A standardized framework for integrating indigenous knowledge of traditional birth attendants into the formal health system to enhance reproductive health outcomes in northern Namibia

Abstract

Background: Traditional birth attendants play an important role in reproductive health in many communities in Africa. However, there is lack of evidence to support the adoption of traditional knowledge in reproductive health to support collaboration with formal health systems. This study sought to develop a standardised framework for integrating indigenous knowledge of traditional birth attendants into the formal health system to enhance reproductive health outcomes in selected regions of Northern Namibia. Method: Underpinned on the Constructivism philosophical paradigm, Health Belief Model (HBM) and the Donabedian SPO Model; this study employed a scoping review (Phase I) and the exploratory and descriptive qualitative (EDQ) phenomenological design (Phase II). Phase I: 11 articles were reviewed to map evidence of existing frameworks integrating TBAs into modern healthcare. The Preferred Reporting Items for Systematic reviews and Meta-analysis for Scoping Review (PRISMA- ScR) statement to describe the process and qualitative content analysis using an inductive approach for scoping reviews were applied. Phase II: Participants comprised 14 TBAs, 22 healthcare professionals (HCPs) and 15 women of childbearing age who were recruited through purposive sampling and sample size was determined by data saturation. Data collection were through face-to-face interviews and focus group interviews with TBAs and women of childbearing age. Semi-structured interviews through individual technology-mediated online interviews were provided for HCPs. Findings were analysed using latent content analysis which included data preparation, familiarisation, coding, and analysis of coded data to identify patterns and themes. Phase I Findings: The scoping review found that integrative frameworks are developed in response to the need aimed at improving maternal and newborn care rendered by TBAs as the need to empower community-based maternity care facilitated by TBAs is underscored. Out of the 11 articles reviewed, only four (4) articles comprised of frameworks. Despite the recommendations to integrate the two systems, there is a lack of collaborative frameworks in many countries, and a lack of implementation where they exist. Phase II Findings: Five themes emerged: indigenous knowledge, preconception care, antepartum, intrapartum and postpartum roles. Some of the TBAs perform minor surgery-related procedures similar to haemorrhoidectomy in their homes, which can cause sepsis and bleeding. Majority of HCPs perceive TBAs as relevant while supporting that training and regulating the TBAs can facilitate their integration in reproductive health promotion programmes. Some HCPs disagreed, expressing concern for harmful practices associated with the care rendered by TBAs. The women of childbearing age prefer TBAs due their availability in remote areas and cost-efficient services. However, some indicated that they have no interest in TBAs services. The scoping review conducted in Phase I, and the study findings in Phase II guided the iii development of the standardised collaboration framework (Phase III) and the training manual for TBAs in Phase (IV). Conclusion: TBAs are indigenously skilled practitioners who fill the gap between their communities and the formal health system. Recommendations to integrate TBAs into formal healthcare systems have been put forward by a multitude of researchers, but stagnation towards implementation is evident due to the unavailability of collaborative frameworks. Although the recommendation is that all women should be attended to by skilled healthcare professionals at healthcare facilities; poverty, socio-economic factors and cultural beliefs cause women to seek care from TBAs. The developed framework and training manual can guide integration, and empower TBAs with evidence-based knowledge to ensure optimum reproductive healthcare in their communities.