- Medicine Access and Rational Use > Primary Health Care
- Traditional Medicine > Traditional, Complementary and Herbal Medicine
(1995; 146 pages)
Case Study Three: Manda TBA Project, Bangladesh
Sponsored by Christian Commission for Development in Bangladesh
A. DESCRIPTION OF PROJECT
The Christian Commission for Development in Bangladesh (CCDB) is a nonprofit, non-governmental organization and is an autonomous service organ of the National Council of Churches of Bangladesh. It is engaged in a wide variety of multi-sectoral training and other rural development programmes, all aimed at achieving sustainable development in health, literacy, agriculture, the environment, women’s advancement, and savings and credit. CCDB’s approach is to involve local people in planning and implementing programmes according to their own needs.
In 1985, CCDB started a programme to train Traditional Birth Attendants (TBAs) at four rural residential training centres. Since its inception CCDB has trained approximately 5564 TBAs in 10 Districts of the country. The district chosen for this evaluation was the Manda Thana (region) of Rajshahi District, approximately 270 kilometres northwest of Dhaka.
The TBAs, when interviewed, described some of the most serious health problems of women in the communities they served: edema of feet and legs; severe anaemia; severe bleeding of haemorrhoids; difficult presentations at birth including breach, hand, cord, leg or placenta first, or transverse position of the baby; long vaginal tears or vaginal fistulae; severe bleeding before or after birth; umbilical cords wrapped around the neck of the baby; retained placenta; and the fact that many women do not get tetanus injections.
The main objective of the TBA programme was to impart knowledge and enhance the skills and health care practices of TBAs by arranging periodic training courses to enable them to perform the following tasks:
• perform safe and hygienic deliveries;
• provide prenatal and postnatal care;
• select high risk pregnancies for referral;
• give nutritional advice to pregnant and lactating mothers;
• advise on immunization in pregnancy and childhood;
• advise on family planning.
C. RECRUITMENT AND SELECTION OF TRADITIONAL PRACTITIONERS
CCDB slightly modified the Government’s procedure for recruiting and selecting TBAs. Their procedure was to select 5 TBAs per Ward (approximately one per village) and 15 per Union (approximately 15 villages). A letter was written to the Union Parishad requesting them to prepare, in consultation with all its members, a list of names of eligible TBAs. A CCDB Field Organizer then went to the Union and visited all eligible TBAs in their own homes to talk with them and obtain some basic information about their eligibility.
The CCDB criteria for selection of TBAs generally follows the Government of Bangladesh criteria, which are:
• between 30 and 45 years of age;
• conducts at least 5 - 10 deliveries per year;
• married, widowed or divorced;
• a resident of the area;
• well-accepted in the community;
• interested in training.
In addition, the Field Organizer consulted with formal and informal leaders in the community to get their views and to identify other TBAs who may have been missed by the Union. On the basis of these findings the final selection took place.
D. TRAINING CONTENT
The basic course consisted of 11 days of training followed 6 months later by a refresher course of four days, then followed by a second four-day refresher course after another six months. The total training time totalled 19 days, carried out over approximately a year’s time.
CCDB staff believed that this pattern of training was very satisfactory and sufficient, since, being residential, it offered TBAs ample opportunity to elaborate, discuss, and repeat the learning material outside the formal sessions.
The training content covered all the MCH areas listed in the objectives in Section B.
E. TRAINING METHODS
A wide variety of training methods and materials were used in the CCDB’s training programme. Many visual aids were used in presenting information. These included flip charts, anatomical models and slides. Heavy emphasis was given to participative group discussions, demonstrations and role plays. Through past experience the CCDB found that informal settings, such as TBAs sitting on mats in a circle on the floor, encouraged group interaction and active participation.
F. FOLLOW-UP SUPPORT
After initial training, regular follow-up support was provided to the TBAs through forums organized at four month intervals. These forums were held at the Union level, and were arranged for groups of 15 trained TBAs of that Union, which was within walking distance. In between these forums, the TBAs met by themselves once a month, with one of their own group as a leader and usually at one of their homes.
G. CHARACTERISTICS OF PERSONS INTERVIEWED
1. Health Agency Staff - Five official health agency staff representatives were interviewed concerning their opinions on the effectiveness of trained TBAs in villages. Three males and two females were interviewed; their average age was 27.8 with a range of 23 to 37. Their staff positions were, TBA Programme Officer, Senior Trainer of TBAs, Assistant Trainer of TBAs, Health Organizer, and TBA Forum Organizer. They had worked in their current positions from 3 to 8.5 years, or an average of 5.1 years.
2. Traditional Practitioners - Eleven TBAs from five villages were interviewed, all were female. Their average age was 40, with a range of 30 to 55. Four of the eleven were able to read and write, and these had attended from 5 to 7 years of school. The average number of years worked was 12.7 with a range of 5 to 24.
3. Community Members - Fifteen members of four villages were interviewed to determine their views on the services provided by local TBAs. There were five males and ten females, and the average age was 31 with a range of 18 to 60. Their occupations included, farmer, labourer, student, businessman, and mother.