Leaning over the pregnant patient before her, Regina Korgbendeh touches the woman’s looming stomach and speaks softly in a Kono-dialect: “Thank you for this child.” Blessing an unborn baby is a custom strictly followed in communities throughout Kono, Sierra Leone. Once the prayer is complete, Regina, 48, leads her patient over to a chair, where a waiting midwife asks about previous pregnancies and the woman’s medical history. It’s Regina’s job as a traditional birth attendant (TBA), to incorporate local customs, like this one, into the medical care that Partners In Health-operated, Wellbody Clinic, provides.
Historically, TBAs have been the go-to women in village communities for anything related to pregnancy and childbirth. Neighbors often refer to them as “auntie” or “mother” – terms of enormous respect. After experiencing a traumatic labor herself, Regina decided to become a TBA to prevent other women from enduring what she went through. Many countries, however, now discourage expectant mothers from relying on TBAs, due to the dangers that women face during childbirth without supervision from a trained clinician. Sierra Leone’s government enacted a law in 2010, banning TBAs from carrying out deliveries away from a clinical setting. The punishment for disobeying this law is severe—not just for a TBA, but for expectant mothers and anyone else involved.
Although there’s no question that safety during childbirth should be a priority, restriction of TBAs doesn’t necessarily ensure good health outcomes for women. A lot of women in Kono, for example, consider health care facilities to be strange, nerve-wracking places, meaning many choose to avoid them altogether during pregnancy. And with TBAs no longer able to help, they are left to deliver without any experienced supervision. This sentiment arguably contributes to the horrifying reality for women in Sierra Leone: a 1 in 17 lifetime chance of dying during pregnancy, delivery, or its aftermath.
Dr. Bailor Barrie understood this when he founded the maternal health program at Wellbody Clinic in 2010. He knew that it wouldn’t be enough to offer high-quality medical care without also ensuring that women felt comfortable seeking and receiving the care. To bridge the gap between tradition and a formal health care setting, Dr. Barrie pioneered the employment of TBAs, like Regina, at Wellbody Clinic. This decision was in contrast to the opinion of numerous institutions, however. World Health Organization has previously discounted the role of TBAs in clinical practice, saying they are simply “an interim solution” and United Nations once defined TBAs dismissively as “independent (of the health system), with no formal training”.
At Wellbody Clinic though, Regina, along with her team of seven TBA’s, are now breaking the mold.
“TBAs have an incredibly special bond with Sierra Leonean women. They can connect on a level that clinicians aren’t always able to,” Dr. Barrie explained. “When TBA-handled deliveries became illegal, a lot of women were left feeling abandoned during their labors. They feared bad treatment and costly charges at the hospital. At Wellbody, we felt strongly that by engaging TBAs we would begin to evolve the mindset of communities and, more importantly, meet the needs of women.”
Regina, after years of experience supporting expectant mothers, echoed these thoughts. “Girls used to hear rumors about being treated aggressively. They worried about injections that prick the skin,” she said. “Some believed the clinical staff would test drugs on them. Giving birth was always something women did as a tight-knit group in ‘the bush’ – a highly honored tradition in village communities.”
Being Sierra Leonean himself, Dr. Barrie has a firm understanding of local culture. He approached chiefs of the fourteen chiefdoms within Kono, to gain their support for his plan to employ TBAs. Regina remembers being asked by her village chief to be trained as an official TBA at Wellbody Clinic. “Dr. Barrie showed us how to talk to patients in the community about the risks and dangers of delivering alone. Patients listen to TBAs because we’re like mothers to them.”
When Dr. Barrie invited Partners In Health (PIH) to take full-responsibility of Wellbody Clinic in 2014, TBAs were firmly embedded into clinical practice. Their inclusion is something PIH has strongly advocated for ever since. A team of eight TBAs now work hand-in-hand with midwives. Each TBA lives in a different area of Kono, guaranteeing that women throughout the district, populated by over 500,000, have access to high-quality care and safe births.
“I live in the catchment area Sefadu, so I watch over all the women there. I’m happy not to deliver their babies myself, though. Now I’ve been properly trained, I realize how many dangers there are. Sometimes after I delivered a baby, I would look down and see a lot of blood on my hands and all over my feet. It was terrifying. At that time, if a baby died, people would say it was the woman’s fault because she hadn’t pushed hard enough or she hadn’t been cooperative. They would say she had bad water (infected blood),” Regina said solemnly. “Lots of things are done differently at Wellbody though, and babies don’t die anymore. Women no longer deliver on a rug on the hard floor; we lift her high onto a bed. And we don’t cut the umbilical cord with a blade or a piece of thread; everything is clean and we wear gloves. A trained midwife catches all of the dangers and I’m there to soothe the woman.”
TBAs aren’t just responsible for drawing pregnant women to the clinic either. They accompany women throughout their pregnancies – from initial antenatal class (ANC) appointments, through delivery, all the way to the postnatal appointments. The roles of midwives and TBAs are clearly defined: Midwives are trained to administer clinical care and TBAs play an accompanying role, to both midwives and patients. By providing access to regular training and leading medical equipment, PIH enables midwives and TBAs to deliver the best possible care, at every point along a woman’s pregnancy.
After blessing her patient’s unborn baby, Regina shared: “This woman hadn’t been to a clinic before today so she was quite nervous to come to ANC. At Wellbody we have a saying: ‘If you push women too hard you will step on your own toes.’ It’s important not to be impatient or this woman might not come back to us.” Regina continued, “When she arrived, staff gave her medicines and a mosquito bed net. She couldn’t believe everything was free. It made her so happy.”
A new mother, sitting outside the postnatal ward with her baby on her lap, expressed gratitude for the TBA who supported her pregnancy. “My TBA was by 
my side from month one, all the way to the end. She even visited me afterwards because a woman’s grave is open for 40 days once she’s delivered her child,” she said. “I now tell everyone in my village to go to Wellbody. I say they will be treated well and given real medicine.”
While the role of a TBA might initially sound like a straightforward one, there’s so much more to it than simply blessing a stomach. A TBA’s position in village communities, such as those throughout Kono, allows her to encourage women to pursue a safer, yet still familiar, type of care.
“Women used to stick together in the village and support one another through pregnancy because this made them feel safe,” Regina shared. “I tell them that we’re living in a computer world now, though! There are machines at the clinic to make sure everything is ok with a woman. Why wouldn’t you use that?”
Having access to a safe, compassionate environment during pregnancy is something that all women need. This is not unique to women in Kono, Sierra Leone, but worldwide, every woman deserves to be listened to and should receive care that makes her feel most protected. PIH recognizes that both the medical and emotional needs of women should be met through maternal health care. By including and empowering TBAs at Wellbody Clinic, PIH also empower patients and their communities.
“I do this job because I want to help women see that they deserve the best health care. I’m honored to play this role for my community,” said Regina.
Partners In Health (PIH) is a global health organization committed to providing a preferential option for the poor in health care. In 2014, PIH eagerly embraced the government of Sierra Leone’s request to help with the county’s Ebola response. They pledged to support the Ministry of Health and Sanitation not just during the emergency, but for years to come. Like their work in Haiti, Rwanda, and seven other countries, PIH wanted to help Sierra Leone to build a durable, high-quality health care system for all.
Since the Ebola epidemic formally ended in 2016, PIH has supported several health care facilities across Sierra Leone, tackling a number of persistent health care challenges in partnership with the Ministry of Health. They do daily rounds in hospitals and clinics, operate an ambulance service, stock pharmacies, install generators to guarantee continuous electricity, and fix broken plumbing, while renovating medical buildings. They help local clinicians improve the quality of care they deliver through clinical mentorship, and modernize medical record systems. The list goes on, and will only continue to grow.
While there’s more to do for Sierra Leone’s health care system, the ministry and PIH also have much to celebrate. Take, for example, Wellbody Clinic: In a country with the highest maternal mortality rate outside of a war zone, it hasn’t seen a single maternal death since 2016.
Article by Emma Minor of Partners In Health
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