“My job is to get pregnant women to the hospital”: a qualitative study of the role of traditional birth attendants in the distribution of misoprostol to prevent post-partum haemorrhage in two provinces in Mozambique

Bleeding after childbirth (post-partum haemorrhage) is the leading cause of maternal deaths in Mozambique. The majority of these deaths happen when women give birth at home, without a skilled or trained health worker. In 2011, the World Health Organization stated that they support the distribution of misoprostol (oral medicine tablets) to prevent bleeding after childbirth. These tablets are important for women who cannot get to a health clinic to give birth because they are easy to use, prevent bleeding and can save their lives. A woman simply swallows three tablets of misoprostol directly after the baby is born and before the afterbirth (placenta) is delivered.

In 2015, the Mozambique Ministry of Health launched a National Strategy to prevent bleeding after childbirth for women who give birth at home. The strategy included two ways for women to receive the misoprostol tablets. First, women can get misoprostol when they visit the health clinic for a maternal health check-up at 28 weeks in their pregnancy. Or second, they can receive it from a Traditional Birth Attendant, a community woman who helps other women give birth. Traditional Birth Attendants receive training about the medication and how to assist women in childbirth but is not a qualified health worker. The Traditional Birth Attendant gives the misoprostol to the woman directly after the baby is born. The study looks at the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent bleeding after childbirth.

The maternal mortality ratio in Mozambique is 489/100000 live births [1] and post partum haemorrhage (PPH) is a leading cause of maternal deaths [2, 3]. Mozambique experienced a 64.8% reduction in maternal mortality between 1990 and 2013 [1, 4] almost reaching the Millennium Development Goal target of a 75% reduction. Still, the lifetime risk of maternal death remains high; one in 40 Mozambican women will die during child birth [1]. The Mozambican Health Sector Strategy 2014–2019 prioritises the reduction of maternal mortality as a primary goal [2].

Results from a 2015 survey in Mozambique found that overall, 70% of births were assisted by Skilled Birth Attendants (SBA) [5]. The Ministry of Health marked significant improvement from the Demographic and Health Survey (DHS) in 2011 which found SBA coverage to be only 54% [1]. However, disparities exist; disaggregated results from urban and rural populations show heath facility births are much more prevalent in urban areas (91%) compared to rural areas (67%) [5]. Access to rural health services in Mozambique remains limited by geographic distance, lack of transport options, coverage and quality [6, 7].

In Sub-Saharan Africa, approximately 23% of all births are attended by a Traditional Birth Attendant (TBA, only half of which were formally trained in modern medical childbirth techniques with a focus on clean delivery [8]. A TBA is defined as, ‘community-based providers of care during pregnancy, childbirth and the postnatal period’ who are traditional, not-formally trained and work independent of the health system [9]. TBAs were largely ignored through the 1990s by governments and the global health community after multiple studies suggested that TBA training was cost ineffective and had minimal impact [10–12]. Notably, TBAs were not armed with birth kits or uterotonics alongside this training and thus some argue that new technology and evidence could improve outcomes [12, 13]. There is also growing evidence that TBA training may improve linkages with facilities and improve perinatal outcomes [10]. The aim of this paper is to analyse the role of TBAs in the provision of a maternal health innovation in Mozambique.

Home births are a reality for women in rural and remote areas of Mozambique, despite the country’s policy to achieve the highest possible coverage of facility births with SBAs. TBAs play an important role in promoting ANC, often accompany and attend facility births, and assist at home births when women cannot access the facility births. Women in rural Mozambique often give birth at home with a TBA who may have limited or no training and few resources to ensure a safe delivery.

Prior to 1985, the MoH largely discouraged the involvement of TBAs as they were seen to detract from facility based births [14]. Investment and training in TBAs commenced in the late 1980s in Mozambique as an acknowledgement of the shortage of SBAs and limited coverage of facility births amongst rural women. TBA training first took place between 1991 and 1998; 3734 TBAs were trained, one-third of which were located in Zambezia Province [14, 15]. In 1996, a study of TBA training in Manica Province found no significant difference in maternal, perinatal or infant mortality between trained and untrained TBAs [14]. This was published amongst mixed evidence on the utility of training TBAs for improving the quality of care and reducing the mortality of mothers/newborns [10–12]. The authors recommended that TBA training be balanced with improvements to health facility infrastructure and the provision of professional support to midwives working in remote locations. Since 2014, there has been a concerted effort in Mozambique to re-engage in promoting early antenatal care (ANC) and facility births [2]; they have also engaged TBAs in the use of both chlorohexidine for the prevention of neonatal sepsis and misoprostol for the prevention of PPH [16].

Misoprostol has proven to be a safe alternative uterotonic where oxytocin is not available, such as at home births [17, 18]. Numerous countries have piloted the community-based distribution of misoprostol using either advanced distribution for self-administration during ANC visits or via Community Health Workers (CHW), or through distribution to TBAs who attend births [19–24]. Scale-up of community-based distribution of misoprostol remains limited; while there are early success stories emerging from Nepal and Bangladesh, many programs have been delayed or abandoned by donors or governments for political reasons and the lack of trust in community distribution [25].

The Mozambique MoH has committed to the expansion of misoprostol for the prevention of PPH alongside a network of CHWs known as Agentes Polivalentes Elementares (APEs) [15] and newly trained TBAs. A pilot distribution of misoprostol conducted in Nampula, Mozambique from November 2009–October 2010 found that distribution through both TBAs and Antenatal Care (ANC) achieved 99% misoprostol usage at home births [26]. In 2011, the Mozambican MoH formally approved the distribution of misoprostol at the community level for the prevention of PPH.

In 2014, the MoH launched the ‘Strategy for the Prevention of PPH at the Community Level’ (referred to as the National PPH Strategy), which included guidelines for the use of misoprostol for PPH where SBAs are not available [16]. The aim of the misoprostol program is to increase access to misoprostol for women who give birth in the community to reduce maternal mortality associated with PPH. The National PPH Strategy named 35 districts across the country to be included in the program for distribution. TBAs have a key role in the distribution and administration of misoprostol for the prevention of PPH. Pregnant woman at 28 or greater weeks of gestation may receive misoprostol in advance at ANC or they may receive it via a TBA in their neighbourhood. APEs act as the link between the health facility and the TBAs by providing misoprostol to the TBA in their zone. APEs are formally recognised by the health system, have a higher level of education than TBAs, often have a bicycle for transport, and receive a monthly subsidy [27]. Misoprostol for the prevention of PPH is branded as ‘Misol’ as a way to differentiate it between misoprostol used for inductions or abortion.

Implementation commenced in 2015 in six districts in Inhambane and Sofala provinces, and is ongoing in 35 districts across the country at the time this article was sent to publication. TBAs were recruited via recommendations by the health staff or APEs. Distance from the health facility was not considered in recruitment. Some TBAs prefer to remain autonomous and maintain their status outside of the formal health sector. Health staff, TBAs and APEs all received training on the use and distribution of misoprostol in May 2015 in Inhambane Province and August 2016 in Nampula. TBAs received three- day training on safe birth practices and the use of misoprostol; 47 TBAs were initially trained in Inhambane and 80 in Nampula Province. Training was provided in a cascade ‘Train the Trainers’ approach and was supported by UNFPA and Jhpiego’s Maternal and Child Survival Project. TBAs distribute misoprostol to women directly at the birth and are not permitted to provide the misoprostol in advance.

The aim of this study was to explore the role and perceptions of TBAs in the distribution of misoprostol for the prevention of PPH at the community level in two provinces in Mozambique. The facilitators and barriers that TBAs experienced working within the misoprostol program were also examined. We also sought to understand the views of women who had used misoprostol for the prevention of PPH.

Qualitative semi-structured interviews were conducted with 16 purposefully selected Traditional Birth Attendants (TBA) (11 in Inhambane and 5 in Nampula Provinces). Four FGDs were undertaken with TBAs in Nampula Province with 3–5 women in each group. In total, we interviewed 11 women who had used misoprostol; 5 women were interviewed individually in Inhambane and Nampula Provinces and 6 women participated in a FGD in Nampula Province.

The findings were organized in the following themes: a)Understanding of misoprostol: correct use of misoprostol; misoprostol as risky b) TBA identity and role: satisfaction with misoprostol; encouraging facility births; trust between TBAs and health staff; sense of identity;, trauma and responsibility and c) Program operations: stock management;, resources limitations; and transport and distance. These themes were then organised in the context of facilitators (groups a and b) or barriers (group c and trauma and responsibility) to the misoprostol for prevention of PPH program. See Fig. 1.

This study aimed to understand the role and perceptions of TBAs in the distribution of misoprostol for the prevention of PPH at the community level in two provinces in Mozambique. The facilitators and barriers that TBAs experienced working within the misoprostol program were also examined.

We encountered tremendous support for the misoprostol program from TBAs and women themselves. Women who had used misoprostol appreciated the medication and encouraged community members, relatives and friends to use it. TBAs highly valued the program, and spoke confidently about distributing misoprostol and understood its role in preventing PPH. Similar to other studies in Nigeria [31] and Nepal [32], most TBAs correctly explained how and when to administer misoprostol.

TBAs expressed a strong sense of identify and pride in their work, and described their role as a respected member in their community. Many TBAs spoke of the calling they had either from God or a family member to assist women to give birth. T-shirts and capulanas with the MoH logo provided them with a uniform and a means of identification in the community. TBAs felt a heavy responsibility to the women they assist which at times caused them to feel stress. Few TBAs were present when a woman passed away in labour or shortly after giving birth; however many discussed the risk of death and their fear of being able to assist with complications.

TBAs described strong, positive relationships with the APEs and MNCH nurses which often bolstered their sense of identity as a link between the informal and formal heath system; other studies have also seen an increase in referrals and awareness of medical care with the engagement of TBAs [33, 34]. TBAs were satisfied that their work was recognized by the formal health sector, and interestingly some appreciated the opportunity to observe the facility delivery as a learning tool. These findings are in keeping with a systematic review which found that including TBAs within health facilities increases skilled birth attendance and the more involved the TBA was with the health facility, the greater the impact [35]. Facility births can be improved with the creation of a supportive environment that links TBAs and SBAs and also removes barriers to women’s access to health facilities and SBAs [32].

TBAs consistently described accompanying pregnant and labouring women to the health facility, a finding in keeping with the strong commitment by informal and formal health care workers and community members in southern Mozambique to promote ANC and births at the health facility [7]. TBAs were aware of the national policy to encourage health facility births, and understood that misoprostol should be used only in the event of emergencies or unexpected births. Findings from a recent systematic review of task shifting in Active Management of the Third Stage of Labour support this approach; first promoting facility birth and then including additional interventions, such as community distribution of misoprostol, in place as a safeguard [36]. While it is encouraging that misoprostol is being used only as a last resort, it is important also that health providers and TBAs receive the message that it is a life saving medication and therefore they should not be overly cautious and avoid using it for fear of repercussions.

This study unveiled several unintended consequences of promoting facility deliveries without major investments in transport or communication systems. While some communities did have access to a maternal waiting home, often women were not able to leave their children at home without care and/or husbands did not see it as appropriate for their wife to be away from the home. Giving birth “on the way” to the facility, with no protection from the elements has also been described in Malawi, where women had to give birth on the roadside often due to a delay to seek assistance from a TBA or SBA at the health facility [37].

Some informants attributed their lack of resources for safe and clean birth as a way the health facility emphasised their role to promote facility births. Almost all TBAs discussed the lack of soap and gloves as having a negative impact to their work and motivation. Some TBAs spoke about using alternatives like used sugar bags or plastic sheets as makeshift gloves or none at all. They were fearful of contracting blood-borne illnesses themselves. Clean birth kits are not available to the TBAs; this includes soap, gloves, plastic sheets, razor blade and a cord clamp or string [38]. Clean birth kits are an affordable intervention and relatively easy to implement; they are used in at least 51 low-income countries with high prevalence of home births [38]. Lack of gloves and soap was seen to be a greater barrier to the work of TBAs than any other, including transportation and lack of financial incentives.

Poverty was the root of discussions around TBA and women’s lack resources, and transportation. TBAs do not receive payment for services besides what the community or households may offer informally – food, material or other small gifts. APEs are supported by the national program and receive a monthly subsidy of approximately 20 USD. Despite not receiving a stipend or incentives, the majority of TBAs said that they did not feel resentment towards the APEs for their earnings or expect a salary. However, many were impoverished by the out of pocket transportation costs associated with accompanying women to the health facility. All TBAs in the study said they would appreciate basic resources to assist with their work. Many described the hardship of encouraging facility based births coupled with the reality of the great distances, lack of transportation, lack of money and poor access. These barriers to healthcare are widespread across Mozambique as cited in other studies [6, 7, 39].

This paper contributes to the growing body of research supporting the community distribution of misoprostol for PPH prevention in settings where births that take place outside of health facility are still a significant proportion of all deliveries, and provides particular contextual findings for the role of TBAs in two provinces of Mozambique. TBAs play an important role in the distribution of misoprostol, encouraging facility based birth and advocating key messages for safe motherhood. This study adds to the evidence that TBAs are appropriate channels for the distribution of misoprostol for prevention of PPH; they are willing, capable and understand how and when to safely distribute the medication. Many TBAs highly valued their inclusion in the health system, receiving training and being provided with misoprostol.

A consistent supply chain of misoprostol is necessary to ensure the sustainability of the program. TBAs request resources such as birth kits, communication and transport options to heighten their efforts to ensure women can access to the safest birth possible. The MoH should expand their support to TBAs as allies with the health system to improve maternal and child health outcomes.