Umama Salamas: A case for including traditional healers in modern health systems

By Sarah Heerboth, VUSM Class of 2019 (expected)

Mama Irene confidently stepped in to coach a struggling primigravida, and Mama Regina expertly anticipated the clinician’s needs—these women were more than just the cleaning ladies. With growing suspicion, I approached them during a quiet moment to inquire about their pasts. The women, beaming with pride, stood to answer me, explaining that they had all once been traditional birth attendants (TBAs). They finished each other’s sentences as they spoke, excited to share their knowledge with someone who had independently recognized their expertise. Soon after this interaction, they draped a rubber apron over my head as if it were a championship medal, giving me their official blessing to assist in their domain.

I went on to spend much of my free time folding gauze and hanging laundry with these Umama Salamasso that I could learn about their experiences. Leah, a Community Health Worker (CHW), told me about a particular delivery that still haunts her: she knew long before the baby was born that it had died. Her bare fingers macerated the fetus during her exams, but she couldn’t tell the mother or express her sorrow—she was fearful the patient would be too distraught to continue. She explained how helpless she once felt in the face of maternal and child mortality. What she loved most about being a TBA was not delivering babies, but rather meeting new women, earning their trust, and helping them in whatever way possible. When Lwala was founded and began offering antenatal services, Leah was not at all sorry to see her former profession go. She expressed gratitude to the organization for welcoming her into a formal health system. Now, she says, she has the tools she needs to truly make a difference in her community.

Mama Elizabeth wrote for me some of her former practices that she now regrets

In low resource settings, the inclusion of lay health workers is crucial to the success of the health system. Infectious disease and childbirth are still major sources of mortality, so education and prevention are of the utmost importance. But with only a handful of clinical officers and nurses working at each health facility, it is also essential to ensure that they are spending their time working at the top of their capabilities. With some training, community members can easily fill gaps in health education and prevention initiatives, often doing so in ways even better than their formally trained counterparts. In fact, significant reductions in childhood morbidity and mortality are achieved when lay health workers are deployed as a foundational component of health care systems. They’ve also been shown to increase breastfeeding, childhood immunizations, and tuberculosis treatment completion.[i]It is not a far leap to say that lay health workers have the power to help many of the Sustainable Development Goals become reality.

Debate remains, however, on the inclusion of traditional birth attendants in the lay health worker framework. Within their communities, TBAs are respected sources of health information and possess experiential knowledge of health problems. But many TBAs are illiterate, making training and data collection more difficult, and there is fear they may be overconfident in their abilities or reluctant to abandon traditional medicine. One study examined whether outcomes improved if TBAs were given a basic training in modern practices. While the results were somewhat promising, statistically significant impacts on mortality were not achieved.[ii]Conflict and distrust between TBAs and health care professionals have been cited as reasons why other similar efforts have been unsuccessful.[iii]

When TBAs are integrated into a larger healthcare system, however, significant increases in skilled antenatal care and birth attendance are seen.[iv],[v]Mama Elizabeth, who was a TBA for 20 years before joining Lwala, told me that women still show up at her door pregnant and bleeding or in labor. She herself had brought some of those mothers into the world, but “Lady’s Delivery Home of Uriri Village”is no longer open for business. Now, when she receives these unexpected visitors, she immediately accompanies them to the health facility, leaving their side only after they have been admitted. In my literature searches, a dichotomy emerged between studies showing success and failure of TBA engagement, perhaps accentuated by the success I have witnessed at Lwala. When TBAs are ostracized or seen as a lesser member of the healthcare team, challenges outweigh results. But when efforts are made to respect, include, and learn from TBAs, maternal and child health outcomes improve.3

Elizabeth writes what she now tells women who visit her

It is my firm belief that Lwala has its TBAs to thank for much of the success they have seen in maternal and child health. This success has been impressive: 97% of women deliver in the health facility, compared to a county average of only 53%; they’ve seen a 64% reduction in childhood deaths and a 73% reduction in neonatal mortality.[vi]  By earning the trust of the TBAs and treating them with the respect that they deserve, the organization itself earned the trust and respect of the community at large. They gained an army of strong, intelligent, and dedicated women in the fight against maternal and child mortality. Other organizations would do well to follow Lwala’s lead, finding new roles for traditional healers in modern health systems.

 Flora estimates that she conducted over 2,000 deliveries before joining Lwala as a CHW. She is unable to write her name, but has a wealth of experiential knowledge and is a treasured member of both the health facility and the local community.


For more information about Lwala Community Alliance, visit:

[i]Lewin, Simon, et al. “Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.” The Cochrane Library(2010).

[ii]Sibley, Lynn M., Theresa Ann Sipe, and Danika Barry. “Traditional birth attendant training for improving health behaviours and pregnancy outcomes.” The Cochrane Library(2012).

[iii]Glenton, Claire, et al. “Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis.” Cochrane Database Syst Rev 10.10 (2013).

[iv]Byrne, Abbey, and Alison Morgan. “How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance.” International Journal of Gynecology & Obstetrics 115.2 (2011): 127-134.

[v]Hamela, Gloria, et al. “Evaluating the benefits of incorporating traditional birth attendants in HIV Prevention of Mother to Child Transmission service delivery in Lilongwe, Malawi.” African journal of reproductive health 18.1 (2014): 27-34.

[vi]“2017 Annual Report” Lwala Community Alliance. 2018