All this time I thought that sorting out my dissertation would be a piece of cake. I had an internship during Lent Term that provided me with essentially all of the background information I could want and because of how they asked me to structure my research I figured my literature review was basically done. WRONG! I have been writing myself in circles (granted, I took 6 days off to prance around Italy, but that’s besides the point).
Luckily, after sitting down in the library yesterday surrounded by pez and venti cups from Starbucks I had a breakthrough! Before delving into the details of my breakthrough, I suppose it makes sense to tell you what my dissertation is even about….
Traditional Birth Attendants (TBAs) are a highly contested issue in maternal health policy across the developing world. I’ve decided to structure my dissertation as an analytical narrative that addresses the issues surrounding TBAs and maternal health policy through a comparison of case studies. For those of you who are unfamiliar with TBAs, they are people (typically mature women) in rural/remote areas. They typically have little to no medical training and learn through practice or from other TBAs in the community. Their role is emotional in addition to medical. Not only do TBAs deliver babies, they provide support to pregnant women and their families both before and after the delivery. These women are highly respected within the community and are often viewed as leaders. The issue is that untrained TBAs can and often do contribute to the high rates of maternal mortality. This is where organizing the circular issues surrounding TBAs becomes a problem…
Untrained TBAs often perform unsafe medical procedures, particularly during delivery (for example – massaging or sitting on the stomach to induce labor which can result in harming the fetus, unsafe and unnecessary caesarean sections). But…TBAs, untrained or trained, are often the only option women have, particularly when considering remote areas. In some cases, even when women have access to a hospital or clinic where they can be assisted by a medical professional they choose to deliver with a TBA because of cultural considerations, issues of trust, and finances.
In the 1970s the major international organizations responded to this issue by introducing training programs for TBAs. Women were trained to properly assist women with uncomplicated pregnancies and to recognize obstetric emergencies so that women can be referred to trained medical professionals. Unfortunately, the evidence that these training programs have worked is questionable. The World Health Organization doesn’t consider the training programs to be cost-effective due to the fact that individual TBAs don’t carry a large work load and deliver a very small number of babies each year. Other studies have found that in some cases TBAs have delayed referral systems for obstetric complications. Overall, there appears to be little evidence that trained TBAs have had a significant impact on maternal health at all. As a result, since the 1990s many players in the international community have called to abandon TBA training programs and ban TBAs all together, stating that each delivery should be assisted by a trained midwife, nurse, or doctor.
It is largely agreed upon that in the most ideal world every pregnant woman would have the option of delivering with a highly skilled medical professional and in a sterile, supportive environment. But that is not the world we live in. Moving away from policies that have supported TBAs has not dealt with the issue of brain drain in many developing countries (doctors and nurses from one country leave to practice elsewhere, largely due to financial opportunities), nor has it resulted in better infrastructure and access to clinics where medical professionals do work. In fact, it has only created a more apparent gap between women who reside in remote, rural areas and the formal healthcare system. This means women are either delivering with no help or they are delivering with TBAs who have been forced to work underground or are untrained.
So what is there to do? We can’t suddenly make up for the abysmal doctor-to-person ratio in many developing countries (Uganda has 1 doctor for every 10,000 people). We can’t build roads and clinics in a month, stock them, and then watch the maternal mortality rate plummet. Certainly, developing countries and the international community can and should be working towards these things and the other variables that link with why the maternal mortality ratios are so high. In the interim, can TBAs serve as a safe and viable option for pregnant women ostracized from the formal healthcare system? Even where medical clinics and hospitals are affordable and accessible, shouldn’t a woman also be able to make her own decision regarding her pregnancy and delivery, yet trust that cultural considerations shouldn’t result in unsafe practices?
My dissertation will explore and analyze (hopefully well) all of the issues outlined above…and hopefully in a less stream of thought manner! I’ll be comparing different policies that countries in East Africa have implemented with regards to TBAs and seeing what lessons can be drawn from their experiences.
Now for yesterday’s breakthroughs! I FINALLY chose my case studies. Our dissertations are incredibly short (10,000 words) and I wanted to be able to do 2 or 3 case studies very well rather than skimming the surface of 4 or 5 case studies. I have narrowed my research down to Uganda and Ethiopia. In 2009, Uganda’s Ministry of Health banned TBAs while Ethiopia has a very inclusive policy. I think that juxtaposing the two extremes will serve to be most beneficial and encompassing of the different considerations. So that was exciting, but even more exciting than that is that I have secured interviews! They’ll be informal and potentially via email (one person is in rural Tanzania, the other in Ethiopia), but I think it’ll be good to talk to the specialists directly. I’ll be talking with Staffan Bergström. He has written a number of articles and done significant research on the work of informal healthcare workers in East Africa. Also, by some miracle, I have secured a phone interview with the Director of Policy and Planning at Ethiopia’s Ministry of Health, Kiros Kidanu! So that’s what I’m working on today – I need to do a lot more reading and analysis before I can construct some good questions. I am really excited though!
Now that I’ve finally gotten my act together regarding research I hope to update a bit more regularly. After working on this post, I find it helps me organize my thought processes.
Until next time!
PS feedback is always always always welcome!