Purposeful Survey to Verify the Relevance of Traditional Birth Attendants in Maternal Healthcare in Rural Bugiri District, Uganda

1. 22. 2024

Socio-economic challenges perpetuate disparities in accessing healthcare, particularly among vulnerable mothers in rural Uganda. Traditional Birth Attendants (TBAs) emerged in Africa to address this gap. This study investigates the relevance of TBAs in maternal healthcare services in Bugiri. Inadequate access to maternal healthcare results in approximately 60 maternal deaths annually. Mothers confirmed the relevance of traditional birth attendants (TBAs) in providing essential services to pregnant and delivering mothers in three healthcare facilities in the district. Maternal mothers preferred TBAs over skilled birth attendants (SBAs) due to their better behavior, proximity to home, affordability of services, convenience, post-delivery service incentives, trust, and confidentiality. We conclude that TBAs continue to be relevant in rural Bugiri and suggest that the government establish systems to gradually onboard them into Uganda's legal healthcare system. Such a move would improve access to maternal healthcare in rural areas and reduce maternal mortality rates.

Research question: Are TBAs still enabling access to maternal mothers' healthcare services in the Rural Bugiri District, Uganda?

1. Introduction

The maternal mortality rate in the world is still high, with low- and middle-income countries contributing to about 95% of global maternal deaths despite a 34% reduction, and several reports showed that about 800 women die every day due to pregnancy or postpartum-related conditions (Kurjak et al., 2023). TBAs have been identified as one of the barriers to access to maternal health care by several studies, but due to the lack of SBAs in most rural health facilities around the world, such as in rural Indonesia, TBAs fill the gap by providing maternal health services to mothers without serious pregnancy complications (Allou, 2018; Aryastami & Mubasyiroh, 2021; Kumakech et al., 2020).

Available literature indicates that about 86% of births are attended by a skilled health worker worldwide, with North America, Latin America, Central Asia, the Caribbean, Europe, North Africa, and the Middle East achieving near universal coverage of births assisted by a skilled health worker, and about 70% of births in sub-Saharan Africa (SSA) being assisted by a skilled health worker (Budu, Chattu, et al., 2021; Nishimwe et al., 2021; UNICEF, 2023).

However, Sub-Saharan Africa (SSA) has the highest rate of early childbearing in rural areas at about 99 births per 1,000 adolescents aged 15-19 years, but about 59% of births in West and Central Africa and 63% of births in East and Southern Africa were delivered in a health facility. If the coverage of attended births does not steadily improve in SSA, 16 million unattended births will occur in 2030, negatively affecting maternal health and survival (Ahinkorah et al., 2021; UN Statistics Division, 2021; UNICEF, 2023).

Mothers in rural areas of SSA give birth at home either with the help of relatives or TBAs due to limited access to skilled maternal health services associated with a shortage of skilled labor, limited medical supplies and drugs, and long distance to the health facility. Therefore, identification, training, and recruitment of TBAs for skilled maternal health care are crucial to improving maternal health, especially among teenage mothers who often lack knowledge and information on maternal health care (Chi & Urdal, 2018; James et al., 2023; Musyimi et al., 2019; Ntoimo et al., 2022a).

The World Health Organization (WHO) revealed that SSA countries face a shortage of skilled health workers to meet the health worker-to-patient ratio. The integration and engagement of TBAs is the best option to fill the human resource gap and increase deliveries in health facilities. Since the integration of Traditional Birth Attendants (TBAs) into Skilled Birth Attendants (SBAs) in health facilities, especially in African countries such as Nigeria and Kenya, a decrease in maternal mortality has been observed, although at a slow pace (Kassie et al., 2022; Muzyamba et al., 2017; Mwoma et al., 2021; Pieterse & Saracini, 2023).

TBAs have been classified by the World Organization as skilled midwives with formal education, TBAs with skills usually acquired through apprenticeship, while others are informal home-based birth attendants in rural areas. TBAs are known by various names such as traditional midwife, community midwife, midwife, doctor, and extra, depending on the country (Mendhi et al., 2020a). TBAs are seen as a good option to address the chronic shortage of skilled birth attendants (SBAs) in rural areas of Uganda(Chi & Urdal, 2018; Graham & Davis-Floyd, 2021; Kolié et al., 2023).

Despite the low level of training and education of TBAs, they have been credited with assisting mothers during childbirth and can be of great help in mobilizing and engaging men in maternal health programs. As in other parts of Africa, TBAs have proliferated in rural, often hard-to-reach areas to consolidate as the primary source of maternal and newborn care where access to modern health facilities is limited (Hobday et al., 2018; Kassie et al., 2022; Professor, 2020; Rodríguez-Romo et al., 2023).

The Ugandan government's health policy formally banned TBAs from their practice due to concerns about their inability to manage hemorrhage in women, a leading cause of maternal death; instead, the policy shifted to promoting skilled birth attendants, whose definition excluded TBAs; nevertheless, old and teenage mothers still visit TBAs for delivery (Kyeyune, 2020b; Munabi-Babigumira et al., 2019).

although TBAs have not received the necessary support in terms of training and financial support in Uganda, the services they provide, such as providing maternal health information, counseling, engaging men in maternal health, assisting with deliveries and referrals, play an important role in providing necessary maternal health in Uganda and are trusted by most rural men and family members (Dektar et al., 2023; Kifle et al., 2018; Sub-county & Urendi, 2023).

However, TBAs could only manage mothers with no or minor complications, thus creating a basis for most of the health facility midwives to underscore their competence in managing maternal health due to a lack of skills and knowledge in managing many pregnancy-related complications such as eclampsia, pre-eclampsia, sepsis, obstructed labor, unsafe abortion overbreeding among others. Some studies claimed that if TBAs are logistically supported and intensively trained by the health system, they will provide better maternal health services(Esan et al., 2023; Kassie et al., 2022; Yuan et al., 2017).

The factors that cause the very low access to SBAs in SSA include poverty, unemployment, long distance to the health facility, long waiting at the health facility, limited spousal social and emotional support, younger maternal age,  never married status, low levels of education, mothers’ belief in TBA services, lack of motivation among health workers, poor client care and lack of fully furnished health facilities, shortage of skilled professional medical workers, discriminating attitudes from health workers, high cost of maternal health services (Addo et al., 2023; Dahab & Sakellariou, 2020; Sidze et al., 2022).

These factors prioritized the preference for TBAs for delivery by rural mothers (Nasir et al., 2020; Ntoimo et al., 2022b). According to available sources, an average of 72 mothers in Nigeria deliver with the help of TBAs annually. The integration of TBAs into the healthcare system has been partly recognized as one of the key strategies to support maternal health in hard-to-reach communities, though others have witnessed the failure of TBAs in reducing maternal mortality (Haruna et al., 2019).

Recent studies conducted in Uganda revealed that TBAs in rural areas are always willing to collaborate with the formal health system, but they urgently need capacity building in neonatal resuscitation and management of pregnancy-related complications and maternal mental health problems to reduce the workload of SBAs to improve maternal health. Similarly, midwives in health care are willing to collaborate with TBAs in providing maternal healthcare services in rural areas (Kyeyune, 2020b; Mendhi et al., 2020b; Musie et al., 2022; Musie & Mulaudzi, 2024; Rutindangyezi & Nakasolo, 2022).

The previous reports have shown that maternal mortality in Uganda is still high at about 435 maternal deaths per 100,000 live births due to about 416,000 deliveries without the assistance of SBAs outside the health facility, and 27 percent of deliveries were assisted by illegal TBAs. Most of the pregnant mothers in the rural areas of Uganda find it difficult to deliver or manage pregnancy-related complications under the maternal care of TBAs, but because of poverty, long distance to the health facility, long waiting time at the facility, and limited access to maternal health care services at the health facility along with illegal TBAs. The courtesy, autonomy, and client care provided by TBAs made it inevitable (Dantas et al., 2020; Dektar et al., 2023; Kyeyune, 2020b; Musasizi, 2023b).

Uganda is one of the poorest countries in Africa, with a national poverty rate of about 30%, which is close to the international poverty rate of about 42%. This situation is due to weak economic growth (-0.8%), heavy dependence on agriculture, and inflation (World Bank, 2023). Government spending on health has been around 7-9% of the general annual budget, which is too low to facilitate maternal health programs, thus affecting access to maternal health care. This poor economic situation favors spatial inequalities in health facility coverage and private sector investment in health infrastructure in the country (Foundation, 2021; Nannini et al., 2022; Schein, 2019).

Furthermore, Uganda's general government expenditure on health is around US$9 per capita, below the WHO standard of US$34. The density of health workers is 1.55 per 1000 population, which is an alarming public health concern that can be addressed by recognizing and recruiting TBAs in the Ugandan health system. Despite 73% of births in health facilities as of 2023, about 27% of pregnant mothers in rural areas of Uganda were reportedly assisted by TBAs during labor, and these mothers preferred their services to SBAs because of the former's courtesy, comfort, client care during labor and after delivery (Dektar et al., 2023; Foundation, 2021; Kwesiga et al., 2020).

As a result, access to health care is very limited, especially for the 80% of the population living in rural areas where poverty levels are high; about 45% of the people are poor, and about 74% of the population often do not have access to health care (Dispatch et al., 2022). Most of the rural poor pregnant mothers in Uganda are predisposed to low access to maternal health care at health facilities due to lack of transport fare and medical fees, which puts them at high risk of maternal mortality attributed to deliveries assisted by TBAs (Ministry of Health, 2021; Mugambe et al., 2021; Njagi, 2023).

Several studies have found a significant association between the poorest rural women and low maternal healthcare utilization, while other researchers have found a significant association between poverty and deliveries assisted by traditional birth attendants in rural areas (Adatara et al., 2018, 2020; Atuhaire et al., 2023). Limited community health infrastructure was also identified as one of the key challenges related to choosing a place of delivery, where many mothers prefer to deliver from the TBAs' place to the health facility(Dektar et al., 2023; Mugambe et al., 2021). This calls for constructive and strategic interventions to increase deliveries in health facilities and reduce maternal mortality in Uganda to achieve SDG 3:1 (Kyeyune, 2020a; UNICEF, 2023).

A study conducted in Rubaare Sub-county in Mbarara highlighted that traditional birth attendants provide a good service in advising pregnant mothers on good and balanced nutrition during pregnancy and after delivery. The study also found that the influence of partners on the place of delivery and long distances to health facilities discourage mothers from giving birth in health facilities, and therefore, the recruitment of TBAs in established community mobile clinics would increase facility deliveries (Rutindangyezi & Nakasolo, 2022).

In previous studies conducted in Busia, Uganda, TBAs have a strong influence in rural communities and should, therefore, be involved in ensuring better maternal health care (Nalwadda, 2018). In rural Northern Uganda, TBAs reported that they had gained experience in assisting- mothers during labor and postpartum when called upon by their husbands; however, TBAs in the Busoga sub-region recognized the importance of referrals and formal training in managing deliveries(Fulton, 2020).

The study conducted in Iganga, Eastern Uganda, showed that TBAs are crucial in ensuring better options for maternal health care as most of them are knowledgeable about herbal medicine (nutrient medicinal plants) that can be used to supplement antenatal care drugs to treat anemia and more research is needed on the safety, efficacy, and availability of these herbal medicines used by TBAs to treat some of the maternal conditions and diseases (Nalumansi et al., 2017).

Bugiri is also known for the use of TBAs to assist mothers during labor and postpartum, and according to the current study, most births occur outside the health facility. About 48% of the mothers had not recognized the importance of TBAs in Bugiri District (Mulondo L., 2023). Today, there is little agreement on the relevance of TBAs in maternal health care, but the use of TBAs is currently increasing in most Sub-Saharan countries like Rwanda, Burundi, and Nigeria (Aliyu et al., 2023; Chi & Urdal, 2018; Golooba-Mutebi & Habiyonizeye, 2018). However, there is a lack of information on their relevance in the available literature for the Bugiri District Health Department.

The studies conducted in Uganda, Tanzania, and some other  SSA countries revealed that midwives often have various arguments against the operation of TBAs, stressing that they have contributed to low attendance of mothers for antenatal care (ANC), resulting in high maternal mortality. In contrast, some midwives recognized the value of TBAs in maternal health care and that they should continue to operate in rural areas where health facilities have few birth attendants (Mendhi et al., 2020b; Ohaja et al., 2020; Shimpuku et al., 2021).

However, most of these studies were conducted in countries with cultural, geographic, and health system settings different from Bugiri and Uganda, creating a research gap that has been filled. A recent publication in New Vision Uganda on maternal health care revealed that 62% of mothers in Bugiri District give birth annually either at home or at TBAs (Mulondo L., 2023, December 16Th).

TBAs have been preferred by pregnant mothers to SBAs at the health facility due to several factors, including financial constraints, accessibility factors, client care, and availability of herbal medicine; based on this point, TBAs should be fully employed in the health system after being fully trained to handle serious maternal complications for maternal and infant health (Adatara et al., 2020; Ntoimo et al., 2022b).

No survey has been conducted to confirm the relevance of TBAs in maternal health care in Bugiri district amidst high maternal mortality in the area in maternal health care, and the recent studies conducted in the Eastern region only focused on birth assisted by TBAs and their roles (Musasizi, 2023a), thus creating a research gap that was filled by this survey. This focused preliminary study aims to investigate the continued relevance of TBAs as essential maternal health service providers in rural Uganda. The results of the study would inform the research design of a larger study to explore how mobile health clinics can be piloted to promote effective collaboration between TBAs and mainstream hospitals to improve access to maternal health care in rural areas for the benefit of mothers-to-be and ultimately lift the ban on TBAs in Uganda.

2. Methodological approach

Description of the study site

This preliminary study was conducted in May 2023 in Bugiri, a rural district in eastern Uganda, Busoga sub-region, 132 km from Kampala (See figure 1). The choice of the study site was informed by the findings of previous studies that revealed high maternal and neonatal mortality (Nassaka, 2023; Opio et al., 2018). Bugiri District comprises eleven sub-counties, 68 parishes, and 598 villages. This preliminary scoping exercise was conducted in three villages: Buwundi, Nabukalu, and Muterere.

The main economic activity in the district is agriculture, but with low productivity regarding health services management, the Bugiri government, with a100- bed government facility serving a population of over 30,000 people in Bugiri and parts of neighboring districts, has been supporting health service delivery through the facility, but still faced understaffing, inadequate medical supplies, and drugs alongside limited beds (Galukande et al., 2013; HoM-UG, 2014).

Given these challenges, the difficulty in accessing antenatal care by expectant mothers and teenage mothers has significantly increased their vulnerability and risk of maternal mortality. Over the past decades, they hardly accessed maternal health services (Budu, Seidu, et al., 2021). In addition, long distances to the facility associated with high transport costs, long waiting exacerbated by understaffing, increased user fees, and inadequate nutrition have been highlighted in previous studies as other significant hindrances to skilled birth services utilization, hence resort to unskilled TBA maternal service providers which further puts them at high risk of maternal mortality (Kassie et al., 2022).

Sampling size

The sample size for this study was determined based on purposive sampling methods, as seen in table 1 in Appendix 1, showing 238 participants for the survey.

Data Collections methods

Planning the data collection

Before the trip, we contacted acquaintances to identify and organize potential interviewees (local stakeholders). By the help of local contact persons who were able to visit various the groups of participants and introduce the project to them, the individual contact mobile phone numbers were obtained, a WhatsApp group setup to facilitate field work planning after obtained the informed consent of the participants for the interviews.

Key informant interviews with traditional birth attendants and midwives

The investigators conducted key informant interviews with TBAs to understand their views on maternal health and child mortality and their work circumstances. Due to the illegal nature of their activities, three informants were identified and interviewed, and these individuals agreed to share information on the condition that their identities remain anonymous. The interviewees responded to the questions listed in Appendix 3.

Focus group discussions with mature and teenage mothers.  

The investigators also conducted two focus group discussions with mothers who had given birth before the age of 18 and a second group of mothers over 18 and students. This exercise aimed to understand what prevents mothers from going to the hospital during and after pregnancy and whether they found TBAs useful in supporting them during and after pregnancy. Light refreshments and transport were provided for the participants due to discussions that lasted more than 2 hours.

Ethical considerations

All interviews and discussions were recorded in notebooks (given their preliminary nature) after seeking and obtaining permission from respondents, following the protocols outlined in (Guion et al., 2011). Before starting each field session, the team read out the purpose of the task: "Academic research aimed at contributing to the reduction of maternal mortality among pregnant mothers and adolescent girls in rural areas by exploring and testing strategies that could facilitate effective and efficient access to health care".

The team also informed respondents that all data would be used for academic purposes only and were also assured anonymity by LIGS University's data protection procedures. The team was introduced to the relevant stakeholders at the beginning of each interview session by either a community assistant or a leader (pre-identified).

3. Results

Traditional Birth Attendants

Under tight security, the investigators interviewed 13 TBAs in the three villages, with strict instructions from them not to disclose their identities due to the ongoing ban on TBAs in Uganda. The TBAs had an average of 9 years of experience in assisting deliveries. Approximately 60% of the TBAs reported learning through self-study, while the remaining 40% learned through inheritance from supportive aunts or their mothers. None had any formal medical training.

On average, a TBA received 100 pregnant mothers per year, range [60-196], of varying ages in the range [13-45] years. In 1 in 2 cases, TBAs often provided transport for the women after delivery; about 95% of teenage mothers only visited TBAs. All TBAs were aware of illegal operations outside the facility, although they complained that the government does not support them as community health providers for pregnant women.

All TBAs during the Interviews reported that they had experience providing midwifery services such as basic abdominal massage, delivery and umbilical cord cutting, postnatal care and administration of postnatal remedies such as paracetamol and local herbs. Indirectly, modern clinics often worked TBAs by referring challenging cases to them. It’s important to note that TBAs reported that maternal mortality was declining in their area because all emergencies were often referred to hospitals and private clinics. On average, 10-25 maternal deaths per year in the three villages were observed.

Interviews with midwives

The team interviewed 8 midwives in three health facilities in the three villages of the district. Of the 8 midwives, 3 were senior, and 5 were junior. They had an average cumulative experience of 70 years and an average of 12.2 years. Only 10% of the midwives reported that they were well paid. All practitioners were involved in carrying out 3-6 interventions, including booking and attending antenatal appointments (50%) and routine antenatal care (100%), neonatal care (90%), ultrasound and antenatal blood tests, and postnatal care (40%), nutrition and health education, family planning awareness and immunization.

On average, midwives attended 120 pregnant mothers per year, ranging in age from [50-200] to [17-45] years. Despite the high numbers, due to the relatively high cost of antenatal care, an average of only 7 pregnant mothers attended antenatal appointments ranging from [4-20] per month. All hospital births were vaccinated immediately after delivery.

All midwives reported that they had no relationship with TBAs, and 30% of them blamed TBAs for not referring pregnant women to hospitals when they had problems during childbirth. They also reported that no financial support was offered to vulnerable mothers and adolescent mothers who often traveled long distances to the health facility, couldn’t afford antenatal care services, and could only be provided with basic paracetamol and folic acid to pregnant women.

All the midwives confirmed that maternal mortality is a significant problem in the district, with up to 60 deaths per year in some hospitals, and that the hospital keeps records of both pregnant mothers and deaths. In addition, all the midwives complained of overcrowded wards during antenatal clinics, although the statistics are low.

Interviews with older mothers

The team organised eight focus group discussions with 150 mature mothers in the three villages. On average, each mother had 2 children [1-6]. Most women (62%) reported giving birth in hospitals, although they preferred TBAs because of the absence of strict medical protocols (no antenatal medical history required), their availability and 50% relatively cheaper than standard clinics, ease of access, and proximity to rural areas. In addition, TBAs provide transport for mothers after delivery in 1 in 2 cases.

The survey findings revealed that about 68% of teenage mothers only attended TBAs, and older mothers aged ≥ 40 years preferred TBAs to SBAs because of their belief in their experience in handling old mothers without blaming them for having children at an old age. Generally, almost all mothers did not know about the legal permission granted to TBAs’ operations in Uganda but were aware of the operations of their operations in shadows or hide-outs. All the mature mothers believed that TBAs are helpful and that banning them would lead to significant maternal health problems since modern hospitals are far away and maternal services are expensive.

About 80% of this group of mothers were aware that some mothers in the villages lose their children or die during childbirth but are not familiar with the terminology of maternal mortality. Getting to hospitals during pregnancy is difficult because of bad roads, lack of money, and few hospitals, which often lack essential medicines and staff. The government can help us mothers by providing more community hospitals and medicines and reducing hospital fees for antenatal care. Some of us depend on the herbs that TBAs give us because of a lack of money.

Interviews with teenage mothers

The team organized four focus group discussions (two in a village in Nabukalu and one in each other) with 62 teenage mothers from the three villages. On average, each teenage mother had one child [0-2], and 20 were expecting. Most of these young mothers -80% - reported that they had given birth with the help of TBAs and preferred the TBAs to SBAs because there were no strict medical protocols (no medical history required). They felt safe because the confidentiality of the TBAs did not give information to the government social services to arrest them.

In addition, some TBAs were able to treat them on credit for payment at a later date. About 95% of all teenage mothers visited only TBAs. About 100% of teenage mothers are not aware that TBAs are allowed to operate in the country. However, 90% of them know that TBAs often operate in the shadows and prefer their services because of better accessibility, being located in communities, better relationships with TBAs, being known by family members, convenience, transport fare offered after birth, and freedom to use traditional birthing positions and herbs).

In addition, about 45% of teenage mothers reported that TBAs provide services based on intimate relationships and trust with mothers and the community at large. The survey findings revealed that all teenage mothers believed that TBAs are essential in their communities and that banning them will perhaps lead to significant maternal health problems that cannot be solved by modern midwives due to the long distance to the health facility, high medical user fees and limited medical supplies and drugs in the available far distanced health facilities.

Only 60% of teenage mothers were aware that some mothers in villages lose their children or die while giving birth but didn’t know the terminology of maternal mortality. During the interview, they pointed out the difficulties encountered in accessing health facility-based maternal health services during pregnancy because of the lack of money associated with never single motherhood and rejected pregnancies, besides a limited number of hospitals in the villages serving a large population.

The teenage mothers stressed the need for well-equipped community hospitals or maternal health clinics to address these challenges. Further, the participants emphasized that most parents should provide support to their daughters who unexpectedly conceive by reducing their antenatal care hospital bills and offering them regular counseling on pregnancy management and family planning use instead of sending them away because of their pregnancy or after giving birth.

4. Discussions

This survey conducted in rural communities of Bugiri District, Busoga Sub-region, highlights the valuable role of traditional birth attendants (TBAs) as maternal healthcare service providers. The study indicates that TBAs are critically important for managing pregnancy issues among teenage and mature mothers by facilitating access to healthcare. These findings are consistent with previous studies by (Murungi et al., 2023 Musie & Mulaudzi, 2024 and Nabugoomu et al., 2020).

Health facilities and access to maternal healthcare 

Although this study did not conduct a comprehensive inventory of health facilities in the district, interviewee responses confirm a shortage of healthcare facilities. The available facilities in rural Bugiri are under-resourced and lack essential medical drugs, supplies, and equipment. Additionally, they are understaffed and have poor referral systems. The weak economic situation of the country has led to spatial inequalities in establishing health facilities, with a preference for urban areas (Dowhaniuk, 2021; Sub-county & Urendi, 2023).

This has resulted in inadequate facilities and resources, compromising the development potential of a large proportion of rural patients and pregnant mothers and undermining the prospects of achieving the national delivery of the Sustainable Development Goal (SDG) "to reduce the maternal mortality ratio to 70 deaths per 100,000 live births" (Khalil et al., 2023; Kota et al., 2023). Our findings are consistent with those of  Nguyulu et al. (2020), Mulungi (2023), and Chirwa et al. (2023), who found that a lack of medical facilities in rural areas, including midwives, is a common challenge that undermines maternal access to health care (Chirwa et al., 2023; Murungi et al., 2023; Ngunyulu et al., 2020).

Our studies also show that both mature and adolescent expectant mothers prefer to consult TBAs because they are more compassionate and confidential despite being outlawed. Other studies from Uganda and beyond agree with our studies and point to the value of TBA as an important component in improving access to health care for maternal mothers in rural areas (Kassie et al., 2022; Munabi-Babigumira et al., 2019).

However, an important question is how and which skills should be improved so that TBAs are no longer considered a risk by the Ugandan government. Studies suggest that training TBAs could reduce pressure on limited government health facilities and resources and allow for some equity in the distribution of access to maternal health care (Kassie et al., 2022; MacDonald, 2022; Mendhi et al., 2020).

Our findings suggest that modern TBAs continue to perceive TBAs as competitors and adversaries rather than partners. For this reason, it is important to continue to generate information about the value and importance of TBAs to raise awareness among decision-makers and other health professionals that TBAs are part of the solution, not the problem (Ohaja et al., 2020; Shimpuku et al., 2021).

Other studies suggest recruiting and training TBAs to reduce the workload of limited government facilities (Kassie et al., 2022; Sarmiento et al., 2020). Such a recommendation is good, although it is vague because it does not specify the type of training. Therefore, we suggest that the government establishment national systems that can begin to recognize the value of TBAs, followed by a complementary assessment of capacity-building needs for them to ensure that their potential participation in the health system is complementary to the services of midwives.

This combination will likely improve the quality of access to maternal health care in rural areas (Aryastami & Mubasyiroh, 2021). Most government interventions have ignored TBAs and focused on improving the skills of midwives and maternal management (Kumakech et al., 2020; Munabi-Babigumira et al., 2019; Ssetaala et al., 2022)This marginalization has not yielded the desired results, as the maternal mortality rate in rural communities in Uganda and many other African countries is not improving.


The Relevance and Contribution of TBAs in MMH

Most participants interviewed during this study emphasized the importance of TBAs in providing maternal health services. All the adolescent and old mothers believed that TBAs are relevant and helpful in providing maternal health services despite the lack of knowledge, skills, logistics, and equipment needed to manage emergency and difficult pregnancy or childbirth-related conditions. These findings are consistent with those from other rural SSA countries (Ateudjieu et al., 2023; Kassie et al., 2022; Musyimi et al., 2019; Nyirenda & Maliwichi, 2016).

In addition, about 45% of teenage mothers reported that the ability of TBAs to provide services is based on the intimate relationships and trust they have built with mothers and the community at large. TBAs are, therefore essential to these communities, which means that banning them could perpetuate the lack of maternal health facilities and related services to address the antenatal and postnatal needs of pregnant mothers (Population, 2020; U & E, 2019)

Continuing in this direction will significantly undermine the ability of rural mothers to physically access the health facility and acquire appropriate care (and exacerbate the challenge of financial difficulties. These findings are similar to those from rural communities in Ethiopia, Burundi, and northern Uganda that have highlighted the relevant role of TBAs in maternal health care (Kassie et al., 2022; Mendhi et al., 2020a; Musie et al., 2022; Sub-county & Urendi, 2023).

Given the shortcomings of SBAs due to limited health facilities in rural areas, the recruitment of TBAs into the health system could help increase human resources to address the maternal health challenges highlighted in the findings of this study. However, given the current social and economic situation in Uganda, TBAs are likely to be a better option to support equitable access to health care in rural areas of Uganda (Delzer et al., 2021; Iqbal et al., 2023). An advantage of TBAs is that they can mobilize and engage men in maternal health care programs, including ANC, and research on the effectiveness and impact of herbal medicine on maternal health care (Chizoba et al., 2020; Esan et al., 2023; Muheirwe & Nuhu, 2019).

While the SBAs from our study seem to suggest that TBAs are bad, they could be an asset that complements the activities of modern health facilities by providing counseling and referral services for emergencies at the community level (Adatara et al., 2020, 2021), thus confirming their relevance. For this reason, the Ugandan government needs to start exploring how to support TBAs by establishing well-designed recognition programs that will enable them to officially broaden the maternal healthcare systems in the country. Therefore, providing TBAs with logistics, equipment, salary, and training as incentives would help them to perform better in ensuring maternal health. This has been reported in studies conducted in Uganda, Chad, and SSA as a whole (Ateudjieu et al., 2023; Kassie et al., 2022; Musie et al., 2022; Sarmiento et al., 2020).

5. Conclusion

This focused preliminary study has confirmed the validity of TBAs as essential maternal health service providers in rural Bugiri District, Uganda. The preference of maternal mothers for TBAs to provide services to both mature and adolescent mothers is facilitated by the intimate relationships and trust they have with mothers and the community at large. This means that rural women or community members enjoy confidentiality and often need support during pregnancy. Ironically, the relationship between TBAs and SBAs does not seem to exist, and for this reason, all TBAs operate outside the legal framework of health facilities in Bugiri District. Due to the lack of professional midwives in the health facilities in the District, there is an urgent need for the government of Uganda to put in place systems that would enable the rapid empowerment of TBAs to be integrated into the country's legal maternal health care systems.


Author: Robinah Namulindwa

Co-author: Chris Byaruhanga



Traditional Birth Attendants (TBAs), Maternal, Healthcare, Skilled Birth Attendants (SBAs), Mortality Rate.

Research question: Are TBAs still enabling access to maternal mothers' healthcare services in the Rural Bugiri District, Uganda?


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