Efforts to take forward universal health coverage require innovative approaches in fragile settings, which experience particularly acute human resource shortages and poor health indicators. For maternal and newborn health, it is important to innovate with new partnerships and roles for Traditional Birth Attendants (TBAs) to promote maternal health. We explore perspectives on programs in Somaliland and Sierra Leone which link TBAs to health centers as part of a pathway to maternal health care. Our study aims to understand the perceptions of communities, stakeholder and TBAs themselves who have been trained in new roles to generate insights on strategies to engage with TBAs and to promote skilled birth attendance in fragile affected settings

A qualitative study was carried out in two chiefdoms in Bombali district in Sierra Leone and the Maroodi Jeex region of Somaliland. Purposively sampled participants consisted of key players from the Ministries of Health, program implementers, trained TBAs and women who benefited from the services of trained TBAs. Data was collected through key informants and in-depth interviews and focus group discussions. Data was transcribed, translated and analyzed using the framework approach. For the purposes of this paper, a comparative analysis was undertaken reviewing similarities and differences across the two different contexts.

Analysis of multiple viewpoints reveal that with appropriate training and support it is possible to change TBAs practices so they support pregnant women in new ways (support and referral rather than delivery). Participants perceived that trained TBAs can utilize their embedded and trusted community relationships to interact effectively with their communities, help overcome barriers to acceptability, utilization and contribute to effective demand for maternal and newborn services and ultimately enhance utilization of skilled birth attendants. Trained TBAs appreciated cordial relationship at the health centers and feeling as part of the health system. Key challenges that emerged included the distance women needed to travel to reach health centers, appropriate remuneration of trained TBAs and strategies to sustain their work


Our findings highlight the possible gains of the new roles and approaches for trained TBAs through further integrating them into the formal health system. Their potential is arguably critically important in promoting universal health coverage in fragile and conflict affected states (FCAS) where human resources are additionally constrained and maternal and newborn health care needs particularly acute.


In the past two years, there has been a growing commitment to the goal of universal health coverage (UHC) and wide reaching and high-level discussion about the centrality of UHC to the post-2015 Millennium Development Goal agenda and the development and formation of the Sustainable Development Goals. Taking forward UHC will be futile without specific effort and action in fragile states. While definitions and figures vary, some 1.2 billion people are estimated to live in fragile and post-conflict settings. It estimated that ‘one third of the global poor lived in fragile states in 2010, and projections indicate that roughly half will do so by the year 2015’. In fragile settings, access to equitable and quality health services is not only vital, but of huge importance for rebuilding the social fabric of countries.


The TBA program is part of a larger project named “Improving the Reproductive and Sexual Health of Internally Displaced People, Maroodi Jeex, Somaliland”. It was implemented by Health Poverty Action (HPA) in partnership with the Liverpool School of Tropical Medicine (LSTM) and the Somaliland Ministry of Health (MOH) from 2008 to 2012. The project composed of supporting increased SBAs and creating an enabling environment through new partnerships with TBAs. The program of work included improving all five maternal and child health (MCH) centers and one referral hospital in Hargeisa with infrastructure rehabilitation, supply of medical equipment, drugs and consumables, running costs and salary top-ups for staff working in the maternity area and competency-based training for SBA in skilled birth attendance and emergency obstetric and newborn care. TBAs were trained as “health promoters” and “birth companions” and provided specific links to MCH centers. The trainings focused on their understanding of the dangers of home births, the benefits of facility delivery and the need for prompt referral of all pregnant women to the MCH centers. Additionally, TBAs received USD$5 for each patient referred or escorted to any of the five designated MCH centers

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