Journal of Community Health Vol. 16, No. 6, December 1991

T R A D I T I O N A L BIRTH A T T E N D A N T S IN AN ENDEMIC AREA OF T E T A N U S N E O N A T O R U M IN THAILAND: PITFALLS IN THE CONTROL PROGRAM Virasakdi Chongsuvivatwong, MD; Luan Bucharkorn, MD; Ruthaiporn Treetrong, RN, MS

A B S T R A C T : A survey of the characteristics of traditional birth attendants in Krabi Province, Thailand, where the incidence rate of tetanus n e o n a t o r u m was the highest in the country, was conducted in o r d e r to obtain b a c k g r o u n d information necessary for planning a training curriculum and to evaluate previous training courses. Five second year medical students were used as research assistants. After the questionnaire was constructed and tested, the students went to visit a sample o f 116 traditional birth attendants (TBAs) to interview them about their personal backgrounds, techniques and practices in delivery and beliefs and attitudes towards midwifery. T h e study revealed that these TBAs were a mixture o f Buddhist and Islamic females whose literacy rate was 53 percent. Ninetyone per cent knew about the availability o f an injection fi)r antenatal care at the health center, but only about half knew that it was for tetanus prevention. More than half provided antenatal care at their own home but 85 p e r cent conducted delivery at the client's home. About eighty per cent o f the TBAs claimed that sterilization of instruments was p e r f o r m e d . However, dressing o f the umbilical cord was done inappropriately using various kinds of powders by about 40 per cent. T h e majority of TBAs had experience with complicated labors but only 30 per cent were referred, perhaps, due to excessive selfconfidence and supernatural beliefs. T h e trained T B A s possessed a higher level of knowledge of immunization and sterile techniques for cord cutting and dressing o f the stumps o f the umbilical cord than the untrained group. However, knowledge o f sterilization of instruments was not significantly different, indicating a need to improve teaching in this area. It was concluded that past training programs had increased the knowledge o f the TBAs. However, they were not effective enough to eradicate tetanus n e o n a t o r u m and to prevent other torms o f peri-

Virasakdi Chongsuvivatwong is Chief of Epidemiology Unit, Faculty of Medicine, Prince of Songkla University; Luan Bucharkorn is the Head of Provincial Public Health Office in Krabi; Ruthaiporn Treetrong is Assistant Professor in Faculty of Nursing, Prince of Songkla University. This research was supported by the Ford Foundation, Grant number 880-0312A. Requests for reprints should be addressed Io: Virasakdi Chongsuvivatwong, Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90112, THAILAND. © 1991 Human Sciences Press, Inc.

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natal morbidity and mortality. Refresher courses emphasizing the dangers of improper dressing of the stump, increasing postnatal visits by professional midwives to detect and avert risks to the newborns and mass immunizations of females of reproductive age are clearly required.

INTRODUCTION

T h e two strategies to p r e v e n t tetanus n e o n a t o r u m are assuring that infants are b o r n with protective levels of transplacental acquired antibodies a n d r e d u c i n g the likelihood of e n v i r o n m e n t a l exposure.' However, this highly preventable disease, is still c o m m o n in m a n y develo p i n g countries. ~ In T h a i l a n d , the r e p o r t e d incidence rate o f tetanus n e o n a t o r u m has been declining rapidly for the past few years. However, in Krabi, a province in the s o u t h e r n region, the decline has been relatively slow. This province, which faces the A n d a m a n Sea, is f a m o u s for its peaceful resorts. Yet in 1988, tetanus n e o n a t o r u m was one of its most i m p o r t a n t health problems. T h e incidence rates had been a r o u n d 3 per 1,000 live births for m a n y years, almost ten times h i g h e r than the average rates for the c o u n t r y 3 in spite of the m a n y training p r o g r a m s for traditional birth attendants (TBAs). Before the c u r r e n t study, a p r e c e d i n g o n e was c o n d u c t e d in the same area to obtain baseline statistics on prenatal care, birth delivery a n d post-natal practices a n d service utilization f r o m 210 r a n d o m l y selected m o t h e r s ? In brief, it was f o u n d that 79 p e r c e n t of the w o m e n had at least o n e visit to an antenatal clinic r u n by professional health workers, 70 p e r c e n t had at least two i m m u n i z a t i o n s o f tetanus toxoid d u r i n g the p e r i o d o f their pregnancy, a n d 45 p e r c e n t of the deliveries was c o n d u c t e d by TBAs. In 78 p e r c e n t of deliveries, the umbilical cord was cut using a sterilized (boiled or flame-heated) i n s t r u m e n t . However, in 61 percent, h o m e - m a d e or o t h e r i n a p p r o p r i a t e powders were applied to umbilical cord stumps. T h e c u r r e n t research project was aimed to gain m o r e information about the T B A s so that a p r o p e r r e f r e s h e r course could be planned. Its p r i m a r y objective was to gain b a c k g r o u n d characteristics, beliefs a n d practices of the T B A s in this e n d e m i c area. T h e secondary objective was to evaluate the past training p r o g r a m in o r d e r to identify weaknesses in the previous curriculum.

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METHODS The research was carried out in 1989 over a period of two months. Name lists of all active TBAs in the province were obtained from health centers. All untrained TBAs and a randomly chosen sample of sixty percent of trained TBAs were studied. The questionnaire was tested and data collection was done using semi-structured interview technique. Five volunteer second year medical students were trained in data collection and served as the interviewers. Appointments with the TBAs were made in advance by local health officers who were responsible for supervision of the TBAs. The interviews took place in the villages where the TBAs resided. They were told that the medical students wanted to learn from the experience of the TBAs for comparison with what they would learn at the medical school. In cases where the TBAs frequently conducted deliveries in their homes, the houses were also visited. Information collected included personal demographic data (such as age, religion, marital status, occupation, income, literacy and pregnancy history), advice given during the antenatal period, including tetanus toxoid and nutritional supplements, practice methods used in conducting deliveries, umbilical cord cutting and dressing techniques and supernatural beliefs related to labor. After the interview, the TBA was asked about her health and a physical examination was performed by the medical student, which included measurement of near vision acuity, blood pressure, pulse rate, and cleanness of finger nails. Finally, each item of the midwifery instrument kit provided by the Ministry of Public Health was inspected.

RESULTS Personal Backgrounds of the TBAs T h e r e were 102 trained a n d 14 u n t r a i n e d TBAs. All were female f r o m 26 to 80 (an average o f 55) years o f age. Sixty-one (53 percent) were Buddhist, 53 (46 percent) were Moslem a n d o n e was a Christian. Ninety-three (80 percent) were married, 20 (17 percent) were widows, two were divorced a n d one was single. Fifty-seven (49 percent) e n g a g e d in agricultural work, 15 (13 percent) did not work a n d eight (7 percent) were laborers. A m o n g the 102 trained TBAs, five were trained in 1964, 35 in 1978, 28 in 1985 a n d the rest 30 in 1987. Ninety-one (79 percent) o f all T B A s h a d received their major training f r o m relatives. Fifty-nine (53 percent) could read a n d write, 15 (13 percent) could read but could not write a n d 38 (34 percent) could not do either.

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Techniques and Behaviors One hundred and six (91 percent) claimed that they advised their clients to go to the health center and to have injections. However, only 61 (54.5 percent) knew that the injection at the health center was for tetanus prevention. Sixty-six (57 percent) had the clients come to their homes for antenatal examinations and 24 (21 percent) performed the examination at the clients' homes. All said that body massage and "womb-shaping" (a traditional practice consisting of palpating and gently manipulating the uterus and believed to result in easy labor) were given to all clients. Ninety-eight (85 percent) attended labors at the clients' homes and seven (6 percent) at their own homes. The rest conducted deliveries at both sites. Before conducting the delivery, 81 (70 percent) said their hands were scrubbed using soap and a brush. Twenty-nine (25 percent) used soap only. Four used plain water, 1 did not wash her hands and 1 used other preparations for hand-washing. Thirty-eight (33 percent) tied the umbilical cord with thread boiled in water for 20 minutes. Thirty-one (27 percent) soaked the thread with hot water. Twenty-four (21 percent) soaked the thread in alcohol. Nineteen (16 percent) used untreated thread. Fifty six (48 percent) cut the umbilical cord with scissors boiled in water for 20 minutes. Six used flame-heated blades. Two used scissors soaked in alcohol. Nine used untreated scissors. Two used bamboo. The rest used other kinds of instruments. Immediately after the cord cutting, 92 (79 percent) used alcohol to clean the stump and four used water. Thirteen did not use anything. For daily dressing of the umbilical stump, fifty (43 percent) used alcohol alone, twenty-tour (21 percent) used alcohol and other preparations, twelve (10 percent) used "Pong-Pi-Ses" (A brand name of sulfonamide powder), ten used curcuma powder and five did not use anything. One hundred and nine (94 percent) made a postpartum visit to the client's house for an average of five days. One hundred and ten said advice was given to the mother to have the baby immunized at the health center. Eighty-one (70 percent) advised imrsing the infant with colostrum. Thirty-five advised the mother to discard it. Experiences with Complicated Cases Seventy-five (65 percent) had assisted at one or more labors in which the presenting part of the fetus was not the head. Seventy-one claimed that all the abnormally presented newborns were safely deliv-

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ered. Twenty-six (30.6 percent) did not refer any difficult cases. T h e rest never encountered any difficulties. Eight of the 116 TBAs encountered at least one case of tetanus neonatorum (the symptoms and signs of which were explained by the medical students). Only four of those newborns were referred to hospitals. Other Attitudes and Beliefs

Ninety-six (83 percent) of TBAs said that supernatural methods were used to assist in labor. Ninety-three used magic sentences. T h e aims of these methods were to protect the mother and the fetus (56), to protect the mother (31), the fetus and the TBA themselves (31) or to protect only themselves (2). Eighty-eight (76 percent) used herbs to treat the mother immediately after birth, 62 to prevent excessive bleeding and 8 to prevent retention of the placenta. One h u n d r e d and three (89 percent) gave advice about birth control to the mothers. Attitudes to the Training Courses and Assistance from MoPH

Seventy-six said the training course was useful but only 64 thought the knowledge from the training course could be directly applied to their practices. Each of the trained TBAs was given a midwifery bag. Forty-two percent were not using it because it was too large and too heavy. A m o n g the 14 untrained TBAs, five did not want to attend any training course. Difference in Knowledge Between the Trained and the Untrained TBAs

T h e trained and the untrained TBAs were compared with regard to knowledge of immunizations, sterilization of instruments, cord cleaning and cord dressing. It was found that in all but sterilization of instruments the trained group was better informed. This indicates an improvement in knowledge after training. However, sterilization techniques were not adhered to by a significant proportion of TBAs (Table 1). DISCUSSION

T h e findings of this study are consistent with those of the preceding household survey, ~ in which information was obtained from the

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TABLE 1

Comparisons of Practices Between Different Groups of Traditional Birth Attendants, Krabi Province, Thailand Experience

Trained

Untrained

102(100%)

14(100%)

Knowledge about tetanus toxoid

61 (60%)

1(7%)

11.69

Sterilization of instrument

53(52%)

3(21%)

3.45

Correct immediate cord cleaning

86(84%)

6(43%)

10.49

Correct daily cord dressing

48(47%)

2(14%)

4.14

Total

X 2.

P-Value

.0006 .06 .001"* .04

*Chi square test with Yates correction **Fisher exact test 2-tailed p-value = .0014

mothers. TBAs play an important role in maternal and child care in the study area. Yet there are obviously many incorrect procedures being performed which might contribute to tetanus neonatorum. A previous case-control study in Pakistan revealed that in addition to a lack of immunization with tetanus toxoid, application of ghee (rancid butter) to the cord stump was a risk factor, whereas non-aseptic technique in cord cutting was not? In this and our previous study, the percentage of inappropriate dressing of the stump of the umbilical cord was higher than non-aseptic cord cutting. Moreover, in reviewing the previous training curriculum, it was found that there had not been enough emphasis placed on the importance of the former. There was also insufficient stress on the value of immediate postpartum visits by professionally trained midwives to detect and remove unsuitable substances. Therefore, important measures for improving the control of the disease include minimizing the percentage of non-proper dressings and providing adequate immediate postnatal care by professional midwives so that the at risk newborn can be detected and suitably managed. According to their replies, the majority of TBAs in this series took some notice of advice given in the training courses as shown by the

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proportion who subsequently gave advice about antenatal visits, immunizations and family planning. However, many important techniques such as sterilization might not be strictly adhered to and their self-confidence is quite high as evidenced by the fact that only a few complicated cases were referred. T h e roles of TBAs in rural areas of developing countries cannot be overestimated. Training, as demonstrated here, has a lot of positive effects. It is unrealistic to expect a remarkable improvement in the practices of most of these TBAs in the very near future unless programs are regularly evaluated and appropriately revised. While the results of this study were being prepared, a mass immunization program for all females of reproductive age groups, regardless of their pregnancy status was underway in addition to refresher courses for the TBAs.

REFERENCES 1. Stanfield, JP, Galazka A, Neonatal tetanus in the world today. Bull WHO 62:647-699, 1984. 2. Hinman, AR, Foster SO, and Wassilak, SGF, Neonatal tetanus: potential for elimination in the world. Pediatr Infect Dis J. 6:813-816, 1987. 3. Division of Epidemiology, Weekly Epidemiological Reports 1987-1989, Ministry of Public Health, Bangkok. 4. Kongnark, W, Phukioaluan S, Netrapukka, S, and Aksornwecha N: A Study on Behaviors of Villagers on Antenatal Care, Birth Delivery and Post-natal Care Related to Risk for Tetanus Neonatorum. (in Thai) Krabi Provincial Health Office, 1988. 5. Traverso, HP, Bennette, JV, Kahn, AJ, et al., Ghee Applications to the Umbilical Cord: A Risk Factor for Neonatal Tetanus. Lancet. 8636:486-488, 1989.