As a traditional birth attendant, Christina Chulu has assisted in the delivery of approximately 500 babies in the villages surrounding Makwatata over the past fifteen years.

“I am on duty 24 hours a day,” she says. “When a woman goes into labour, someone will come to tell me and I must leave what I am doing in my field or at home to attend to her.
“Many women prefer to give birth with a TBA because we have more time to give them. At the clinics and hospitals, the nurses could be taking care of four or five women at once, but usually I have only one woman to attend to.”

The closest health clinic to Makwatata is 5km away. There is no doctor here, just one nurse, who is not on duty at night. The closest hospital is in Chipata, 30km away. Many women opt to deliver with a TBA because of this, and others have no choice once their labour begins.
Many health centres in rural areas have a dormitory where expecting mothers who live far away can stay in the weeks coming up to their due date in case they go into labour, but for the majority of rural women, a TBA is more convenient and affordable.

Legally, babies born with a traditional birth attendant must be brought to the antenatal clinic at the local health centre for a check up and registration within six days of birth.

Impoverished women in rural areas are most at risk of maternal death or stillbirth, as the cost of transport makes it more difficult for them to access medical care when they go into labour. This is compounded in remote rural areas, especially those with a low population density where the nearest TBA may be just as far away as the health clinic.

Zambia has an extraordinarily high infant and maternal mortality rate. Infant mortality rates are dropping, from 191 per 100,000 births in 1992 to 119 per 100,000 in 2007. However, Zambia still has a long way to go if it is to meet its Millennium Development Goal target of just 56 per 100,000 by 2015.

Almost 1% of women pregnant in any given year will die in childbirth in Zambia, with a lifetime risk that one in 16 of all women will die as a result of maternal health problems. The most immediate causes of maternal deaths are the lack of access or uptake of maternal health services such as antenatal and delivery care, poor nutrition, and malaria. Haemorrhage, sepsis and obstructed labour account for half of all maternal deaths, and the risk among teenage mothers is twice that of those aged over 20.

Just half of all Zambian babies are delivered at health facilities. The remainder are delivered at home, with or without a TBA. The incidence of stillbirth and maternal death is much higher for babies born in the absence of a skilled health worker, but thankfully this is improving since the government introduced formal training and delivery kits for TBAs.

Christina was delivering babies as a TBA for five years before she received eight weeks’ formal training along with eight other local women back in 2000. “I began delivering babies as an assistant to the elderly traditional birth attendants in my village. They showed me how, and I learned from their experience,” she says.

“I learned so much from the training. Before the course, many of the babies I delivered would die, but I am proud to say that not one of the 386 babies I have delivered since have died.”

“Before the training, the woman used to give birth on the floor. We didn’t realise that this was unsanitary, and could put the baby at risk. Now, we have mats with plastic covers and blankets to make sure the area is clean for the baby to be received.”

“Many women prefer to give birth with a TBA because we have more time to give them.”

One of the most fundamental lessons that she learned on the course was to insist that women with complications deliver in a clinic rather than at home. “We were told that all women with HIV, diabetes, high blood pressure or a disability must go to the clinic, where there is an ambulance to bring them to hospital if something goes wrong during the birth. I think this is the biggest reason why all my deliveries since have been successful,” she says.

The community have built a structure near Christina’s home where expecting mothers can stay, and she was recently provided with a delivery bed by World Vision (@WorldVisionIre).

The Zambian government are now encouraging all women to deliver at a health clinic, an initiative which Christina supports. “It would relieve my workload enormously, and it would also mean that the women are safer if there are any complications,” she says.

TBAs play a vital role in rural communities, but many are still under resourced, under trained, and lacking adequate transport or means of communication to enable them to provide the best service. Being a TBA is a voluntary position, so commitment is also a major problem.

“Most women would bring me gifts to show their appreciation after they deliver, like soap or some vegetables, or a chicken,” she says. “But I have to farm to support myself financially. Most of the other TBAs I know no longer do this job, because it is unpaid, but I love it, and wouldn’t give it up for anything. I feel I have an obligation to do this, to help to bring new life safely into this world.”

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