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.
Understanding of misoprostol
Correct use of misoprostol
The vast majority of TBAs correctly understood how to administer the misoprostol: three pills (600 micrograms) after the woman had given birth and prior to the removal of the placenta. For example, “The mother, after giving birth, and before the placenta [is birthed], has to take three pills before the placenta leaves to reduce postpartum haemorrhage” (TBA1, FGD 2). Another TBA explained, “In the training I was informed as soon as a mother finishes giving birth, I must immediately give three pills and she should swallow immediately to avoid bleeding” (TBA 4).
Three TBAs were unsure of how to administer the medication and they had not had the misoprostol provided to them since receiving the training. Because training took place in May 2015 in Inhambane Province and August 2016 in Nampula, there was often a time lag between training and the actual distribution of misoprostol. The majority of TBAs clearly described the administration of misoprostol prior to birth as ‘dangerous’ and knew the exact timing to give the medication. When asked if there were any other uses for misoprostol, none of them could name any, including when probed about use for abortion. However they were strictly told during their training to hide the medication from children and for others, saying for example:
Uhhhh, I personally have never heard of it [giving misoprostol before the birth], see even in the training about Misol we were not told that, we were told to give it after the birth, before the birth it should not be given. (TBA 9)
Misoprostol as risky
There was a strong focus on the risks and dangers (both real and fictional) associated with misoprostol as taught during the training and reinforced by the nurses. The TBAs receive three doses in a blister pack from the APE. If a zone or neighbourhood did not have an APE, the TBA received the doses directly from the Maternal Newborn and Child Health (MNCH) nurse at the health facility. Many TBAs were told that the medication, despite being in closed blister packs, attracted rodents and there would be a high risk of death if consumed by a child. One TBA explained,
They told us that we should be very careful with these tablets, keep them very well and safely, if they are opened even if it is a small opening, they become unusable, so we should not administer in this situation. (TBA 13)
One TBA mentioned that if the drug were to be sold, that the TBAs would experience severe consequences. “…we were warned not to sell any pills, anyone found to do this could pay a fine of one million and go right to jail” (TBA 14).
TBA identity and role
Satisfaction with distribution of misoprostol
Overall, the majority of TBAs stated that they had positive feelings about administering misoprostol and believed it was useful for their work and the community. They made statements such as:
... the pills really help a lot, because there are times when the patient loses a lot of blood and if there are no pills it can be fatal, especially since everything here is distant, there is no transport and in the middle of the bush little can be done to save the patient. (TBA 15)
When we got the child out, I took out the Misol and gave it to the lady and removed the placenta. There was no bleeding problem. I am very pleased with this work. It is rewarding when everything goes well without bleeding, and even if the delivery goes well, I always advise her to go to a hospital for a brief check-up. (TBA3, FGD 3)
Women in the community who had taken misoprostol also spoke positively about the medication and felt that it made them strong and their ‘body firm’. The majority of the women did not know the name of the medication; they referred to it as the pill that stopped the bleeding. All stated that they wanted the program to continue, for instance:
When I left the hospital I walked by myself until I got home. I did not need to stay in bed or be hospitalized, the pill had a good effect on my body. I was able to walk by myself. (Participant 3, FGD 6 Women who used misoprostol)
A few women spoke about some people who had not yet taken misoprostol that had worries about taking medication. They said that they encouraged other women in their community to use misoprostol as this woman explained.
People who have not yet taken it [misoprostol] say they are afraid to take it because they do not know what the reaction will be. Now we have tried to pass on to them the experience that it is a good medicine and that it does not harm the body and that it does not kill, we are here alive and healthy. (Participant 2, FGD 6 Women who used misoprostol).
The men when their wives have not taken it yet say that this pill is nothing, people are just excited, but for those of us who have already taken it our husbands have a contrary opinion because they have already seen the good effects of the Misol. (Participant 1, FGD 6 Women who used misoprostol).
Encouraging facility based births
All TBAs in both Inhambane and Nampula provinces emphasised that their primary responsibility was to bring women to the health facility to give birth. TBAs sometimes give talks to the community and women about seeking antenatal care, giving birth with an SBA and childhood vaccinations. APEs and community leaders also play a role to encourage health seeking behaviour and facility births. Women who used misoprostol also said that they encourage friends and relatives to seek care early and, if needed, use misoprostol in cases when they cannot get to the facility, for example:
…since the government has thought of putting a traditional midwife [TBA] in each neighbourhood or community, several advances have been recorded. In fact, it was a wise decision. And the mobilization or campaigns of sensitization is not only done here in the hospital, but also in the neighbourhoods. Local structures such as Ward Clerks, Community Leaders, are all aligned on spreading information about pregnancy and Misol. Even the structures of the district government have collaborated. When we met with a Director and asked for help to take a woman to the hospital, there was never anyone who refused. We all collaborate. (TBA 3, FGD 4)
It was commonly accepted that misoprostol was to be used only if a woman could not reach the health facility. Most of the informants, unprompted, described the importance of facility births as the safest option. TBAs described misoprostol as a medication only to be used in the event of a ‘surprise’ birth, or ‘birthing along the way’ to the facility. Any birth that they assisted with at home was either because the woman would give birth on the road, had progressed too quickly, could not walk, or a transfer could not be arranged despite her efforts. TBAs made comments explaining this including:
When I started this program, we were taught that we cannot perform births at home, but there may be some surprises and we have to deliver before we get to the hospital, so we should have these pills to give the woman after the baby is birthed. However, it is our duty to mobilize and sensitize pregnant women to the health unit. (TBA 6)
Some TBAs took a staunch approach to implementing the policy on health facility births and refused to assist home births. One TBA mentioned that ‘their house was not a maternity’ and they would outright refuse women to enter their house to give birth there, for example:
No, I do not usually take much time, when the place is far away I refuse (laughs), because I teach them to go to the hospital, going to the patient’s house is also not accepted, only to call me, saying that she is on her way to the hospital. I do not accept to receive people in my house to give birth; they did not teach me to transform my house into maternity (laughs). (TBA 15)
Trust between TBA and health staff
Trust was identified as a major theme in the study and was a facilitator to the program being accessed in the community. Trust was central to allowing the health facility to move forward with community distribution. TBAs are well known in their community and respected which assisted in introducing misoprostol as a new intervention. Most TBAs enjoyed a positive relationship with those involved in the misoprostol program including the nurses, health staff and APEs.
TBAs often worked closely with the APE in their neighbourhood. They mostly described a good working relationship with the APE and were satisfied with the role the APEs played as the channel between themselves and the health facility for the distribution of misoprostol. For example,
“We take good care of them, along with our nurses, they do not abandon us nor despise us, in fact you just see between us and the nurses we have a good relationship…we understand each other” (TBA 7).
A strong, positive relationship with health staff also appeared to anchor the program and encourage facility births. Many TBAs spoke about attending the labour after assisting the woman to reach the health facility, some TBAs said they would observe or assist in the maternity ward. All TBAs appreciated and felt respected when the nurses included them in the maternity ward. Others mentioned that it was a good opportunity to learn from skilled birth attendants, as illustrated here:
We have good relations, we talk, we respect [each other], we help ourselves and we teach a little of everything, so that the service can go well, after all we all have the same objectives …they always receive [us] with great professionalism, both the traditional midwives [TBAs] as well as the patients that we bring from our communities. Even when we arrive at midnight, the nurses get up and greet us. (TBA 1, FGD 4)
However, not all TBAs reported a positive relationship with the nurses and some were unhappy with the dynamic, for example:
That's why I said that when I arrive at the hospital with a patient, the nurses do not give me importance, until at some point they ask where you are going to sleep? They do not give me the opportunity to watch the work with the more informed colleagues, which is not good. (TBA 4)
Sense of identity
TBAs very strongly identified with their role, some stated that their skills to assist with births were a gift from God, or a skill passed on by their mother or family member. Often they were chosen by the community to work as a TBA.
I used to do many births, it was not by accident that I was taken to work in coordination with the hospital, although I could not read or write, but God gave me this gift to help women. Nowadays, since we started talking about the need for women to go to the hospital, these cases have greatly diminished. (TBA 8)
TBAs mentioned the importance of having t-shirts or capulanas (traditional material worn as a skirt, dress or to carry babies) with MoH logos to help with their identification in the community and to help them to gain acceptance and be respected in their work. The TBAs that had received a MoH printed TBA t-shirt wore it very proudly; it was clear this small incentive was a positive means to show they received support from the MoH. For example:
As we have this t-shirt, although it is the only one that was given to us in the hospital [a TBA printed MISAU shirt], it helps them to identify us and see that we work in coordination with the hospital and so they do not reject us. (TBA 7)
Trauma and responsibility
Very few TBAs experienced maternal mortality or newborn deaths, and several noted that they experienced fewer cases of PPH after the introduction of misoprostol. Those that had experienced deaths described a deep sense of responsibility despite their limited skills and resources. This is highlighted in this quote:
There was this one time when I lost a girl here in the house, it was very difficult. Another time as well there was a woman whose family I counsel to go to the hospital but they took their time, and when they arrived at the maternity unfortunately it was too late, and she died. (TBA 10)
They also described significant fear and anxiety around attending homebirths without having the skills or the materials to respond adequately, for instance:
What usually is difficult for me is when you advise someone to go to the hospital and they resist until they give birth at home, it makes me very sad, because there may be a serious problem with the baby or the mother and I am held responsible for being the TBA of that person… Imagine that she gives birth and needs stitches, how will I do it? So I should be able to make the woman come to the hospital on time. (TBA 12)
Overall TBAs felt very accountable to their community and also worried about being blamed for any adverse outcomes. They had a clear sense of responsibility to respond to the needs of pregnant women and women in labour. This also manifested in fear and guilt, that they will not be able to provide for women when needed as explained here:
No, because as soon as you said that you are looking for the pills, for now there are none. This would be the only request because if you find someone in labour, outside the hospital, it is difficult without the pills, and we can only trust God, since we can not leave the person suffering. (TBA 16)
Program operations
Stock management
Stock outs were a source of stress and concern for both TBAs and women; there was concern for the women who would not benefit from the misoprostol. In the National PPH Strategy, the process for distribution of misoprostol is from the Health Facility to the APE to the TBA. TBAs receive the misoprostol in a blister pack from the APE. The APE acts as the link between the health facility and the TBA as they often have bicycles and a formal connection to the health system. APEs are responsible to submit monthly reports to the health facility and can then pick up more stock of misoprostol if needed. In practice, this system does not always function. In some instances, TBAs were not able to retrieve the misoprostol from their identified APE due to distance, unavailability or illness. In other cases, there may not have been an APE who lived in the same neighbourhood or community as the TBA. Some TBAs bypassed the APE “middle men” and picked up the misoprostol directly from the health facility. For example, “They told us in the training that it should be the APE to give us but for my case it is difficult because my APE is far from me, so I come here to pick it up at the health unit with the nurse” (TBA 5).
Other TBAs mentioned that the system whereby the TBA received the misoprostol from the APE was not always functioning due to the distances between the APE and TBA and the reliance on cell phones for communication. One TBA explained it as the following, “We work well [together], but I’m very far from the APE, only my colleagues are close to them. I have more contact with the nurses” (TBA 13).
In some districts, TBAs had been without stock for several months and in a few cases up to a year. Other TBAs said they had received training, but had not yet received any doses of misoprostol. This raised questions about the sustainability of the program; TBAs without regular access to misoprostol questioned whether the program would continue. In other cases TBAs reported that they had received stock but had to return it as the pills were expiring, for example:
When they do not have it we have a real despair. As it is a medicine that helps we run to the hospital to ask the nurse or the midwife. The sad thing is when they say they do not have it and are waiting for it. But when it's in the warehouse there's been no difficulty in giving us the pills. (Participant 2, FGD 6 Women who used misoprostol)
Surprisingly we did not speak to any TBAs that supervised the administration of misoprostol that mothers had previously received at ANC. TBAs who lived further away from the facilities were often those who directly administered misoprostol, probably to women who were less likely to have had received ANC after 28 weeks. A reliable supply of misoprostol which is easy to access, either via the APE or directly from the health facility was seen to be an essential component of the functioning of the program.
Resource limitations
Lack of financial and material resources were prominent underlying barriers to the TBAs involvement in the misoprostol program. TBAs do not receive any salary, incentives or resources for their participation in the program. While this did not seem to have negative implications on the relationships between the TBA and APEs or health staff, all of the TBAs mentioned that they would appreciate support from the government to perform their jobs safely. TBAs that we spoke with did not have any other employment or additional income and were very poor, for example:
Unfortunately I am not lucky enough to earn money for the work I do, I have already brought many people into the world by my hands. If it were a case of working for a boss, I think I would be in retirement now and earning money for the time spent in this activity. (TBA 15)
Many TBAs spoke about their lack of soap and gloves, and resulting fear of infection. They explained that they did not receive gloves or soap to assist with their work as their role, as per MoH policy, was solely to accompany woman to give birth at the health facility, as explained here:
Well, they tell me that my job is to get pregnant women to the hospital, but if it happened before I was there, I should get some plastic [from a 1kg sugar bag], and put it on my hands, that's how I do it, they did not give me gloves, they said they wear the gloves in the hospital. (TBA 10)
Just a few things saddens me in this work, we do not want much, just soap, imagine you my daughter, we are dirty and we have to go home to wash us with the little that our husband tries to arrange, with many difficulties, he even gets annoyed because he says that this work does not help me at all and he threatens to forbid me. Still, I keep doing it because I like to help. Therefore, we do not need much, just soap because it is inevitable that the blood will make us dirty and it is not easy without cleaning ourselves. (TBA 7)
Poverty and shame was also an underlying theme in discussions with women who had used misoprostol. Women spoke of poverty in terms of the lack of resources to deliver comfortably; being transported to the health facility, with a new capulana (traditional cloth) for the baby, and having food to eat after the birth of the baby, for example:
For example when a child is born they do not let it be covered with this capulana that I used, in the hospital they say it must be a new capulana ... where will I get money for a new capulana if my only capulana is this one? So we do not know ... this price we are paying for our misfortune is very high. The nurses only know to say that we should produce vegetables to be able to sell to get money ... but here who will buy what we produce if we are all farmers and poor people? (Participant 3, FGD 6 Women who used misoprostol)
Transportation and distance
In addition to a lack of resources, the majority of TBAs spoke about the challenges they faced reaching the health facility. One of the key roles of TBAs is to accompany women to the health facility to give birth; however transportation was never provided, and many TBAs reported they had to walk or pay for transport out of pocket as highlighted here:
Another problem is transportation, I live far from the health unit, I must pick up two cars and pay 40 meticais just to come, so, round trip is 80 meticais and no one gives me that money, its personal effort. We are told that this is voluntary work and that we should do it of our own free will, so I do it without gaining anything. (TBA 13)
A few TBAs refused to assist in home births, even when transport or walking was impossible, and seemed concerned about being blamed or punished by heath staff if and when they did. ‘Birthing along the way’ or on the side of the road in transit to the health facility was a challenge for both TBAs and women. TBAs described the challenges of walking and assisting women to give birth in the dark without gloves, soap or water. TBAs and women explained that often they only had an unwashed capulana (traditional cloth) with them to wrap the baby.
Women in the community vividly described the hardship of walking 3 hours or more to the health facility in late pregnancy or in labour. The imperative for safe reliable transport to the health facility was a key request by women in the community:
We want to continue to receive your medicines the Misol tablet. Of the many difficulties that women here face the greatest of all is transportation. We need a car to help us. Our bodies are already getting tired, we have to raise children, take care of the house and still go to the fields. We are asking for a lot [a car]... with this, expensive Misol would reach the most distant people... (Participant 5, FGD 6 Women who used misoprostol)