De TBAs ol Senegal
Despite their numbers and their social and economic importance, the traditional birth attendants of the African continent may be extensively used in one place and illegal in another. ln general, no great effort has yet been made to givè them any legal status
by Pape Marcel Sène
T
he first time I visited her, so many people were there that I was unable to see her despite the late hour. The sun was sinking towards the sea and was already hidden behind the Cap Manuel lighthouse, at the southern tip of the Cap Vert peninsula. Thirty or so women sat quietly in the shade of gently rustling mahogany trees, awaiting their turn to enter the hut, a small building that was set apart from the other compounds and served both as bedroom and consulting room.lt was not until three days later that I finally pushed aside the curtain covering the entrance. Night had completely fallen when she received me, in between patients because women were still waiting. 1 con- fess to crossing her threshold with a great deal of apprehension: the isolated setting and the crowd outside heightened the air 22
of mystery which generally surrounds people who "possess knowledge," and particularly this one, Dame Ciré Coly. She came from faraway Casamance, a district renowned for its deep-rooted spiritualism and its worship of ancestral values. But I need not have worried. Indifferent at first, with a trace of tiredness, the features of this woman of indeterminate age became animated and impassive by turns through- out our conversation, which we conducted with the help of an interpreter.
Seated on the ground, she is surrounded by an impressive array of empty bottles which she will fill with decoctions and other medicinal preparations for her many clients, including some white women, who corne to her every day. Sorne will com- plain of stomach aches, others of high albumin or salt levels, sterility or lateness in giving birth.
How many clients does she see each day? Whether from mistrust or modesty, Dame Ciré Coly replies that although there are plenty of them-she cannot give any figures-the money she receives is immediately spent on feeding her large family. She left Casamance, she says, because her son asked her to. "Our know- ledge is handed down within the family,"
she explains. "When I feel my powers are leaving me, 1 shall go back to Casamance to pass this knowledge on to someone else."
Her secrets lie mainly in the properties contained in the plants, leaves and roots which she has sent from her home region.
On this point she complains of the many taxes she has to pay each time to the customs and to the Water Resources and Forestry Department. "Something has to be done to help me," she adds.
A traditional birth attendant in Senegal tends a newborn baby. A short training course has ensured that she knows the importance of clean hands and aseptic conditions when delivering a child.
Photo WHO/UNICEF/J. Ling
What does she think of modern medicine? She thinks it is just as valid as traditional medicine. lt all depends on the disease. "But the two kinds of treatment do not go together," she says, adding that she has frequently rejected offers by the medical authorities to set her up within a hospital.
Does she help with birth? Not specifi- cally, but it does happen from time to time that after a treatment a woman goes into labour, and then she does what is
necessary before sending the woman to a hospital.
Healer or traditional birth attendant?
Dame Ciré Coly certainly deserves the former title in the light of recent develop- ments regarding these practitioners.
Nevertheless, she is the perfect example of the traditional birth attendant of the old society, combining practical skills with a sound knowledge of "magic" and enjoy- ing exceptional prestige among the peo- ple. At the same time the disinterested and essentially humanitarian aspect of her services has to be stressed.
Nowadays Dame Ciré Coly represents a dying species. While she still enjoys a high reputation as a traditional healer, it would seem that-because she clings exclusively to the old values-the term "matrone"
or traditional birth attendant does not fit her.
This is because in Senegal, as in other African countries, a minor "revolution"
has taken place in the way the traditional birth attendants are used, with their knowledge ( or their ignorance). There are various pressing reasons for _this develop- ment. One reason stems from the serious shortcomings of the health infrastructure.
A second, arising out of the first, is the de facto monopoly of deliveries which the traditional birth attendant has in the coun- tryside and even in the towns. A well- known African thinker once said that
"four Africans out of five corne into the
world between the hands of the traditional birth attendants."
Once it became clear that it was not possible to replace the traditional birth attendants by modern medical staff, in other words midwives, it became necess- ary to "salvage" the birth attendants,
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redirect them, train them and, if they could not be integrated into the modem health care system, at least link them with it. In short, it has been necessary to take them beyond the limited and passive role they played hitherto and to involve them full y in the matemity process: pregnancy, family planning and care of the newbom.
Once this objective was decided on, it was necessary to find the means of attain- ing it. Senegal can boast of having set up this ambitious project well before the 1978 Conference of Alma-Ata firmly es- tablished the primary health care concept, although this concept has strongly influ- enced the approach. By setting up health committees, health huts and posts in vil- lage communities, and by training com- munity health workers who form the fab- ric of primary health care, the administra- tive reform of 1972 made a decisive contribution to bringing about a more
· balanced distribution of social welfare, while at the same time mobilising the interest, creative spirit and innovative capabilities of the rural populations.
This community participation is seen by Miss Pellegrin, head of the Centre for Advanced Nursing Studies ( CESSI) in Dakar, as a "philosophy that places a great value on people." Within this pre- cise framework, we are told by the woman who for 15 years was in charge of the 24
School for State Midwives, and was one of the first to suggest the establishment· of rural matemity units, "the traditional birth attendant is an example of commu- nity participation, of human investment."
Human investment. These words were also used by Mrs Aïssata Koité, now a social assistant with the Ministry of Public Health in Dakar. They are impressive words from someone who launched the first rural matemity unit, who made effec- tive use of the first traditional birth at- tendants to undergo training, and who for more than 10 years was in charge of the experimental centre at Khombole, 100 kilometres from Dakar. "It was a tough fight," she says, referring to her team's struggle to change the mentality of the traditional birth attendants. In par- ticular it was not easy to explain to them the microbial origin of neonatal tetanus, because they attributed the many deaths among infants to witchcraft.
Nowadays the battle has been won, as I was told at Khombole by Mr Diallo, State- registered nurse and currently director of the Institute of Social Paediatrics in Khombole. "Mortality from neonatal tetanus is zero in the rural matemity units at Touba-Toul, Ngoundiaye, Ndièyène and Ndiagou, and in the urban matemity centre at Khombole." From its beginnings as a simple test area, the Khombole centre
The TBAs of Senegal
Left: Roots, leaves, the bark of certain trees-all these sources of simple plant medicines are familiar items in African marketplaces. Those who sell them often regard themselves as in competition with orthodox pharmacies.
Right : This little hospital in the Congo is run by practitioners of traditional medicine. One room is reserved for men and three rooms for women patients.
Photos L Sirman C and WHOIR. C. da Silva
has gradually acquired logistic resources more in keeping with its vocation as a research institution and a training centre for the medical and allied professions. The training of traditional birth attendants is one of the most satisfactory aspects of its work. Mr Diallo told me that a first intake of 200 of these workers ( appointed by the villagers themselves) had been trained in midwifery by a team of midwives, and were now working under strict super- vision. A system of payment had been introduced, village pharmacies were now in business, and altogether the results had been outstanding. A further 240 tradition- al birth attendants were being trained with support from UNICEF, and would soon swell the ranks of the first intake.
The Khombole experiment has caught on throughout Senegal, thanks to the assistance of bilateral agencies such as
USAID, the French Volunteers for Pro- gress, and Western governments. The training period ranges from three weeks to three months, depending on the region.
By December 1981, 2,626 community health workers had been trained and were engaged in health work at Senegal's 730 health huts, 535 health posts and 261 rural maternity units. In addition, 1,366 traditional birth attendants had been trained and provided with kits.
This nationwide coverage by the birth
attendants is particularly due to the work of UNICEF. "lt seemed desirable, after setting up community structures, to give a higher status to the birth attendants," says Mr Audat, UNICEF representative in West Africa. The work of his organization has another objective: "To encourage contact between traditional therapy and the prac- tices of modern medicine, to bring them doser together. For there is quite a promi- nent place for traditional medicine."
This is in line with the views of WHO,
which in a document published in 1979 stated: "Concern should not centre on integrating the traditional birth attendant into the modern system but rather on ensuring that, within the traditional birth attendant as a person, modern and tra- ditional concepts and modes of practice are so integrated as to eliminate only traditional practices and rituals that are dearly shown to be harmful, and to instil only modern concepts and techniques that are absolu tel y essential to the safety of the persons under the care of the traditional birth attendant."
About a dozen nursing students at the
CESSI, in their end-of-course dissertations, have dealt with the question of integrating the birth attendants into the modern health care system, and have put forward suggestions about their training, use and supervision.
"What we expect from the traditional birth attendants," Miss Pellegrin wrote in 1970, "is not that they carry out obstetric functions, but that they ensure hygiene in normal deliveries and are able to detect in good time any anomaly calling for hospitalisation.''
A few years later, Mrs Diakhité from Mali warned against recruiting birth atten- dants at too young an age. She laid stress on the training of their teachers, the superv1s1on of the birth attendants once they were trained, and the arrang- ing of refresher courses in nursing and obstetrics.
In 1977, Miss Agnès Djidonou of Benin suggested a training programme that would cover not only pregnancy, labour, delivery and the care of the newborn, but also environmental sanitation, malaria, diarrhoea and measles.
The eminently active role of the birth attendant is well appreciated by Dr White,
USAID's health representative in Dakar. He believes that the project currently being financed by USAID for the training of birth attendants would be more effective if it were supplemented by training of a more technical nature. This second phase, which has not yet been agreed upon, would cover immunization, malaria control, nutritional surveillance and education, and oral rehydration. The birth attendants,
Dr White says, would play a major part in this phase.
Clearly it is no longer the role of the traditional birth attendant to catch and cast out "evil spirits;" she is being turned into a genuine health auxiliary. And an auxiliary who is all the more effective because, as Miss Pellegrin points out," she _has something that the midwife hasn't: the ability to offer deeply human services in the most remote places." The fact that she belongs to the village makes her a member of the family.
Because of the underdeveloped health facilities in African countries, because of the way their peoples ding to ancient beliefs and rituals, and because of the transformation the traditional birth attendants are undergoing, these prac- titioners-far from being doomed to extinction-are in the medium-term at any rate developing into a force that cannot be ignored and must be reckoned with.
Nevertheless, despite their numbers and their social and economic importance, the traditional birth attendants of Africa occupy a varied and ambiguous situation : extensively used in one place, illegal in another. While a dozen African countries have programmes for improving the ser- vices offered by the birth attendants, no great effort has been made to give them
any legal status. •
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