Research for stronger health systems during and after crisis

A midwives and traditional birth attendants’ collaboration in rural north-eastern DR Congo: A complementing strategy where there are few qualified midwives

Posted on Wednesday, 06 Jun 2018

Liverpool School of Tropical Medicine PhD candidate, Amuda Baba, describes some of his work in mainly rural and peri-urban Democratic Republic of Congo which includes looking at the changing role and impact of traditional birth attendants. He considers a collaboration between midwives and traditional birth attendants to improve maternal health in the rural north-east of the country where there is a shortage of qualified midwives.


Maternal mortality ratio (MMR) in DR Congo is estimated at 846 deaths per 100,000 live births, more than 1.5 times higher than the sub-Sahara African average (546 deaths per 100,000 births), with a huge disparity between urban and rural areas. MMR in the urban area of Kinshasa is estimated at 250 deaths, while in rural areas it can be more than 1,000 deaths per 100,000 live births.

DR Congo is classified as a fragile and conflict affected state, as since the mid-1990s the country has experienced a series of war and conflicts. Ituri Province in north-eastern DR Congo was the scene of brutal violence between 1999 and 2003. Since February 2018 it has experienced ethnic conflicts in Djugu territory, causing thousands of people to flee from the area, either to Uganda or elsewhere in DRC, eg south to Bunia or north to Mahagi where they live in camps. In this fragile condition, qualified health workers, including midwives, prefer to stay in urban areas which seem to be more secure.

An African woman attends to four other African women with babies who are all sitting on two beds

A midwife follows-ups with mothers and their babies

A shortage of midwives

During a series of community health interventions in health districts in Ituri Province, we realised that there is a shortage of qualified midwives in remote and rural areas, which is contributing to the high MMR. Most midwives, like other health workers, after having completed their training, prefer to work in safer urban areas within Ituri Province.

My ongoing study in Ituri Province showed that from 2013 to 2017 the average vacancy rates for doctors and nurses were unexceptional compared to the rest of the country (11.2% and 10.2% respectively), whereas 81.1% of posts for midwives were vacant.

Average vacancy rates for all cadres were highest in rural health districts; 23.8%, 24.5% and 85.9% for doctors, nurses and midwives respectively, whereas in urban areas there was a surplus of doctors (177.7%) and nurses (170.8%). Also, vacancies for midwives in urban health districts were half that for rural areas. In semi-urban health districts, there was a surplus of nurses (115.2%), whereas the average vacancy rates for doctors and midwives were 6.1% and 73.6% respectively. As in other contexts, the midwives’ cadre is highly feminised and 87.1 % are women. As part of My PhD study I will be exploring the reasons behind the high vacancy rates of midwives.  
In many of the rural districts that have a shortage of midwives, traditional birth attendants are often the only recourse for pregnant women due to their accessibility and proximity in the community.

Traditional birth attendants

Some rural districts with a shortage of qualified midwives decided to identify traditional birth attendants (TBAs) in each catchment area within the health district to complement the few midwives that are available. This was done with the support of the health districts and local NGOs. The districts organise basic training for the TBAs, focusing on the importance of antenatal care, detecting potential danger signs and the importance of transferring pregnant women in health facilities.  Furthermore, as TBAs are respected in their communities and people listen to them and follow their advice, their training also covers some basic elements of post-natal care, including breastfeeding and weaning babies.  This respect and close, trusting relationship also makes them good advocates for family planning and other health interventions.

After their training, TBAs are integrated into the maternal health activities of health centres. Supported by local community health workers, they are involved in many activities, such as raising awareness of maternal health issues amongst women within the community and organising health education and antenatal clinics in selected close-to-community sites in a health catchment area. They accompany women to health centres when their delivery is due and follow-up with home visits.

An African woman in an apron tends to a pregnant African woman who is sitting on a bed looking uncomfortable

A TBA tends to a pregnant woman in Ituri

Personal success

A TBA, locally known as Mama Sarah, at Araba health catchment area, testified that she had brought a pregnant woman to be seen by a midwife. She added that she was happy to accompany women to the health centres instead of helping them deliver at home

"I'm now working by referring mothers and bringing them here," she said, adding "As for me, I am really happy because I am learning a lot and gaining more knowledge as I work now together with the midwives here at the health centre, and I am in position to better help women here at the health facilities now. Isn’t that wonderful?"

The collaboration between TBAs and midwives in health centres in some rural health districts of Ituri Province is making a great change in terms of maternal health outcomes. There are more women attending health facilities and being assisted by midwives, and TBAs have benefited from basic training. TBAs support also helps midwives to avoid becoming overworked, allowing them to focus on providing quality care.

Meanwhile, for the longer term, communities are recruiting children from rural areas who are interested in midwifery and are sending them to follow a four-year community-based midwifery programme (this follows ten years of school).  Hopefully this will eventually address the shortage of midwives in the context of fragile rural districts within Ituri Province.