From TBAs to 'mothercompanions'

Stories of change from Karonga District Malawi.

The motivation‘I did it out of passion and because itwas the job my grandma left me: notbecause of any other benefit.

From observation I was able to learnhow to deliver the baby and how tocut the umbilical cord. I deliveredabout 50 babies.’

Mbaububo Gumbo, 52, fromChambowo village in Karonga Districtexplains how she came to be atraditional birth attendant (TBA), caringfor pregnant women and helping themgive birth at home.

Another former TBA, 40-year-oldSophie Nkwinka shares her own story:‘For me, I became a TBA so that Icould help people who couldn’t get tothe health facility, because of the longdistances.

'We were conducting deliveries in thevillage as health facilities were faraway.’

Yet, despite the TBAs’ goodintentions, their work often had fatalconsequences.

Sophie says: ‘We were trained but welacked medical knowledge or technicalknow-how. We didn’t even know howto do a breech delivery [feet first].There were high maternal andneonatal deaths in those days.

‘We were living far from health facility,so if a women had profuse loss ofblood we couldn’t even help: shecould bleed and bleed until she died.There were other complications, suchas retained placentas. That hasbrought a lot of maternal deaths.These were some of the challengeswe were facing as TBAs.’

New mother Avery Chaluza Kondowe (25), her baby daughter Faith, and her ‘Mother Advisor’ Mbaububo Gumbo, 52, at Chilumba Rural Hospitalin Karonga District, Malawi. Credit: Christian Aid/Tomilola Ajayi

A cultural practiceThe use of TBAs is a deeplyentrenched cultural practice.However, Malawi’s high maternalmortality rates have, in part, beendue to the use of low-skilled TBAswho are unable to identify obstetriccomplications. Mindful of this, theMalawi government imposed a banon TBAs in 2007, in the hope thatpregnant women would begin look tomedical facilities instead.

That was not the case: only half ofwomen in Karonga were deliveringwith the assistance of a skilledattendant, meaning half of womenstill delivered at home, mostly withthe help of a TBA.

In 2010, the ban was lifted: the thenpresident recognised the need to‘train TBAs in safer deliverymethods’.

Mbaububo agrees: ‘When doing thedeliveries, we were doing it without[medical] training. It had its dangers, aswe TBAs couldn’t replace blood if awoman had heavy bleeding. And wewere not putting on any protectivewear to conduct the deliveries.’

In collaboration with districtstakeholders, including healthpractitioners, Christian Aid and partnerAdventist Health Service have beenworking to address the underlyingsocial norms underpinning thiscustomary practice.

With funding from UKAM, we havesupported TBAs like Mbaububo tochange their roles: they have beentrained and reoriented to become‘Mother Advisors’ – champions ofskilled deliveries.

The mother companions offer womenin their community an entry point forintegrated care, and Christian Aid hasengaged health-workers to support theTBAs’ new role.

The women now refer expectantmothers for antenatal care, andaccompany them to give birth at healthfacilities. They also refer women withcomplications, encourage pregnantwomen to get HIV testing andtreatment, and promote healthypractices at home.

In the first year of the programme,from January to December 2015, 51TBAs were reoriented as motheradvisors. In that period, a total of 2,207women were referred by the TBAs forantenatal care (ANC) and postnatalcare (PNC), according to a ChristianAid study.

Ray of hope‘Now that we have been able train theTBAs, they are bringing awareness towomen in the communities. This hasresulted in increased attendance inante-natal care and also post-natal careattendance in our facilities, which hasreduced some of the obstetriccomplications,’ says Joseph Kasililika,Safe Motherhood Coordinator forKaronga District, who is working withChristian Aid and its partners on theUKAM project.

Mbaububo and Sophie were two ofthe TBAs trained and supported by theprogramme. They have since becomechampions in their communities forsafe, skilled deliveries, helping tocontribute to a drop in maternaldeaths.

Sophie says: ‘It was Christian Aid andAHS who told us to stop conductingdeliveries in the villages and that weshould adopt the new governmentpolicy of identifying and referringpregnant women to the health facility.

‘I was trained in December 2015.Since then I have referred 15 pregnantwomen and all have had a safedelivery. No one had anycomplications.

‘Since the training there has been atremendous change, because thenumber of deaths among women andbabies has reduced, so the communityis very happy with the project and I forone am very much happy. I very muchenjoy my job as we are helping ourmothers. It is very important.’

Mbaububo was also reoriented in2015. ‘Since then I have referred 20women to Chilumba Rural hospital: ofthe 20 women, nobody has died,’ shesays. ‘The village leaders are sayingthere has been a drop in maternaldeaths: pregnant women are no longerdying.’

‘Now, when there are danger signs werefer the pregnant women. We arevery happy. The community and thetraditional leaders are very appreciativeof the [UKAM] project. It is helping toreduce maternal deaths in thecommunity.’

The way forward‘Now, when there are danger signs werefer the pregnant women. We arevery happy. The community and thetraditional leaders are very appreciativeof the [UKAM] project. It is helping toreduce maternal deaths in thecommunity.’

25 old Avery Chaluza Kondowe wassupported by Mbaububo, her mothercompanion. During her pregnancy shesuffered from edema (swelling of thelegs), but was referred to the healthfacility by Mbaububo.

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Seminie Nyirenda, Christian AidMalawi’s Senior Programme Officerfor Community Health, a formernurse says:‘Healthcare staff, the volunteers,the TBAs, they’re all very motivatedto improve the health of their ownpeople.

'But there are still a number ofchallenges, especially in terms ofresources.

'We’re creating demand from thecommunities: we provided some ofthe resources at the district hospitaland the District Health Office, butthey’re not adequate.

'The government budget allocationto district health offices continuesto be decreasing. As such, theresources will continue to be achallenge. So the support is stillneeded, until perhaps there’s astabilisation in terms of resourceallocation.

'As partners we need to worktogether, and we shall continueproviding the technical support.'

Mobile technologynow helps mums inMalawi

Malawi’s 2010 national demographicand health survey found that 56% ofpregnant women in rural areas did notachieve the recommended fourantenatal clinic visits.

Lack of knowledge on the importanceof antenatal care (ANC), long distancesto health facilities and lack of transportwere among the factors.

However, things have been changingin Karonga, where Christian Aid hasbeen running a successful mHealthplatform that is bringing essentialinformation on maternal, neonatal andchild health (MCNH) direct to women’smobile phones.

Funded by the UK Aid Match (UKAM)Malawi programme, this innovativeproject is run by Christian Aid inpartnership with US-based IT company

Telerivet, and is being implemented bylocal partner Adventist Health Services(AHS).

(It is the second iteration of an SMShealth scheme in southern Karongathat was funded by the ScottishGovernment from 2014. UKAMMalawi assumed funding for theproject in March 2015, when ChristianAid brought Telerivet on board androlled the project out more widely,across the entire district.)

How it worksThe SMS Telerivet system operatesfrom a computer stationed atChilumba Rural Hospital. After acommunity health worker registers apregnant women onto the system, itbegins to send her regular textmessages with tips on MNCH themes– each message is bespoke to herparticular stage of pregnancy. Women

Women and their children at an integrated outreach clinic in the rural, remote village of Kasimba, in Malawi’s Karonga District. The once-monthly clinic serves over 1300 people, offering key services to mothers, infants and pregnant women. Credit: Christian Aid/Tomilola Ajayi.

The conceptThe explosive growth of thetelecommunications industry acrossthe African continent is changing theway in which public services aredelivered – including in the arena ofhealthcare.

Agencies like Christian Aid have, forsome time, been tapping into thepotential of communicationstechnologies to transform healthoutcomes for women, girls andbabies.

In Karonga District’s ruralcommunities, Christian Aid has usedSMS mobile technology to connectover 5,000 women with the formalhealth system, bringing them closerto life-saving maternal and newbornhealth services that are ofteninaccessible to them.

also receive SMS reminders aboutANC appointments, nutrition, hospitaldelivery and postnatal checks.

So far, the project has exceededexpectations. Keddings Mwalwanda, ahealth surveillance assistant (HSA),manages the Telerivet machine at theChilumba hospital. He says: ‘Ouroriginal target was to register 5,000pregnant women, mothers andlactating mothers from 2014-15. Wehave registered 5,222 in that time.

‘We managed to reach the targetbefore the deadline, as we are able tosend a message to 50-100 women atonce. The system is very good: wecan reach lots of women at once.’

He adds: ‘This project has reallyworked: we have seen successes, asit has encouraged pregnant women toattend antenatal clinics, and mostwomen are now meeting theappointment dates. When their duedate is near, we remind women tocome to hospital for delivery. So manywomen are being reached andattendance at ANC has increased.

‘Even home deliveries have beenreduced, since health surveillanceassistants haven’t registered anyhome deliveries since 2015. Weattribute this to the reminders womenget from Telerivet. It hascomplemented existing systems: asHSAs we give health information topregnant women at outreach clinics,so the SMS messages enhance theinformation they receive.

‘Husbands are escorting their spousesto ANC clinics, and we’ve seen a risein take up of immunisation. There hasalso been evidence of higherattendance at the “maternity waitinghome”, where women go and waitbefore delivery.’

ChallengesThe project, while successful, hasexperienced some challenges.‘Unreliable mobile networks’ andelectricity blackouts have hampereddelivery of messages, explainsKeddings. Meanwhile, access tomobile handsets is also an issue: ‘Onlywomen with phones were beingreached, and those without phoneswere being left out,’ he says.

The project cannot provide mobilephones to the women: however, incases where a woman’s husbandowns a phone, sensitisation activitiescan help teach the men theimportance of passing on healthmessages to their wives.

Christian Aid and AHS are keen toexplore ways to continue building onthe project’s successes, many ofwhich are not solely down to the SMSsystem: it is due to a combined effortof the integrated approach that theUKAM programme is taking.

‘We thank Christian Aid and AHS fortheir work on the ground. I am veryhappy for their support as it has helpedme do my job better and has easedpart of our work,’ says Keddings.‘Before, we had to go to each andevery household to give messages andinformation. Now, upon receiving atext, the family will come on their ownto the facility. This is good for timemanagement and it means we canoffer more services.’

TestimoniesAgatha Mhango, 34, from Mgoyeravillage (pictured above, on left), says:

‘I have benefited from the SMSmessaging system. I was pregnantwith my third child at the time, and Inoticed a difference between the firsttwo pregnancies and the third one.Getting the SMS reminders onantenatal checks was so important,because in the middle of lots of tasksat home, I was able to get a reminderthat it was time to visit the healthfacility.

‘I was sick during the pregnancy butthe SMS I received gave me theencouragement to visit the hospital,and when I arrived I was helped. Themessages helped me to have a safedelivery. When I received themessages, I was also able to share theinformation with my friends, who werealso pregnant at that time.

‘It is very important that this projectcontinues so that it can assist me incase I have another delivery, but alsohelp my friends so that they too canhave a safe delivery and no maternalor neonatal deaths.’

Eng and Wales charity no. 1105851 Scot charity no. SC039150 Company no. 5171525 Christian Aid Ireland: NI charity no. NIC101631 Company no. NI059154 and ROI charity no. 20014162 Company no.426928. The Christian Aid name and logo are trademarks of Christian Aid © Christian Aid Photos: Christian Aid/

Mwanasha Mbewe, right, fromMgoyera village, has benefittedfrom the mobile technology:‘I was three months pregnant withmy fourth child when I came intocontact with the project.

'I started receiving SMS on differenttopics, including nutrition andfeeding yourself properly as apregnant mother; the danger signsin pregnancy; the danger signs afterdelivery and also the danger signsto the new baby. They alsoencouraged us on breastfeeding.

‘I saw a difference. The first threepregnancies, the issue of feedingmyself was a problem, but with thisfourth one I had to force myself toeat enough food – for my ownhealth and the health of my baby.

‘The messages really helped us,because we did not know most ofthe things. We used to come toantenatal clinics, but we didn’t takethem seriously: sometimes wecame late and missed the healtheducation talk at the start.

‘We were encouraged to attend theantenatal clinics in good time, sothat we also heard the healtheducation talks.

'After having had a safe delivery andlooking at the benefits I got, I amalso now involved in encouragingpregnant women in issues ofnutrition and attending clinics ingood time.’

Renovations, repairsand restoring faith inmedical facilities

In light of this significant obstacle, theUKAM programme is upgrading sixhealth facilities during the lifecycle ofthe programme, to help improve thesupply of maternal and neonatal healthservices in Karonga.

One centre that has benefitted is theNgana medical facility: the facility is ina remote and extremely hard-to-reachpart of Karonga, nearly 60km from thedistrict's centre. Steep, rocky roadsleading to the centre make it a longand arduous journey for a 4x4 vehicle.

The centre has a vital role to play inthis remote part of Karonga. Thefacilities has a dozen rooms offering arange of integrated services, such asdeliveries, antenatal and postnatalcare, immunisations, admissions, adispensary and general medical checksfor women, children and men.

And yet, it has had no running water,no toilets, no electricity and was inurgent need of a facelift – norenovation work had been done sinceit built over three decades ago, in1985. Although the facility had solarpanels to run fridges, there was nopower for lights. ‘It was in a poor stateof disrepair,’ says nurse technicianJosiah Saidi, who is helping to overseethe restoration and repair work.

‘There used to be bats inside thebuilding, which wasn’t sanitary. It washard to do deliveries during the night,because there was no electricity andstaff had to use a lantern,’ adds IsaacPhiri, project coordinator for AdventistHealth Services (AHS), Christian Aid’spartner who is implementing thiselement of the UKAM programme.

Ngana medical facility in Karonga District, Malawi. Located in a remote and very hard-to-access area, the small medical facility offers a range ofservices, such as deliveries, antenatal and postnatal care, and general medical checks. Credit: Christian Aid/Tomilola Ajayi

The contextWhile Malawi has made great stridesin healthcare in recent years, theobstacles facing clinicians in ruralfacilities are far too many.

Healthcare workers in Malawi –particularly rural areas – operate inextremely difficult conditions. In acountry whose government isalready stretched, and where thesector is largely under-resourced,medical staff are forced to do theirjobs in often old, dilapidatedbuildings.

This only serves to hinder attemptsto improve supply and use of qualityhealth services for the poorest andmost vulnerable populations –including pregnant women andbreastfeeding mothers.

This state of neglect was such that iswas putting patients off from using thefacility, including pregnant women,says Isaac.

The transformationNow, new ceilings have been installedthroughout the facility, the drugdispensary has been painted and givena new shelving system, solar panelshave been installed to provideelectricity for lighting, and rooms havebeen painted and decorated, includingthe labour and post-natal wards.

Our partners believe the centre hasbeen fully renovated, they will see anincrease in patient numbers and animpact on maternal health outcomes.Joseph Kasililika, Safe MotherhoodCoordinator for Karonga District, says:‘Looking at our labour wards in thedistrict, they were in a very poor state.

'I think the renovations will bringmotivation and encouragement tohealthcare providers and even to themothers in Karonga. Now that theNgana facility has been renovated, wefeel this is going to have a big impact’

Isaac Phiri adds: ‘Before, women wentto deliver at a traditional birthattendant (TBA) because the TBA’shome was in better condition than thehospital. Now they will come tohospital instead of a TBA, as theenvironment is more conducive. In thefuture, there will be more people beingattended to by skilled health workers.’

Christian Aid and AHS believe therepair work will also help to improveretention of healthcare workersstationed at the centre. Ngana medicalfacility is staffed by a nurse/midwife,medical assistant, and two healthsurveillance assistants (HSAs). To savethem an arduous journey to work, theMalawian government built modestbrick buildings on the site of thefacility, to house staff free of charge.

However, staff were reluctant to stayin the poorly-resourced homes: somemoved out within a matter of weeks,due to the tough conditions, saysIsaac. He explains: ‘Before, healthworkers didn’t like it here, becausetheir houses didn’t have electricity andthey were living in darkness, justrelying on lamps for light.

‘The UKAM project has installed solarpower panels to provide lighting at thehealth facility; it has also installedpanels in one of the health workers’houses. Since the project has giventhem light, staff can now attend topatients and do night deliverieswithout any difficulties. This hasmotivated them.

‘There is a great improvement: thecommunity will be very happy. Now,even if a child gets sick at night theycan come and get treatment. Thesmell of bats has gone, you canbreathe. By seeing an improvedstructure, we expect there will bemore deliveries. We believe thisimprovement will create a conduciveenvironment both for women and theirbabies.’

Meanwhile, at the Ngana medicalfacility, water and sanitation remain achallenge: the building’s huge outdoortank stopped working 21 years ago:it’s rusty façade is a stark reminder ofthe absence of pumped water.

For now, the only water source is aborehole in front of the facility. This isdespite WHO recommendations thatdelivery rooms have running water, toaid with prevention and control ofinfections.

‘It’s a challenge,’ Isaac admits. As arethe fact that the toilets are locatedoutside the facility: without access torunning water, drop toilets are the onlyoption. ‘More investment is needed.There is a lot that needs to be donehere, to help women and children,’ hesays.

Boosting performance andqualityAt Chilumba Rural Hospital, healthworkers have received training inPerformance and Quality improvement(PQI), as part of the UKAMprogramme.

In the box on the right, nurse midwifein charge, Wezzie Tembo tells us howthe training has helped contribute to adecline in neonatal deaths.

Eng and Wales charity no. 1105851 Scot charity no. SC039150 Company no. 5171525 Christian Aid Ireland: NI charity no. NIC101631 Company no. NI059154 and ROI charity no. 20014162 Company no.426928. The Christian Aid name and logo are trademarks of Christian Aid © Christian Aid Photos: Christian Aid/

continued from left column...‘Before the training, the situationwas not ideal. For example, medicalequipment wasn’t stored in anorderly way and this would affectthe care in emergencies.

Some shortcuts that were takencontributed to poor services: thejunior staff had protectiveequipment but were not puttingthem on. You could have incidents,like needle pricks. There were nocleaning schedules. We hadproblems with refuse disposal andwith teamwork: people just did asthey felt. We used to have a lot ofcases of newborn babies sufferingfrom sepsis [a life-threateningillness caused by infection]: weassumed it was due to problemswith our infection prevention andcontrol (IPC).

In August 2015 we received threedays of training on Performance andQuality Improvement. We learnedthat IPC is not just about preventingspread of infection, but also abouthow you provide services. We alsolearned how to arrange equipmentand about the importance of settingaside a day for general cleaning. It’sabout teamwork.

There is a great difference – now,when we go to labour ward, I don’thave to tell junior staff to dispose ofthings: they take initiative.

In September 2016, an assessmentcarried out by a ‘support servicedelivery project’ showed we hadreally improved. We got a 78%rating, which was up from ourprevious rating of around 30%.[These assessments use a standardtool to rate the facility’s cleanliness,waste disposal, availability ofresources, quality of care etc.]

I’m seeing a difference. Theneonatal death rate has reallyimproved – in three months, wehave had just one death. Before thetraining about five babies would diein a month. It has significantlyimproved.