Traditional knowledge and Public health.
Contribution of Traditional Midwives to the Reduction
of Maternal and Neonatal Mortality in Mali
Consultant gender analysis, Traditional Medicine and Intercultural
Communication
Rokia Sanogo, Ph.D.
aidemet@afribonemali.net
MONDAY, JULY 11TH, 2005
MALI
AFRICA
Mali
Overwiew
Introduction
Context and justification
Goals
Traditional medicine against HIV/AIDS
Activities
Workshops of the Traditional Midwives
Methodology
Results to Kolokani
Conclusion
Acknowledgments
Introduction
Data available from EDS III, 2001
• Maternal mortality  582/100.000 births
A maternal death every 3 hours!
• Newborn mortality  55 /1000
80 every day!
• Infant mortality  113/1000
The retraining of TBAs
From the 1980s, many attempts at “retraining” TBAs
and the matrons were supported by WHO, UNICEF,
UNDPA and other bilateral and multilateral
cooperation agencies.
The results obtained from these various programmes
fell short of expectations for many reasons, including
the following:
The retraining of TBAs
• The real “representativeness” of the TBAs without
taking account some criteria (age, traditional
authorities, etc.);
• The retraining methodology, not taking account
experiences and traditional knowledge;
• The performance of the modern health facilities, a
women in distress refereed could not always find a
satisfactory solutions;
• The absence of an efficient and accessible
transportation system; and
• The high cost of the surgical operation.
Context and justification
During the last ten years, all over Mali, efforts have been made to set up a system of
management of obstetrical emergencies; within this framework, Referral Health
centres (CSRef) and Community Health Centres (CSCom) were strengthened
through the allocation of adequate human and technical resources:
• Surgical team
• Operating theatre suite (operative block)
• Ambulance,
• RAC telecommunication network.
• Cost sharing for evacuation and surgical operations charges.
Context and justification
 System of management of obstetrical emergencies
was organized in Kolokani sanitary district in 1997;
 In spite of this new context, the access to this
system still remains very short of expectations.
Context and justification
Context was characterized by following features:
• Weak rate of utilisation in the CSComs of mother,
child care services and delivery (not only to related to
economic and accessibility obstacles, but also cultural
and traditional obstacles);
• Non covered
elevated.
obstetric
need
rates
remained
• Number foreseen of women to risk didn't arrive at
the level of the CSCOm.
Problems
 One of problems detected was the communication
between villages of the CSCom.
Solutions?
To find the solution, we use traditional system of
childbirth management existent in each village
The protagonists of this system are TBAs, who:
• had been practicing this function long before the
creation of health centres; and,
• enjoy the respect and trust of the village community.
objectives
 The main objectives were “information and
organisation of TBAs for their contribution in the
management of the obstetrical emergencies” by
valorising their traditional role, experiences and
knowledge in pregnancies and delivery assistance.
Expectations
 On the basis of these observations it was
considered possible and useful to develop a
collaboration between the traditional system of
childbirth and modern system of management of
obstetrical emergencies..
Goals
The main goals of this collaboration were:
• to detect critical cases and to refer in time, very
quickly;
• to valorise the role of TBAs in delivery assisted in
the villages;
• to involve the TBAs, by valorising their knowledge
and know-how to break the cultural and
communication barriers between the women in
distress and the CSCom. and,
• to allow more equitable and access to the obstetrical
emergencies management system.
Methodology and Approaches
Training “information and organisation of TBAs for
their contribution in the management of the obstetrical
emergencies” were carried out in this new context with
new methodology and approaches:
The training was not a classical type, during which the
trainers to transmit elements of knowledge and knowhow to the participants.
Methodology and Approaches
Rather, it was to facilitate intercultural dynamic
exchanges
during
which
the
experiences,
competencies and even certainties of the all parties
are studied and valorised, but also if necessary, put in
discussion.
Methodology and Approaches
Methodology that can be recommended was
• open-mindedness,
• mutual respect,
• courage of every one to put himself into question,
• willingness of all to listen and learn,
• recognition by all of their own limits:
• frank and equal discussion.
Methodology and Approaches
 The analysis of critical and concrete cases and the
identification of positive and efficient behaviors and
to find realistic solutions to dramatic problems.
Experiment in the district of Kolokani
First activities were supported by NGO Terra
Nuova /University of Turin - Italy.
1999 - 2000: Massantola, Sebecoro I, Ouolodo and
Nonsombougou Health intervention area (CSCOm).
World Bank contribution
1.Traditional Birth Attendances and reduction of
mother and neonatal mortality
2002: Participation to conference “Local knowledge
and development”(Bamako);
2003: Evaluation of impact of experience carried out in
Kolokani from 1999 to 2000; and publication of Article
on IK;
2004: Extension of experiences of TBAs to other
CSCom of of Kolokani
2005: Participation to Pro-Cultura conference
(Washington).
World Bank contribution
2. Collaboration TM and MM against HIV/AIDS
2003: to help integrate IK into the Multi Country AIDS
Program (MAP) in Guinea Conakry.
2004 to date: Mediation to help integrate TM into the
MAP in Mali.
Traditional medicine against HIV/AIDS
From 2002 to date we have many TM actors informed
against the HIV/AIDS
629 TM actors participated to the different activities of
which 440 women (92%).
November 2004: The Malian Federation TM actors
traditional is member of the High National Council
against the AIDS presided by the President of the
Republic (Decree n° 04/550P-RM of November 25,
2004).
Activities
1. TBAs and reduction of mother and neonatal
mortality
1.1. Workshops “information and organization” of the TBAs
on the system of obstetrical emergencies.
1.2. Assisted self-evaluation workshop.
1.3. District Inter-community exchanges workshop at the
level of the District.
1.4. Regional Workshop of inter-community exchanges.
1.5. National workshop of validation
Workshops of information and organization of the
TBAs
Visual supports:
Cases need reference evacuation (visual Supports
with 13 pictures)
Cases need reference and evacuation
Cases need reference and evacuation
Cases need reference and evacuation
Cases need reference and evacuation
Workshops of information and organization of the
TBAs
Hygienic childbirth concept has been summarized
with the help of visual supports and convenient
demonstrations.
Hygienic childbirth Kit have been provided to the
TBAs.
Every AT formed had like first endowment 20 new
blades), of soap pieces, of the thread in cotton and a
tube of ointment tetracycline 1%.
Hygienic childbirth concept
Hygienic childbirth concept
Hygienic childbirth concept
Hygienic childbirth concept
Hygienic childbirth concept
Hygienic childbirth concept
Kolokani 2004
Workshop TBAs
Sebecoro I 2003: Assisted self-evaluation workshop
Kolokani June 2003: District Inter-community exchanges
workshop
Kolokani 2003: District Inter-community exchanges
workshop
Kolokani 2003: District Inter-community exchanges workshop
Kolokani June
2003
Inter-community
exchanges
workshop
National workshop June
2004
Results Kolokani 1999 - 2000
Results of experience in Kolokani from 1999 to
2000
In the year which followed the TBAs information and
organisation workshop compared to the previous year,
In the four health intervention areas covered: Massantola,
Sebecoro I, Ouolodo and Nonsombougou):
the other health intervention areas non covered:
Didiéni,Toussana and Sabougou in the same periods.
Results Kolokani 1999 - 2000
Indicators
Areas covered (%) Areas Non covered (%)
Prenatal
consultation
53,00 to 58,90
57,00 to 58,47
Assisted
deliveries
40,40 to 54,65
51,8 to 47,70
64,85 to 110,40
125,93 to 185,67
References/
evacuations
Results Kolokani 2003-2004
Periods of data collection go from one year before workshops
(1999-2000) at three years after workshops (2001-2003):
Four health intervention areas of health where activities have
been achieved (covered areas): (Massantola, Sébécoro I,
Ouolodo and Nonsombougou), and for the same periods data
are collected in health intervention areas, (non covered):
(Didiéni, Toussana and Sabougou).
Results are following:
Results Kolokani 2003
Indicators
Areas covered (%) Areas Non covered (%)
Prenatal
consultation
55,86 to 97,99
58,85 to 88,52
Assisted
deliveries
40,01 to 62,92
46,76 to 43,59
References/
evacuations
62,23 to 102,42
106,94 to 100
Polio 0
vaccination
35,5 to 62,25
34,22 to 48,06
Results Workshops of information and organization of
the TBAs 2004.
Recommendation
The objective is not to transform the TBAs in agents
of modern health of first level, but to make play them
role of the first link of the chain that begins in the
village with the traditional system and continues
with in the health intervention aerea of CSCom
and the CSRéf with the modern system.
Regional inter-community exchanges workshop 2004
The experience touched in the 8 health intervention
areas about 300 TBAs.
The non covered obstetric need passed from 81
percent in 1997 to 8 percent in 2003.
National workshop validation 2004
Recommendations
The following recommendations have been elaborated and
adapted
1. The formal recognition of the role of the TBAs in the system
of health in particular in the system of reference evacuation;
2. The capitalization of experiences through the country;
3. A national survey on the impact on activities of the TBAs;
4. The implication of the local authorities and the ASACO in
the financing of advanced strategy activities
Conclusion
Activities led 2003 - 2004, twith the financial support of the
World Bank, permitted :
to uptake the activities on the valorisation of the role of the
TBA in the obstetric emergencies management;
to retake contact with different partners;
to confirm to the TBAs importance in the system of obstetrical
emergencies management;
to appreciate the different actors adherence to activities of
valorisation of the role of the TBAs in the reduction of the
maternal and prenatal mortality;
to identify the strong points and difficulties for the
amelioration of the system of involvement of the TBAs.
to note the adherence and the engagement of chiefs of
families and the traditional authorities to activities of
valorisation of the role of the TBAs
Conclusion
Recommendations of the national workshop give us of
tracks for the future activities.
Immediately it will be necessary to continue the advocacy for
an optimal use of the TBAs in the maternal and neonatal
health.
We hope as well as the experience that we led to Kolokani for
an useful implication of the TBAs will be taken henceforth in
account in the context of a national strategy of reduction of the
maternal neonatal and mortality in Mali, on occasion of the
development and the take in the PRODESS and in the National
Politic of traditional Medicine in Mali.
A good news!
For the reduction of the maternal and neonatal
mortality, the advice of Ministers of June 23, 2005,
adopted the exemption from payment of the
Caesarean at the public health structures like as
Hospitals and Reference Centres of Health (CSRéf.).
Acknowledgments
We thank all the people who wanted really enter with us into this
experience, and particularly the TBAs, Staff of health intervention aereas
(CSComs), the staff of socio - sanitary of district (CSRéf) of Kolokani, the
ASACO, Mayors, the traditional healers and the traditional authorities.
Thanks to the Program « indigenous knowledge » of the World Bank to
have been permitted the assessment, the extension and the diffusion of this
experience.
Thanks to the Ministry of Health through the DNS for monitoring attentive
to the advocacy in favour of the implication of the TBAs.
Thanks to all technical and financial partners, to associations and NGO for
their contribution.
Our acknowledgments to the Dr Daouda Mallé for the availability and the
useful advices all along the project and to Ms. Suzanne Essama, to have
believed and pushed the valorisation of knowledge and TBAs ability for the
reduction of the maternal and neonatal mortality.
Acknowledgments
World Bank for the opportunity give me to
exchange my experience with others
persons.
Thank for your attention!