2806 SMJ 10
2806 SMJ 10
2806 SMJ 10
H Yadav SYNOPSIS
520
INTRODUCTION the people and they also perform more duties than the
government midwife. Chen (1977) (4) also noticed that
In Peninsular Malaysia it has been estimated that the bidan kampong performed fourteen traditional
there are 3,000 registered traditional birth attendants. It duties whereas the government midwife performed
has been estimated that 50%-80% of all domiciliary only three of those duties.
deliveries in developing countries in South East Asia Other reasons why the TBAs were more popular than
are attended by TBAs (1) yet many countries have yet to the government midwives were that the TBAs were
realise the important role the TBAs play in maternal and easily available, the TBA were more influential and that
child health care. In the declaration of Alma Ata for the they stayed within the vicinity of the village unlike the
attainment of 'Health Care for all by the year 2,000', all government midwives who sometimes may be a few
possible resources in the community have to be identi- kilometers away and sometimes may not be available
fied and utilised if we are to achieve this aim. In when called. It is also known that the rural Malays have
Malaysia the traditional birth attendant had been utilis- several customs related to child birth in Malaysia (5)
ed for family planning activities. (2) Similarly many and the TBAs were well versed with these customs as
other countries have utilised the traditional birth atten- compared to the government midwives.
dant for maternal and child health program and now Realising the significant role played by the TBAs in
other countries are looking into his 'untapped resource' the maternal and child health program it is important
to achieve its aim of primary care for all by the year that this 'untapped resource' be utilised, and with this
2000. in mind a training program was planned for the TBAs.
This paper deals with the training, utilization and
evaluation of traditional birth attendants (bidan kam- STUDY AREA
pung) for maternal and child health care and the
benefits and advantages which have been derived from The study was carried out in the district of Kerian (Fig.
such a program. 1). Kerian district is situated in the north west part of
Peninsular Malaysia, approximately 320 km from Kuala
BACKGROUND Lumpur. The district is bounded by the Province
Wellesley and Kedah state to the north, the Larut
The district of Kerian conducted a survey of infant,
Matang and Selama district of Perak to the East and
maternal and toddler mortality as part of the high risk South and Straits of Malacca to the West. The district
approach project in maternal and child health care. In has an area of 857 sq kilometers and population of
this study (unpublished) it was found that the TBAs 157,649 (density 184 per sq km). The population is main-
were responsible for 47.2% of the deliveries in the
ly rural and ethnic Malays constitute 65.2% of the total
district in 1976, and they were also responsible for58% population. The Chinese who are mainly more urbanis-
of maternal deaths in the district. (3) Since the TBA were
ed constitute 22.4% of the total population and Indians
responsible for a substantial amount of maternal and constitute 12.3% of the population. The main source of
child health care, the need to utilise the TBA was realis- income is rice growing, rubber and palm oil planting. In
ed. Like many other countries the TBA are accepted by
the coastal area f ishing is the main form of livelihood.
W;
_..._ State Boundary
District Boundary
a- Metal Road.
Railway Line
River
Hospital Midwife Clinic
ed Lake If Oil Palm
A Health center i Rice Field
521
ORGANIZATION OF MATERNAL AND CHILD HEALTH peting with her for the deliveries in the district. The
CARE IN THE DISTRICT pubic health nurse from the nearest health center visits
the midwife clinics and conducts child health sessions
Maternal and child health care is provided both by and immunization for the children in her operational
the government and the private sector, Chen (6) area. She also supervises the midwife's work.
describes the rural health system in Malaysia in detail. General Practitioners are physicians in the private
Briefly the maternal and child health care in the district sector. They play an important role in maternal and
is provided by: child health care because they treat and provide
Hospital, Health Centers and midwife clinics antenatal and postnatal care for mothers and children.
(Government sector) Some of the general practitioners own maternity homes
General Practitioners(Private Sector) where some mothers have their deliveries.
Estate Hospitals (Private Sector) The estate hospitals are small hospitals which are
run by the large rubber estates in the district. There are
Traditional Birth Attendants (TBAs) three such hospitals and they have a midwife who is
The 141 bedded district hospital has 5 physicians responsible for the welfare of the estate workers. A
and it also has a maternity and a paediatric ward. The paramedic is responsible for outpatients department. If
'high risk' children are identified at the health center or any patient requires admission or further treatment
the midwife level and then referred to the nearest they are referred to the nearest government hospital.
hospital for further management. The distance from the The one hundred active TBAs in the district play an
health center to hospital can range from 8-15 km. important role as they are highly regarded and
Sometimes the cases may be referred to a larger respected by the members of the community. They are
hospital (20 km) where specialists are availabel for bet- respected not only for the physical help they provide,
ter treatment of the cases. but also for their humanitarian approach, and they get
Fig. 2 shows that the health center covers a target paid according to the means of the family they assist.
population of 10,000. There are two categories of health They are reassuring unhurried and familiar to the
centers, the main health centers and the health sub - people. They know and fully understand the local
centers. A doctor is available in the main health center customs and they work within the framework of local
and he makes visits to the other health subcenters in beliefs and values. (1)
the district weekly. The public health nurses from all The TBAs in the Malaysian context can be divided in-
the health centers visit the midwife clinics for conduc- to trained and partly trained. The untrained TBA has no
ting maternity clinics and child health clinics. The formal training and the partly trained TBA has some
midwife clinic is the smallest health unit in the rural basic training in the fundamentals of hygiene, clean-
area. liness and asepsis. The daily routine of the TBA con-
Each midwife clinic (28 in number in the district) sists of attending to deliveries on request and visiting
covers a population of 2,000. A single midwife main expectant mothers to advise on antenatal and post-
tains the clinic and quarters. Her main role is to natal issues. She also provides some nursing care to
organize antenatal, postnatal and conducting the babies and teaches the new mothers some basic
deliveries in the home. She may have 3 or 4 TBAs corn- steps on baby care.
The study was carried out from 17th to 27th June MONITORING AND SUPERVISION
1979. During this study all the TBAs were interviewed. It was decided to monitor and supervise the TBAs
The questionaire used in this study had been protested after training. A book to monitor them is to be maintain-
in another district. A total of ninety seven TBAs were in- ed by the public health nurse at the health center level.
terviewed. Only 67 (89%) had formal education at the It was also decided that all pregnant mothers who were
primary school leve. Seventy four (76%) were more using the TBAs were told to go to the health center for
than 55 yrs of age and majority (82%) had more than 10 screening purposes. Here the public health nurse
yrs experience in the community. Only in 40% the pro- would decide whether the case is 'at risk' or not 'at risk'.
fession was passed from mother to daughter. All of If the case was identified as 'at risk' case the TBA was
them were aware of the midwife clinics, health centers not supposed to take the case during delivery. The
and hospitals. Sixty percent had received family plan- public health nurse would keep a record of all the preg-
ning training before and all of them were aware of the nant mothers who are attended by TBAsrin her service
family planning methods. Their attitude towards area. The midwifery kit which is given to the TBAts to be
modern medicine was positive and they also had some used during the time of delivery and the medicines in
knowledge of modern medicine. It was interesting to the midwifery kit could be replenished from the health
note that they also advised the pregnant mothers to at- center free of cost.
tend the antenatal care sessions in the government
clinics and health centers. RESULTS
When practices were examined it was found that
they conducted all types of cases, irrespective whether The training and utilization of the TBA has shown a
the cases were 'at risk' or not. They practised tradi- tremendous improvement in the MCH Care in the
tional customs like advising pregnant mothers on tradi- district. As shown in Table the number of Hospital
I
tional diet especially what diet to take during pregnan- deliveries has increased from 29.5% in 1976 to35.9% in
cy and what not to take. They also performed some form 1983. Similarly the government midwife has shown im-
of traditional abdominal massage during delivery and provement by increasing the number of deliveries from
they also advised mothers todo heat formentation after 23.3% in 1976 to 40.2% in 1983. The number of
the delivery which was harmful to the mother because it deliveries being conducted by the TBA has decreased
523
TABLE I LIVE BIRTHS IN KERIAN BY PERSONNEL OF DELIVERY
(1976.1983)
from 47.2% in 1976 to 19.4% in 1983 inspite of the train- delivery of MCH care. They are popular in the village
ing given to the TBAs. This suggests that there is a and they perform most of the traditional duties during
trend to utilise qualified personnel instead of un- labour which are not all performed by the government
qualified personnel (TBAs). (3) midwives in the Malaysian context.
Similarly the identification of 'at risk' cases in the There had been no control of the TBA's work
health centers and referral to hospitals has helped to previously and with some supervision and monitoring
improve the quality of care. There are more 'at risk' of the TBAs it is seen that more 'at risk' cases are
cases referred to the hospital than it was previously. It referred to the hospital. Some of the 'at risk' mothers
is noticed more primigravida and multigravida are refer- and children are identified early and referred to the
red to the hospital than it was in 1976. hospitals thus reducing the bad outcomes significant-
Table II shows that the utilization of the TBA in MCH ly. It is hoped that the hospitals would be conducting all
care has shown a constant decline in mortality rates. the 'at risk' cases and the government midwives and the
The maternal mortality rate in particular has shown a TBAs conduct the normal deliveries. The TBAs have
significant decline. also been advised to refer low birth weight babies to the
However, it is noticed that among the cases which nearest hospital.
are conducted by the TBAs one third are still 'at risk' The UNICEF midwifery kit given to the TBAs has been
cases. The main purpose of the training program is to very useful. The TBAs are now trained to take the birth -
decrease the number of the 'at risk' cases conducted by weight and the delivery process is much cleaner and
the TBAs and to refer these cases to the hospitals. healthier and more importantly the coordination bet-
ween the government midwife and the TBA has
improved tremendously. This is mainly due to the fact
DISCCUSION that the TBA now conducts the deliveries in a much
cleaner and healthier environment which in turn gives
Traditional birth attendants have existed from time less problems for the government midwives.
immemorail and today with or without legal permis- The monthly meetings between the public health
sion, they continue to conduct deliveries in many third nurses and the TBAs to review the progress regularly
world countries. Their importance in this respect is in- has been very useful. The TBAs now come forward with
dicated by some estimates that they conduct approxi- problems and discuss with the nurses and the govern-
mately two-thirds of the world's babies. (7) Because of ment midwives. The TBA training program has positive-
the significant role played by the TABs in the MCH Care ly influenced the MCH care significantly in the district
in the study area their identification and training proved and it is encouraged that countries with limited
to be useful. Similar form of training have been done in resources should look to the possibility of using this
other countries. (12,13, 15) resource for the attainment of primary health care for
The TBA is a useful 'untapped resource' in the all by the year 2000.
524
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525