. The health
practitioners I spoke with acknowledged that such factors meant village
births would persist. If such births are inevitable, then the question of how
they are to be supported to be adequately safe is an issue that requires
consideration.
The district health officer, Peter, put it this way:

[When] it is an emergency, it is night, there are no resources to bring this

mother to the health facility, she is definitely going to deliver.. . . It is a
normal process, you can’t stop it. The baby will come. If it is to come,
then some people should be there to receive it. In those situations, (the
TBAs) will continue.

Since local health administrators recognize the ongoing involvement of TBAs

as inevitable, at least in the short term, policies on TBAs should enable health
administrators to work with TBAS to facilitate safer birth.
This participant’s story exemplified the challenge of reaching a health
facility while laboring:

I started to feel labour pain in the evening when the sun was down, and
it was hard to get a boda [motorcycle taxi]. So one has to call a boda from
Amuru to take you to the hospital, but also the phone network here is
very poor, so they had to look for the network—one has to go and stand
on an ant hill [to get cellphone reception]. So by the time they called the
boda to reach here, I had already delivered, because the labor started
so urgently. I had to deliver with the help of the trained TBA who was
around here. (Jacky)
 Traditional Birth Attendants in Uganda 13

Factors, such as the paucity of drivers at night (exacerbated by roads with

deep potholes that became particularly dangerous when there was poor
visibility such as at night), poor network coverage, and distance to the nearest
health center, combine to make access to health facility delivery extremely
challenging.
Traditional birth attendants are simultaneously an asset and a hazard for
maternal–child health. They are an asset for their proximity to women and
their ability to assist when access to a health facility is difficult or impossible,
and a hazard because they may not have all of the skills and certainly do
not have all of the equipment to provide basic emergency obstetric care
in the case of complications of labor. Summarizing debates over policy on
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TBAs and TBA training (in a more global context), Bergström and Goodburn
argue that there is consensus that, on the one hand, TBAs offer “empathy,
cultural competence, and psychosocial support,” while, on the other hand,
TBAs cannot handle most serious complications (2000, p. 88). Based on
these strengths and weaknesses, they suggest, “The challenge for policy
makers is to make the best use of this available human resource (TBAs) but
simultaneously plan and implement a definite replacement strategy (Kamal
1998)” (Bergström & Goodburn, 2000). That “meantime,” in which TBA-
attended delivery is discouraged, yet formal health care cannot replace TBAs’
role, is happening now in Amuru subcounty. As indicated by this context,
the challenge is to find a balanced approach to utilizing TBAs while planning
for their obsolescence.
Lack of access to skilled attendants at birth is a prevalent situation in
sub-Saharan Africa, as, for example, Bergström and Goodburn (2000) assert:

Clearly, universal skilled attendance at delivery is a worthy objective.

However, in many countries, where professional birth attendants are
simply not available to rural populations or the urban poor, this ideal
remains a distant goal. (. . .) out of 22 countries surveyed in sub-Saharan
Africa, only one (Botswana) had professional birth attendants . . . in more
than three quarters of cases (Macro International Inc. 1994). (2000).

It is clear that while working toward better access to facility-based skilled

attendance, policy approaches to maternity care in the region must continue
to carefully consider the role of and support for TBAs.
In Amuru, the focus on referral is in keeping with the international goal
that TBAs will only have a role until there is a replacement. Encouraging
TBAs to refer women to the health center recognizes their role, without
allocating many resources to improving their skills as care providers (the-
oretically leaving resources free for formal care). Births attended by TBAs,
however, will continue to take place, a necessity of poor health and road
infrastructure and poverty. Complicated births are one aspect of a concern
over birth location and attendance. Even attending “normal” births, however,
 14 S. Rudrum

becomes more difficult and less safe without the basic supplies and skills
some TBAs mentioned lacking, examined below. A focus on referral means
that there is little in the way of practical or logistical support for TBAs as-
sisting with deliveries at home. Working without a clear policy as guideline,
local health authorities have developed an approach to TBAs that acknowl-
edges the importance of their role and the fact that some births will continue
to take place outside of health facilities in women’s home communities and
that, at such births, TBAs will attend. Local health authorities could be better
supported by guidelines on how to proceed in this transitional period, as
well as by a budget to supply the basic safety supplies required by TBAs. A
study in northeastern Uganda similarly found that “Because they won’t dis-
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appear until every woman has access to a skilled health professional, there
is need to define a model for a strong collaboration between professional
health workers and TBAs in order to increase institutional delivery” (Wilunda
et al., 2014, p. 11).
The TBAs I spoke with felt generally comfortable that referral was be-
ing promoted as their new role, and they saw it as beneficial to women’s
health. Sometimes referral meant accompanying women to the health center
for delivery. Jess noted that this could be a difficult role because it might
mean spending the night away from home, and, unlike attending birth, did
not pay. The TBAs mentioned additional roles in addition to referral and
education: for example, Mala said that in her community, TBAs coordinated
an emergency savings pool that could be used to pay for transportation to
the health center for women whose families could not afford transportation.
Respondents acknowledged that nurses and midwives had more education
than TBAs, but they shared that TBAs had better community knowledge and
were more able to encourage good hygiene or convince reluctant family
members of the importance of health care for pregnant women. As commu-
nity members who had been looked to for support over several decades,
TBAs’ social role had been as important as their clinical role. As the clin-
ical role is increasingly filled by SBAs, the value of this nondelivery work
to maternal health and to TBAs themselves should also be considered. The
status of TBAs and their regard in their community has been tied to their
work with pregnant women, and the loss of such a role has implications for
the health of these community elders that warrants further exploration. A
missing piece of the picture is that, with most research and analysis focusing
on outcomes related to parturient women and their newborns, it is unknown
to what extent TBAs are experiencing income loss and role loss, or how they
are coping.
In addition to identifying challenges with referral, TBAs were looking
for more support with village births. This included a particular kind of “ed-
ucation,” as well as supplies, both of which would make birth safer for
themselves and the mothers they attended. Even with such education and
supplies in place, however, women birthing in their village would continue
 Traditional Birth Attendants in Uganda 15

to risk encountering an obstetrical emergency that their TBA did not have
the skills or supplies to manage. Further, measures for the prevention of
mother-to-child transmission of HIV (PMTCT) could not be practiced at such
births.
In terms of education, TBAs identified that they would like to be taught
how to identify HIV status on a woman’s antenatal card. Each pregnant
woman carried her own antenatal card, where, if she had been tested, her
HIV status was clearly identified. Because the practicing TBAs were illiterate,
however, they did not know where on the card to look, or what to look for.
Not being able to identify the HIV status on an antenatal card presented by
a birthing woman is a barrier for TBAs wishing to protect themselves from
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HIV and other infections as well as to implement effective referral. Their

precarious status, however, and the fact that they are being discouraged
from attending births, makes it difficult to advocate for training. Asked about
this problem, the health center’s public health educator indicated that TBAs
should be able to read this section of the card or otherwise be able to learn
of a client’s HIV status, if the client herself knew. He told me, “Since we want
to prevent them also from being infected with the virus, it’s also good for
them to be aware that they can contract the disease through a delivery. [. . .]
Yeah, we also encourage these women when they are going back home, in
case maybe they deliver from home, they should inform the TBA that they
are infected or not.”
In terms of supplies, TBAs mentioned they had a need for gloves, gum-
boots, and a flashlight (torch) for travel and work at night (since there is no
electricity). The TBAs had been issued supplies including gloves, fetoscopes,
and other materials in the 1990s. In the intervening years, anything dispos-
able ran out, while tools such as fetoscopes had often burned or been lost
during the conflict and displacement. The group of TBAs who identified the
need for such items had just participated in a training session that ran the
course of several weeks. Many of them left the training with a doll and a
mask for demonstrating neonatal resuscitation techniques. The needs for the
more basic supplies went unmet, however, suggesting a mismatch between
the types of support that is funded and implemented, and the support that
TBAs self-identify as important. While the items they list might seem basic,
gloves are essential to prevent a range of infections, including HIV, and gum-
boots would mean TBAs could avoid being bitten by a snake, particularly
when travelling at night on narrow paths flanked by tall grass. They would
also make travelling more clean and comfortable during the rainy season.
Medical gloves and gumboots are not available in small villages and are
costly to someone on a subsistence-level income. The forms of support that
TBAs mentioned lacking, then, are lifesaving as well as basic.
These needs present a potential challenge. On the one hand, for NGOs
or health authorities, providing additional support for TBAs attending births
in the village would contribute to the safety at these births for both TBAs
 16 S. Rudrum

and birthing women. Support in these areas, however, might impede the
goal of referral replacing birth attendance as the main role of TBAs, in that
TBAs might feel able to attend a larger number or wider range of births in
their home villages. (While this is conjecture, in making this speculation I
am reflecting on a TBA who informed me that previous training had meant
she could deal with more complications at home, and thus had to refer less
frequently. This was not a majority view, but it is a logical and possible
understanding of what training might mean.) Facilitating village births con-
tradicts the push for facility-based delivery with a skilled attendant. On the
other hand, denying support means that TBAs will work without gloves,
flashlights, or gumboots, and continue to deliver women without being able
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to read their HIV status on their ANC card. Denying or overlooking the need
for basic supports makes the work of attending birth more dangerous than
necessary for TBAs and for their clients.

Issues of Choice, Autonomy, and Control

In addition to safety at the time of delivery, a further issue raised by current
approaches relates to the rights of childbearing women to autonomy, choice,
and control with regards to care during pregnancy and childbirth. The focus
on TBA referral also means that all births are being brought into essentially
one system of health centers and hospitals. In Canada, where I live, and
elsewhere in many developed countries, decades of activism have resulted
in the professionalization of midwives, whose scope often includes attend-
ing homebirth. (The status of midwifery as well as their scope of practice
varies between jurisdictions within Canada.) In other developed countries,
choice, autonomy, and control are prioritized in principle and women ad-
vocate for policies that support maternity care options that reflect a range of
preferences around provider type and place of birth. A health care system
with options respects women’s rights to choice, autonomy, and control re-
garding the care they receive. In contrast, a one-size-fits-all approach denies
the importance of women’s preference. Preference holds intrinsic value for
women; it also needs to be valued and understood by those trying to change
current approaches to maternity care and birth. The deskilling of TBAs im-
plicit in a focus on referral erodes the range of options for place of birth and
the type of attendant present. The concerns that such a strategy is based on,
such as the transmission of HIV and deaths due to complications of labor,
however, are very real. In a poorly resourced health system, how can issues
such as choice, preference, and autonomy not get lost in the concern over
mitigating risk and reaching the largest number of women possible? Integrat-
ing such concerns into a poorly resourced health system is challenging, but
to ignore these concerns is to ignore an aspect of women’s rights, as well as
 Traditional Birth Attendants in Uganda 17

to overlook the strong ways in which preference and choice already shape
maternity care.
The concern over preference raises a question of whether values such
as choice, efficiency, and equity must necessarily compete. The following
quotation identifies preference, efficiency, and equity as competing values:

To succeed in globalizing the evidence, policymakers must realize that

opportunities to do so will be tempered by three competing core val-
ues: choice, efficiency, and equity. In the United States and many
Western nations, the ability to choose according to one’s own pref-
erences is paramount, allowing citizens the freedom to opt know-
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ingly for treatments that, according to evidence, result in a less fa-

vorable outcome. In other nations, finding the best way to use scarce
resources—efficiency—will govern how research is translated into prac-
tice. In still other countries, devoting resources toward those with the
greatest unmet needs—equity—will dictate how evidence is used. (Eisen-
berg, 2002)

Simultaneously prioritizing these three values may not be possible. Attend-

ing to efficiency without adequate consideration of preference or equity,
however, comes at both an ethical and a practical cost. Service options
that are preferred, such as TBAs, have the tendency to persevere, despite
policy pushes in another direction. It is both ethical and pragmatic, then,
for policymakers, administrators, and practitioners to consider that women’s
preferences surrounding care at the time of delivery are not culturally inher-
ent, but they are shaped by logistical considerations such as transportation,
cost, and other factors.

Conclusion
Throughout my research, issues regarding the roles of TBAs were consis-
tently complex and at times contradictory, pointing to the difficulty of devel-
oping a consistent and effective set of practices regarding their work. At the
same time, within the subcounty, there is a considerable degree of knowl-
edge and resources available for formal health facilities to work with TBAs.
This includes the presence of a skilled public health educator with decades
of experience and strong relationships to local TBAs, and opportunities to
provide training, such as the neonatal resuscitation training described above.
In addition to such resources, health administrators at the district and health
center level have also demonstrated a creative approach to TBA leadership
in the face of confusing and unhelpful government approaches, such as
the “ban” described here. These resources and creativity have already been
mobilized to create a strong referral network among TBAs, to build posi-
tive relationships such that the TBAs are comfortable in communicating with
 18 S. Rudrum

health center staff, and to acknowledge that if women want a TBA present at
a health center birth, this should be acceptable. Attention to the importance
of childbearing women’s right to choice, autonomy, and control regarding
maternity health care reveals that removing a popular option—TBA-attended
birth, before the replacement option of a health center birth with a skilled
attendant is widely available—in practice reduces women’s access to safe
care. As I have illustrated, access to formal health care in rural northern
Uganda is limited to the extent that women will continue to turn to TBAs out
of necessity, meaning that attention to the basic safety concerns for TBAs
attending village births is necessary to prevent poor outcomes including in-
fection. Recognizing that the goal of universal skilled attendance is still some
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way off, and planning accordingly by making sure TBAs have access to ba-
sic supplies and education, would further improve the approach to TBAs in
this setting. The concerns I have highlighted here are also relevant in other
rural, low-resource settings where TBAs continue to practice despite a policy
preference for formal health care providers.

NOTES

1. See, for example, The Guardian’s articles “Traditional birth attendants show no sign of abandon-
ing their work in Katine” (Malinga, 2010) and “Should Uganda ban traditional birth attendants?” (Murigi,
2010). The New Vision, the state-run newspaper, “Revisiting the policy on traditional birth attendants,”
(Kabayambi, 2013) or in The Monitor, a leading independent daily, “Why traditional birth attendants will
keep thriving” (Tegulle, 2013).
2. The Guardian “Should Uganda ban traditional birth attendants?” (Murigi, 2010). Post in a series
on development in Katine, Uganda. March 30, 2010.

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