Ugandan Mothers Opt for Traditional Birth Attendants Despite Risks, Illegality

WAKISO, UGANDA — Maggie Nakachwa, 24, is a mother of two, with another on the way.

Three times during her pregnancy, she will leave her home in the Nsumbi village, in the Wakiso District, and travel over 150 miles to Kyantoni, a village in the Lwengo District.

She makes this monthly trek to see Oliver Nabaggirinya, a traditional birth attendant.

Nabaggirinya’s practice was banned by the government in 2010, but Nakachwa says she doesn’t care.

On her long journey, she passes several public hospitals and health centers where she could get free prenatal care.

But this is the second pregnancy for which she has chosen to consult with Nabaggirinya rather than use the country’s free services.

“I go to Nabaggirinya because my mother recommended her and because I trust her,” Nakachwa says. “She helped me deliver my second child with great patience and politeness.”

She says the experience was much better than the one she had delivering her first child at a government hospital.

“The nurse at Mulago Hospital shouted at me, telling me to climb onto the bed on which I was to deliver. She also said she would slap me if I did not push the baby hard,” she says. “But Nabaggirinya was gentle. She encouraged me to push in a serious, but not rude, tone.”

The government banned traditional birth attendants from delivering babies in 2010, in the hopes of improving maternal- and infant-mortality rates. But despite ubiquitous free prenatal care in government hospitals, the practice continues to be both widespread and popular.

“The traditional birth attendants can’t handle hemorrhage in women, which contributes to 42 percent of maternal deaths and is the leading cause of death in maternal mortality in the country,” says obstetrician and gynecologist Placid Mihayo, the focal point for the Reproductive Health division at the Ministry of Health. (A focal point is similar to a spokesperson.)

The list of reasons for banning the practice is long, he says.

“They work under unhygienic conditions, which can cause infections. Maternal sepsis accounts for 12 percent of maternal deaths, and in situations where a baby isn’t lying properly in the mother’s womb, such a situation might call for a caesarian section, which a traditional birth attendant can’t perform either,” he says.

According to the Ministry of Health’s Reproductive, Maternal, Newborn, Child and Adolescent Health Sharpened Plan for Uganda 2016-2020, about 416,000 women in the country annually are still not assisted by a skilled birth attendant. By 2020 the country aims to have 75 percent of all deliveries performed by skilled birth attendants.

A preference for traditional birth attendants is just one reason the goal has not yet been met.

“Some deliver at home perhaps because the health center was a distance away and it’s an emergency delivery, or because sometimes the cost of transportation is high,” Mihayo says.

Nabaggirinya, 66, says she has continued to deliver babies since her trade was outlawed in 2010. She has delivered more than 120 babies in the last 24 years, she says, and she delivered 10 of those babies in just the last year.

Nabaggirinya rejects claims that traditional birth attendants are not skilled.

“None of the mothers has died, not even their babies,” she says of her many clients.

She says she has been delivering babies for so long that she’s now working with a second generation – her former clients’ babies.

“It’s the mothers who I helped deliver that now send their daughters to me,” she says.

Gertrude Nabukenya, a mother of two and a resident of Kyantoni village, where Nabaggirinya practices, says she gave birth to both of her children with the help of the traditional birth attendant, because her mother recommended it.

“My mother recommended the TBA. She too had gone to the same traditional birth attendant for all her six children. She said that I would be safe delivering at the TBA’s place, and proof is visible because I have never suffered any birth-related complication,” Nabukenya says.

Little is being done to stop the practice, despite the law.

Joseph Mazinga, district community development officer of the Lwengo District, says changing women’s attitudes about the practice is difficult.

“We tell pregnant mothers that TBAs are doing it illegally, and we encourage them to go to health centers,” he says. “But they don’t listen, because TBAs have a lot of influence on these women. These ancestral practices are still significant to many people.”

But Mazinga also says that they haven’t arrested any traditional birth attendants because they haven’t received any complaints.

“No one has come to us saying he has lost a wife or a child,” he says.

The practice remains common for other reasons too.

Many women, like Nakachwa, say they don’t like the way they are treated in government hospitals.

Mihayo, at the Ministry of Health, says he is aware of complaints of nurse rudeness.

“But we’ve given fresh courses to train them on issues of customer care, human rights and privacy with hope that they change this misconduct, so pregnant women are encouraged to come to health centers, rather than going to traditional birth attendants because they are illegal,” he says.

But an even bigger factor is cost.

Delivery is free in government hospitals, but they are often understaffed and in short supply of basic goods.

Mihayo acknowledges that while the services are free, sometimes supplies are not available when people need them.

“No one should be asked to pay for any services, though they sometimes might be asked to buy supplies like gloves when they are not available,” he says.

Private hospitals are preferred but too expensive for many.

Nakachwa says she will need only 30,000 shillings ($8) for Nabaggirinya’s delivery services.

“That is far cheaper compared to private hospitals in Kampala and Wakiso that ask for close to 400,000 shillings ($109) for a natural delivery,” she says.

Nakisanze Segawa, GPJ Uganda, translated interviews from Luganda.