In the new MSF pilot project in Sila, we are trying to walk a new path. We dare to admit that some of our old methods created and exacerbated a power imbalance between MSF and her patients and communities. And that, whilst many lives were saved, at times, our approach had unintended, negative side-effects.
Against the odds
According to UNICEF, the infant and maternal mortality rates in Chad are among the highest in the world. Stillbirths. Miscarriages. Women who die in labour. The numbers are alarming, and some refer to it as an "everyday emergency".
The formal health facilities, communities, tell us, are inaccessible. For some people, the closest health centre is 30 kilometres away and entirely unreachable in the rainy season.
For others, the costs of healthcare are too high.
And for the women that do manage to get to a healthcare facility, they often find broken-down health centres. The facilities may or may not have skilled staff, and pregnant women, they may or may not have a delivery kit that they wash with water and soap after each birth. A healthy child and mother are not a given, nowhere in the world. But in Chad, the odds are against you.
Come work with us
We try to listen not only to people’s challenges but also to their solutions. And here is what they told us in Sila: “Come to the communities. Come work with us.”
The traditional birth attendant is the most courageous woman in the village. She has no fear of blood. No embarrassment. She is there to help.Souat Ahmat Ramadan, a Chadian midwife
The more traditional MSF approach is to work in the formal health structures, such as hospitals or health centres, and to do outreach towards (remote) communities.
This time, they told us, we should centre our work in the communities and look outward through their eyes.
Traditional birth attendants
At the heart of community-level health care in Sila are the traditional birth attendants (TBAs). These are women, usually older women, that support other women in childbirth.
These women are generally trusted and help with childbirth, breastfeeding and other matters.
Most TBAs have had no formal education in midwifery. They have delivered children themselves. Their mothers and grandmothers have shown them the way. They are selected within families and communities themselves.
Research and debate
In global public health debates, TBAs have an ambivalent role that has changed over the decades. Research remains largely inconclusive.
Some research indicates that TBAs cannot be substituted for skilled birth attendants and that training them does not result in reduced maternal and infant mortality. Hence, some people claim they are ineffective at best and dangerous at worst. Some question their traditional practices.
Other research results speak of the positive impact and potential of their trusted and respected role in the community.
All seem to recognize that the lack of qualified staff in remote areas leaves a big gap to fill, and wonder who other than the TBAs will step in.
Needless to say, safe care is our priority.
And so is self-care. If we move away from the hospital's perspective and start thinking from the eyes of the patient, what would we see? How does the patient herself choose to be cared for? Where does her path lead first? Whom does the patient trust? What is reasonably accessible for the patient?
We listen, and we build our project around her.
According to UNICEF, in Chad, only two out of five births take place in the presence of a skilled birth attendant such as a midwife or doctor.
In Koukou district in Sila province, only three out of 11 health centers have a skilled birth attendant. And as health centers are inaccessible to many, it is clear that TBAs have a role to play. And so we became partners.
Filling gaps and identifying needs
Our very first step was to ask the communities to identify the TBAs to collaborate with. In a workshop with community representatives, they defined the criteria for ‘a good TBA’: ‘motivated to help, loved by her community and between 25 and 60 years old'.
Each village then elected a TBA to participate in our project. In collaboration with them, we identified the gaps and needs, and we designed a training program to strengthen their practices.
Over the last weeks, we have trained 31 TBAs in recognizing signs of danger before, during and after delivery. She is then trained to sensitize the rest of the community.
Equipped for the job
Souat shares, “in the future, we will be distributing kits (backpacks) to all of them. They will have a blouse, gloves, razers, cords, disinfectant, a torch, masks and cloth, as well as sturdy boots to help the TBAs reach remote areas during the rainy season. They will then be properly equipped to do the work they have been doing for years.”
In the future, we also consider training them on community pre-natal care, sexual violence, family planning and other topics.
In collaboration with the local Ministry of Health, we will accompany and provide peer-to-peer support for their work over the coming years.
In the coming months, we will start a new cycle with another 50 TBAs in a new area. You could call it a chronic emergency response.
Challenges and Impact
This is a worthwhile project. After decades of working in this field, I have not yet worked with such an approach. We face big challenges. None of the TBAs can read or write. We are limited in what they and we can do. But this approach is sustainable, this can work.Augustine Nsiloulou, MSF midwife activity manager in Chad
After a few months, the first signs of impact can already be seen. Antenatal care consultations have increased substantially. Referrals to the health center for complicated deliveries are picking up. The TBAs tell us that their skills and confidence are growing.
Heads held high
The World Health Organization (WHO) estimates that community health workers in maternal health roles fulfil 17 trillion dollars’ worth of healthcare services a year. They are mostly women, almost always unpaid.
The increased recognition of TBAs in Sila is leading to a new financial compensation system that the communities are developing themselves.
For years, these women performed their work without financial compensation. They would at times receive some sugar, oil, soap or flour from the families of the women they helped.
Now, the community has started collecting a monthly household fee to pay the TBAs 5,000 XAF ($8) per month. One TBA shared with us during the last training session, “I have worked for my community for years. Now, I walk with my head held high.”
New approach, more questions
We listened to the communities, and it led us to a new path. A path that is full of questions and dilemmas. Should the government not be carrying this responsibility rather than the communities themselves? By working in this way, are we condoning a broken system?
We are aware that our approach requires careful evaluation and needs to be accompanied by an advocacy strategy targeting structural public health deficits.
Meanwhile, we will keep walking, step by step, alongside the patient. It is, after all, her path.