Many traditional birth attendants (TBAs) share the same memory from their earliest years of providing care–expectant mothers seeking support during delivery but unable to access health facilities. Wilfreda, a Lwala-supported community health worker (CHW), clearly recalls this. “I still remember how women used to cry in pain, and we had no medication or facilities to help. Sometimes, women delivered on the ground in their homes.” But most TBAs are also proud of the role they played in stepping up to support mothers when health care was inaccessible. For many generations, TBAs were the best and only option women had for delivery, and communities had deep trust in these caregivers.
Decades of support amid unavailable or inaccessible care
In Kenya, the picture of health is shifting for women and girls. More women can now deliver in facilities with a skilled provider present, and more health providers are trained and equipped to ensure safe deliveries. As such, maternal and newborn health outcomes have improved significantly–across the country, skilled delivery has increased from 62% in 2014 to 89% in 2022.
In marginalized communities that are under-resourced, however, many expectant mothers continue to lean on TBAs for home delivery. TBAs are women who assist during childbirth and who initially acquired skills through necessity via generational knowledge passed down from other TBAs. When Wilfreda became a TBA, being the only option for pregnant mothers inspired her to serve from a young age. “I was 24. It was not easy to see a good number of babies die in the community. But mothers needed our help, so I became a TBA.” Many TBAs–the majority of whom are older women from rural communities–lack formal training and may have lower levels of literacy, often because of unequal access to education when they were girls.
Because TBAs are competitors of skilled delivery, their work is often criminalized by governments, and they are isolated from the formal health system. Yet excluding TBAs from the formal health system disregards their generational knowledge and the deep trust of the women they serve. In 2004, the World Health Organization encouraged countries to work with TBAs to refer patients to health facilities, but in most cases TBAs remain an untapped resource for improving rates of skilled delivery.
A collective vision for community health driven by TBAs
“When we opened Lwala Community Hospital, deliveries at our hospital were very low,” says Robert Kasambala, Lwala’s Hospital Director. “A vast majority of women delivered at home in unsafe circumstances. We wanted to encourage women to deliver with a skilled health provider.” To find a solution, Lwala, community members, and TBAs gathered to craft a shared vision for improving skilled deliveries. TBAs had gained the trust of their communities by caring for mothers and infants for many years–meaning the path to improved skilled delivery relied on their expertise and insights.
“Although many survived because of our work, we lost a lot of women and babies in the past. I was one of the seven TBAs who met with Lwala to find a solution. It was good to have us there in those early discussions because we were the ones supporting women to deliver until that point.”
- Wilfreda Anyango, CHW and former TBA
Lwala and TBAs co-designed a CHW program to support skilled deliveries–the same program that forms the backbone of our community-led health model today. Building on their trusted role in communities, TBAs became champions for improving maternal and child health–advocating not only for skilled delivery, but also for antenatal care, postnatal care, immunization, family planning, and other health services.
Our vision for a gender equitable community health workforce
Our work to elevate TBAs is deeply connected to our advocacy for CHW professionalization, which is an issue of gender equity–73% of CHWs in Kenya are women. The status quo is that governments and donors rely on the unpaid labor of these women as the foundation upon which the health system is built. This perpetuates gender inequality and prevents CHWs from reaching their full potential and impact. After years of advocacy from Lwala and our partners, this status quo is changing. The national government passed legislation to pay CHWs and launched initiatives to equip CHWs with digital tools and a kit of commodities.
But our work is not done. As professionalization takes hold, women who have served as “volunteer” CHWs risk being pushed out of the workforce. The group most at risk is TBAs, who are often barred from CHW cadres by discriminatory literacy and education requirements. Lwala aims to remove the barriers that keep women out of professional CHW cadres: our research shows that professionalization and experience are more reliable predictors of CHW knowledge and performance than formal education and literacy. Equitable gender representation within the CHW workforce is vital–increasing women’s leadership in health improves maternal and child health outcomes, as well as power and agency among women and girls.
Our strategy to include TBAs in the community health workforce ensures women are given dignified, formal positions for the care they give. We work with governments to map TBAs so that we can understand how many women are actively providing maternal care to which communities. Then we partner with community health committees, CHW supervisors, and local leaders to identify vacant CHW posts that could be filled by a local TBA–and we give TBAs the support and training they need to take on those roles. “I went to Lwala for rigorous CHW training,” says Wilfreda. “Even if my education is not finished, all I needed was my interest and passion. My community needed someone who both understands them and is willing to develop their skills to offer better help.”
Where CHW vacancies are not available, we work with the government to train TBAs alongside CHWs and then find them other roles, including serving communities as birth companions–a role that offers mothers emotional and physical support throughout their pregnancy.
Mapping TBAs and creating inclusion strategies across three counties
Across the three counties where we are implementing community-led health–Migori, Homa Bay, and Baringo Counties–we have mapped and validated 1,262 TBAs who are actively working to support expectant mothers. Doing so gives us a picture of where home deliveries are taking place and where we can work with TBAs to become advocates of skilled delivery, as well as maternal, child, and reproductive health.
In Migori, we identified 424 active TBAs. Here, we knew that further training TBAs alongside CHWs would strengthen the longstanding link they have with women in their communities–especially in Rongo Subcounty where we have implemented the longest. As we documented improvements in health outcomes, we used this evidence to advocate to the government, who then went on to formally incorporate 55 TBAs into the government’s CHW cadre. Today, we are working with the county government to develop a strategy for TBA inclusion and identify training needs. The strategy also outlines how we will support TBAs not incorporated into CHW cadres to become birth companions.
In Homa Bay, we have mapped and validated 798 active TBAs. Our next step is to develop their technical knowledge and work with the county to formalize how TBAs are included in community health. In Baringo, we partnered with Dandelion Africa and the county to identify 40 active TBAs in a test sample. Next we will determine a collective strategy for mapping all TBAs.
As we expand, we know challenges will arise. In Homa Bay, for example, a lack of 24 hour coverage at facilities forces some women who deliver at night to lean on TBAs to deliver at home. And across Kenya, TBAs are not formally recognized by the government, fostering fear of victimization or criminalization. Including TBAs in community health must go hand in hand with strengthening health systems–and evidence showing the impact so far in Migori will help us advocate for these efforts. A recently published study shows that skilled delivery rates improved most in our intervention sites when compared to changes in other sites.
“When we incorporate TBAs into the community health workforce, our indicators for maternal and child health, like skilled birth attendance and antenatal care uptake, really improve. A number of them also assist in household visits, educating mothers on breastfeeding, and newborn care. This has so much impact, which we couldn’t do without them.”
- Wycliffe Odhiambo Obonyo, Primary Health Care Program Officer, Lwala Community Alliance
Healthy futures through TBA leadership
Working to include TBAs values women like Wilfreda, whose goal remains unchanged–ensuring all mothers and newborns survive at delivery. “When I became a TBA and then a CHW, I never looked back,” says Wilfreda. “I love to see my communities and people healthy, and it gives me pride that I can still be that support for mothers.”
