Expanding the role of traditional birth attendants in Lesotho



Marumo Marumo, the Traditional Birth Attendant (TBA) Coordinator, with four TBAs at a recent training.


In the small southern African country of Lesotho, about one out of every four adults is HIV positive, and high rates of maternal mortality and morbidity threaten the country’s young mothers. The rough, mountainous terrain and lack of roads exacerbates the situation, preventing many people from easily accessing the medical services needed to curb the epidemics.

To help address these problems, Partners In Health Lesotho (PIHL) is using traditional birth attendants (TBA)—local traditional midwives—to provide women living in rural mountain villages with access to comprehensive services including HIV testing, counselling, and treatment; methods of preventing HIV transmission from mother-to-child; and antenatal (prebirth), delivery, and general post-birth health care; immunizations; as well as general reproductive health services.

In May 2009, PIHL, in partnership with the Elton John AIDS Foundation, began to pilot a TBA program in a catchment area that includes 71 villages around PIHL’s health center in Bobete. PIHL hired and trained 100 local women to serve as a link between the clinic and pregnant women—who are literally their neighbors. The TBAs locate and accompany the expectant mothers through their pregnancy and birth to ensure that they have full access to the clinic’s comprehensive services. This includes bringing the women to the clinic to deliver their babies.

The TBAs are a part of Lesotho’s traditional midwifery community and PIHL seeks not to replace them, but to further their education and employ them in an expanded role as community health workers in the communities of which they are already a part. And as families traditionally pay TBAs for delivering babies, the PIHL program provides a cash incentive for each woman a TBA accompanies, replacing the income lost when women choose to deliver at the health center.

Accomplishments of the Lesotho TBA project during its first seven months:
  • 399 antenatal visits at the Bobete clinic.
  • 250 pregnant women counselled by TBAs.
  • 172 (69%) of the women counselled by TBAs attend at least one antenatal visit.
  • All 172 women weretested for HIV—15 tested positive for HIV.
  • Had 64 mothers give birth at the Bobete clinic. Of these, 53 (83%) were accompanied by TBAs.
  • Surveyed 7,655 women of childbearing age to establish baseline data for monitoring and evaluating the project.

In the first six months of the project, the TBAs completed their training, surveyed their villages, and began to visit pregnant women in their homes. They accompanied 172 women to the clinic for antenatal care, and accompanied 53 women to deliver at the clinic. Clinic deliveries have steadily risen in response to TBA outreach, with at least 24 women giving birth at the health center last month.

The advantages of delivering in the Bobete clinic are significant, particularly in preventing the transmission of HIV during childbirth. Delivering with the assistance of a skilled nurse decreases the risks of maternal mortality and morbidity, and infants with health issues can receive immediate medical attention.

To enable more women to deliver at the health center, PIHL is renting waiting houses near the clinic that can shelter six women at a time. Rough terrain separating the remote villages from the health center can make the journey virtually impossible for a woman with labor complications, so these houses make it possible for women to make the journey before labor begins.

As an extra incentive, PIHL also provides new mothers who fulfil certain criteria (get tested for HIV, attend at least three antenatal visits and deliver their baby at the clinic) with a new baby package, which includes clothing (hat and sweater), pins, and a bathtub. During the programs first six months, PIHL distributed 60 new baby packages.

PIHL believes that the accompaniment of the TBAs and the general knowledge and care delivered during the antenatal visits will encourage each woman to deliver her baby at the clinic, and that in doing so families in the Bobete catchment area will see a decrease in HIV mother-to-child transmission rates, as well as maternal and infant mortality and morbidity rates. In the coming year, the PIHL team hopes to expand this program to six more rural health centers.