The Experience of Being a Traditional Midwife: Relationships with Skilled Birth Attendants the Experience of Being a Traditional Midwife: Relationships with Skilled Birth Attendants

Introduction: This article focuses on an unexpected finding of a research project which explored the experience of being a traditional midwife. The unexpected finding was that traditional midwives often perceive skilled (professional) birth attendants to be abusive of both them and the women who are transferred to hospital for emergency obstetric care. Methods: Eighty-four traditional midwives in the Western Province of Kenya were interviewed individually or in groups with a Bukusu/Kiswahili/English-speaking interpreter. Interviews were audiotaped and the English components were transcribed verbatim. Interview transcripts and observations were thematically analysed. Results: A minority of relationships between traditional midwives and skilled birth attendants were based on mutual respect and collaborative practice. However, the majority of encounters with skilled birth attendants were perceived by the traditional midwives to be abusive for them and the women requiring emergency obstetric care. In the interests of improving health outcomes for women and their newborns, interpersonal skills, including maintaining respectful communication and relationships must be a core competency for all caregivers. Providing opportunities for reciprocal learning and strategies to enhance relationships between traditional midwives and skilled birth attendants are recommended. Conclusion: Current global strategies to reduce maternal and newborn mortality by increasing the number of women birthing with a skilled (professional) birth attendant in an enabling environment may be limited while the reasons for traditional midwives being the caregiver of choice for the majority of women living in areas such as Western Kenya remain unaddressed.


Introduction
The research project informing this article explored the experience of being a traditional midwife (TM) in the Western Province of Kenya and the impact of AusAID funded resources on their practice 1 .An unexpected finding of that project is the focus of this article: TMs' reports of abuse and assault by skilled birth attendants (SBAs) when TMs transfer a woman to hospital in an emergency.
For the purposes of this article, a TM is a person who provides intrapartum care for women and who has usually learnt their skills in a mentorship/apprenticeship model but has not satisfactorily completed a prescribed course of study for licensing as a midwife in Kenya.In contrast, a SBA is defined by the International Confederation of Midwives (ICM) and WHO as a health professional (medical practitioner, nurse or midwife) who has acquired the formal qualifications to enable their legal licensure 1 .A TM is usually referred to as a traditional birth attendant (TBA) by organisations, including the ICM and WHO.However, the nomenclature used in this article is TM, in acknowledgement of the term used by women, health professionals in this area and the participants.
A search of the literature yielded many articles discussing maternal and newborn mortality rates (MNMR), and skilled/unskilled birth attendance but very few specifically explored how TMs and SBAs related to each other 2,3 and none explored the relationship from the perspective of the TM.One text provided multiple international case studies of effective maternity service models 2 .Showcased models from Mexico 4 , Samoa 5 and Brazil 6 all adopted similar principles which associated the integration of TM and SBA care with consequent positive outcomes for women and their newborns.
In contrast, there were multiple instances where SBAs, armed with higher education levels, authoritative power, obstetric technology and symbolic appearances such as uniforms, exerted power in a destructive, de-humanising and abusive way over women and TMs [7][8][9] .Examples of rude, bullying, abusive, intimidating and even violent SBA behaviour are not limited to sub-Saharan Africa but have also been reported in literature describing maternity care in both resource-rich and resource-poor nations, including Afghanistan 10 ; Australia 11 ; Laos, the Philippines and Thailand 7 ; Mexico 12 ; Nepal 13 ; UK 14 and the USA 15,16 .The voices of TMs were silent in this literature.
Between 1978 and the mid-1990s, global policies including those from WHO identified the potential of TMs to provide valuable intrapartum care, especially in world areas where resources, including health professionals, were very limited 17 .Since the mid-1990s, global policies and organisations have not supported the utilisation, resourcing or training of TMs but have focused on increasing the number of women accessing SBAs 17 .It is argued that this change in policy direction occurred without rigorous evidence that it would improve the MNMR 17 .Furthermore, this change was based on lower grade evidence that is historical, observational and experiential and has impacted on sub-Saharan African women more than any other population group 18 .Contrary to expectations, policy changes have failed to make the anticipated improvement in MNMR.
For example, the maternal mortality rate in Kenya is estimated to be 560 per 100 000 births, with no sustained improvement since 1998 19 .The lifetime risk of Kenyan women dying from childbearing-related factors remains at 1:22 (compared with an Australian woman's risk of 1:7300) 19 .Traditional midwives, no matter how skilled in their midwifery practice, continue to be held responsible for the high MNMR 17 while social factors such as poverty, gender inequity, war/regional conflict, unsafe and unavailable emergency care, inadequate transportation, malnutrition and low levels of literacy, all of which impact MNMR, are ignored 20 .
In contrast to promoting the practice of SBAs only in an enabling environment, there is a second school of thought in the literature.This alternative argument is that because there are universal components to safe and effective maternity care, a key strategy to reduce the MNMR is to respect the practices and knowledge of TMs 2,17 .This argument promotes the development of culturally sensitive, practical and effective training programs for TMs, in places where they still practice 2,17 .
This article provides an in-depth description of the relationships between TMs and SBAs, from the TM perspective.The voice of the TM is pivotal in the discussion, and recommendations are made for improving these relationships for the benefit of all, especially the childbearing woman and her newborn.

Methods
The research was set in the Western Province of Kenya, one of the most disadvantaged areas of this resource-poor nation.The province is slowly recovering from drought and the post-election violence of early 2008 1 .Most people in the area live in rural villages, as do the TMs who are well known in their communities.Between 75% and 90% of all birthing women in this area utilise the services of a TM during labour and birth (S Kibuywa, policy analyst; pers.comm.; 13 January 2005).The author, an Australian midwifery academic, has worked with two of the TM participants as well as many SBAs during annual faculty practice in Kenya and the Democratic Republic of Congo since 2004.
Eighty-four participants identified or self-identifying as TMs provided informed consent to be interviewed either individually (18 participants) or in groups (66 participants).
Twenty-four of the participants were invited to participate in the study initially because they were identified as TMs who belonged to networks established by the African Non-Government Organisation (NGO), the Mission in Health Care and Development (MHCD) to provide opportunities for peer support, dissemination of AusAID-funded birth kits and ongoing education.All 24 of these TMs agreed to participate.The remaining 60 TMs were recruited through an unanticipated snowballing effect when they were informed by participants about the study and also requested to be interviewed as individuals or in groups.All participants had provided midwifery support for at least one woman during labour and birth in the 3 months preceding the interview.Participants were reimbursed for travel costs and received light refreshments during the interview but there was no other incentive, apart from their desire to share their experience of being a TM.
Of the 84 participants, 83 were female and one was male.Few knew their exact age but most appeared to be in their 40s, with an age range of from 18 to approximately 80 years.
All female participants had birthed themselves but their inclusion in the study was as a TM rather than a childbearing woman.In contrast to SBAs, their literacy levels were generally very low, as evidenced by more than half the participants signing their informed consent form with an 'x'.
A qualitative research design, exploratory in nature, was used to gather data during semi-structured interviews, and from field notes taken during and immediately after interviews about the experience of being a TM and the impact of AusAID-funded resources on their practice 1 .It was not the intent of the study to collect data about the relationships between participating TMs and SBAs and this data was not requested, but it was spontaneously shared by participants during interviews.
The author facilitated each interview and was assisted by a Bukusu/Kiswahili/English interpreter.Non-specific, openended prompts were used to avoid influencing participants' responses.Prior to interview, participants were informed about what they might be asked to share and that this may include: information about their role and practice as a TM; when, where and how they learnt their midwifery skills; the services they offer women and the records they keep; what they enjoy and fear most about being a TM; the impact of birth kits on their practice; and anything else they would like to share about their experience of being a TM.It was stressed that the participants' experience was important, and that the interviews would follow their lead.All English language components of interviews were transcribed verbatim.Data from transcribed interviews and observational field notes were thematically analysed by the author working with the research assistant, an African medical practitioner.Themes identified by paired consensus of both researchers were selected.The primary theme that being a TM is about being in relationship with others had a sub-theme relating to their relationships with SBAs.
Practical considerations precluded returning the transcribed interviews to participants for discussion and/or verification.These considerations included the low literacy levels of the participants and their distribution over a very large geographical area with extremely limited transport and no postal services outside the town area.Therefore exemplars, using the participants' translated words, were identified using paired consensus by the author and research assistant and were used for analysis and presentation purposes.TMs or SBAs (to help ensure translations were literal).Cultural advice included but was not limited to whether or not contracts should be established prior to group interviews.
All participant information about the study and informed consent forms were written in Kiswahili (the primary written language of the area).However, given the low literacy levels of most participants, written information was backed with oral explanations in the Bukusu/Kiswahili language by the research assistant and/or the interpreter.The research was conducted in compliance with all relevant laws and at all times conformed to the provisions of the Declaration of Helsinki in 1995 (revised Tokyo 2004).
This research project was set in one area of inland Kenya and so its findings may not be generalizable to other areas in Africa.While data were collected from 84 TMs, 83 of whom had birthed in the area, data were not collected from SBAs nor childbearing women who were not TMs.These are limitations of the study which require redress in future research.

Results
The primary theme identified during data analysis was that being a TM means being in relationship with others.This theme had a number of sub-themes including relationships with women and SBAs, based on participating TM reports of their relationships with SBAs.The participants all expressed a desire to stay with the woman when she was transferred to hospital, but this was rarely allowed.Traditional midwifes believed their presence may serve to advocate for the women and prevent women from being abused by the SBAs, and that this was the reason they were not allowed to stay:

Discussion
Collaborative practice has the potential to be life-saving for birthing women.It has been argued that the MNMR will be reduced when social factors such as gender inequity, poverty and its associated infrastructural deficits are addressed 20 , and when TMs are treated as colleagues and potential lifesavers, rather than unskilled, under-performers 21,22 .
The TMs perceive that they are being blamed for complications and that this may be the cause of the abuse they report.With the exception of the participant who said that the doctors referred their wives to her, the only interactions with SBAs described by the TM participants were in the context of transferring a woman to hospital in an emergency.When a woman who has planned a homebirth is transferred to hospital by a midwife, abuse of the woman and midwife by hospital staff is not limited to the Kenyan setting.It is a common phenomena 2,23 that has been described in the American 15 and Australian context 24 .It has been argued that that abuse of women is due to hospital staff experiencing time pressures and frustration at their own inability to provide the kind of maternity care they idealise, with the result that they abuse the person/s less powerful than they 24 .In this study, the less powerful include TMs and birthing women.
The literature provides a number of alternative explanations for SBAs acting aggressively.It has been suggested that the SBA responds out of fear, because the medicalised model of birth in which they practice is underpinned by fear and dependent on professional and community fear of birth for its existence 25 .Skilled birth attendants may fear for the wellbeing of the woman and fetus, feel inadequate in dealing with complex situations with limited resources, and may respond by abusing the woman and the TM.Other explanations for abusive caregiver behaviour toward labouring women range from professional insecurity to feelings of superiority to TMs and women 26 .Whatever the explanation, when SBAs are abusive, they put lives at risk by discouraging access to emergency obstetric care.
There have been reports of SBAs abusing women and TMs, providing them little support, discouraging them for accessing services and, on occasions, denying them access to medical care in an emergency 27 .Even emergency treatment can be dependent on the woman's ability to pay.
Reports of intimidation and physical assault of women by some SBAs is not limited to the participants of this study.This has also been reported in countries as diverse as the Democratic Republic of Congo and the USA 16,28 .Abuse of women is thought to be particularly severe when a woman was transferred from home to hospital in an emergency; hospital midwives have been observed trying to sabotage the role and practice of homebirth midwives in both the USA and Australia 15,24 .Whether attempted sabotage is perceived or actual, in this rural setting in Kenya, it is the antithesis of the collaborative practice required to reduce the MNMR by encouraging women and TMs to access obstetric care in an emergency.

Recommendations
In Western Province of Kenya, the large majority of women either choose, or have no option other than to choose, intrapartum care with a TM rather than a SBA.Encouraging integrative, collaborative and mutually respectful TM and SBA relationships and practices will benefit women.When developing health policies, the opinions and preferences of women must be acknowledged and the practice and experience of TMs recognized.Interpersonal and communication skills that demonstrate reciprocal respect should be a valued core competency for all caregivers.Technical competence (which may or may not be based on evidence and best practice) must not be the sole criteria on which to base the skills assessment of any caregiver.Furthermore, caregiver kindness (the opposite of some SBA behaviour reported by participants) should be valued along with knowledge and technical competence as a means to enable safe practice 29 .
There are both policy and practice implications in the findings of this study.In recognition of the majority of women's continued utilisation of TMs as caregiver in this area, it is recommended that policies return to resourcing and providing ongoing education (that is culturally safe and based on best available evidence) to TMs and SBAs alike 20- 22 .
Practice implications impact on both SBAs and TMs.
Effective birth models encourage SBAs to spend time working with and learning from TMs, where they still exist in the community 30 .To be effective, the usual assumed roles must be reversed so the TM becomes the teacher and expert in 'out of hospital' care.The SBA, with an attitude of cultural humility, could learn from the TM how to be with and support labouring women in the community.Time spent with TMs would have the secondary benefit of increasing understanding of why the majority of women in this area prefer to birth outside the hospital with a TM.As Fathalla argued, 'The question should not be why do women not accept the service we offer, but why do we not offer a service that women will accept' (pvii) 31 .
It Future qualitative research is required to provide a balanced perspective and also give the SBAs a voice.Although almost all the participants were women who had birthed in the area, as well as being TMs, future research must also consider the experience of childbearing women who are neither TMs or SBAs.Furthermore, the outcomes for women and their newborns accessing TM services, compared with those accessing SBA care in a hospital setting, need to be determined through future mixed methods research.

Conclusion
The participants illuminated why they believe the TM is the caregiver of choice for the majority of women in this area of rural Kenya.Current global strategies to reduce the MNMR focus on increasing the number of women birthing with a skilled (professional) birth attendant in an enabling environment.Such strategies may be limited as long as the reasons that TMs are the caregiver of choice for the majority of women living in areas such as the Western Province of Kenya (the research setting) are not given consideration.
The resourcing of maternity services must consider the context of service delivery and address the social determinants that impact on the MNMR in sub-Saharan Africa.It may not be the status of the caregiver that will have the most influence on the MNMR.Collaborative practices that identify the experience of TMs and SBAs alike and value collegiality and reciprocal learning have the potential to optimise health outcomes for the woman and her newborn, especially when services are required to manage obstetric complications.Skilled birth attendants treating women and the TMs who may accompany them with kindness, patience and respect may encourage women to access SBAs and help provide an enabling environment for the woman requiring obstetric care in an emergency.
Each interview opened with the request, 'Please tell me as much as you can about what it is like for you to be a traditional midwife'.Conversational prompts were then used to clarify issues and encourage the participants to describe phenomena in greater depth.Venues for interviews included participants' homes, fields, village meeting places, clinics and church halls.
As the only affiliated organization with an institutional ethics committee (IEC), Charles Sturt University IEC approved the project (2009/45).Community consultation and careful consideration of cultural values occurred prior to and during recruiting of potential participants (and two interpreters/cultural advisors).There are no known professional interpreters in the geographic area and, therefore, two suitable interpreters were selected by the research assistant and employed for the purpose.Selection criteria included fluency in the Buskusu/Kiwahili/English written and spoken languages, female sex, ability to provide cultural advice and having no previous affiliation with either is not suggested that TMs have nothing to learn from SBAs.Rather, sharing of knowledge should not be valued only when the SBA teaches the TM.Both should have the opportunity to communicate and learn from each other in the home/community and hospital setting as equal partners.The findings of this study affirm the value of resourcing participating TMs with simple birth kits and the opportunity to attend workshops/seminars on evidence-based, womancentred midwifery care, which are facilitated by professional caregivers.In the interests of enhancing collegiality and SBA-TM interactions outside the emergency context it is recommended that such workshops be made available to local SBAs as well as TMs.