Traditional Birth Attendants (TBAs) are one of the trickiest topics in global health. On the one hand, they are a popular, affordable option for women who are unable or unwilling to use conventional medical care. On the other hand, they are often untrained and may do more harm than good to mothers giving birth. Recent developments in Uganda make that dilemma very clear.

When dealing with TBAs, there are a few ways you can approach the situation. You can train the TBAs to provide good medical care to pregnant women. That’s hard because you are taking non-medical professionals and allowing them to provide medical care. You can forbid them from practicing, which is difficult since you are taking thy livelihoods away from an entire field of women. Or you can try to change their role; have the TBAs do things like counsel and refer pregnant women but not provide care themselves.

That third option – gently shift their area of practice – is the most common choice. It capitalizes on the bonds that TBAs have with women in their community while preventing them from providing dangerous quasi-medical treatments. As Uganda has discovered, though, it is hard to make women stay in their new roles.

Ten months ago, the Ugandan Ministry of Health forbade traditional birth attendants from practicing. They found that “they had deviated from their major role of identifying and referring pregnant mothers to health centres.” In other words, the traditional birth attendants were still providing medical care.

The ban has had little impact. The TBAs are still practicing and women are still going to TBAs for their care. The TBAs themselves state that they’re not going to refuse care to women who come to them for help. They’re unwilling to give up their responsibilities to the women they care for or the income they earn from their work.

I suspect that the TBAs in Uganda will keep practicing as long there is demand for their services. They won’t disappear until everyone woman has true (affordable, geographically near, friendly) access to a trained midwife. At that point, the government can outcompete traditional midwives and they’ll fade away on their own.

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