When Home Birth is Preferred to Facility Birth, a Critique of a Qualitative Study in Rural Tanzania

In modern western society, choosing to give birth at home is an act of counter-culture. In general, for more than a century, birth has been taken away from homes, where they were mostly attended by traditional birth attendants and midwives and brought into the hospital together with the advent of a new kind of doctor - the obstetrician - and into a new paradigm of birth: the technocratic model, as Robyn Davis-Floyd explores in her books.

In October 2017, the BMC Journal published an article by researchers Fabiola Moshi and Tumaini Nyamhanga entitled "Understanding the preference for homebirth; an exploration of key barriers to facility delivery in rural Tanzania". They used qualitative methods of research to try and understand the reasons why most parents in rural Tanzania still choose to give birth at home attended by either TBAs (traditional birth attendants) or relatives rather than SBAs (skilled birth attendants) in delivery facilities that exist in those areas. The main motivation for the study to take place was the high number of maternal and infant mortality in that region and the belief that facility delivery is safer than home delivery in all circumstances.

The study was mostly well done. They chose a remote rural area in Tanzania, Rukwa, with deeply rooted traditions, where the rate for home delivery is as high as 69,5% despite having facilities for delivery with an average of one of those per 2 villages and within 2 km of distance from the villages. 16 couples (32 individuals in total, being half men and half women), living together at the time of the birth of their youngest child, aged 0 to 12 months old and born at home, gave their informed consent and were selected to participate in the study.

They used a descriptive exploratory study using two kinds of qualitative methods: FGDs (focused group discussions) and IDIs (in-depth interviews). The groups were divided by gender (16 men, then 16 women) and the FGDs took place first. Then each individual was interviewed without their partner. The lead researcher used a general African greeting to break the ice, then she would proceed with questions in English that the research assistant translated into Kiswahili. While the participant was expressing himself/herself, the assistant would tape-record the conversation. This material was later transcribed, translated, and interpreted in three stages by each researcher, who then met and exchanged their views so as to get all the language nuances down.

They found out that: 1) men have limited decisions on the place of delivery, this being the realm of women; 2) men have a low-risk perception of delivery and believe "birth is normal", which impairs facility birth; 3) men have little resource for mobilization. Their first choice is home, their second choice is the facility. TBAs are inexpensive and available. Men's main role is to save money for potential transports, baby's clothes and food for the postpartum mother and TBA; 4) women have a perception of pregnancy and childbirth as low risk. All of them (all 16 of them were multiparas) had had successful births at home prior to the last birth.

These findings are important because they convey a message that these women and men alike are inherently trusting and have little to no fear when it comes to childbirth. There is also the belief that birth is the realm of the divine and that "bad outcomes" happen because of god's will. In this region, the traditional ways of life have not been completely annihilated as they have been in modern western society. Women support each other in childbirth and the community shows up for them, including the TBAs. Gender roles are respected and well-established. When the women are pregnant and approaching the time of birth, men's role is to save money, and women's role is to give birth assisted by the women in the family and/or TBAs.

Only in a few places in the world nowadays do we find communities that respect and value mothers', grandmothers' and TBAs' knowledge as we see in this region in Tanzania. In most western societies, childbirth is feared and almost entirely happens in institutions with practitioners that have limited understanding of both the normal physiology of childbirth and mother-baby attachment and the importance of community support for the mother. The technocratic model of birth is counter-intuitive and actually causes more harm than good. That is not to say that all practitioners are ill-intentioned and unnecessary, on the contrary, having access to facilities with skilled professionals is a blessing for when their expertise is needed.

The motivation to conduct this study was noble, meaning that they aim to reduce maternal and infant mortality in remote (and mostly poor) areas of the world. However, there is bias on the part of the researcher who openly blames mothers for poor results in childbirth, calling them "negligent" for choosing to give birth at home. In no instance did the researcher postulate that the reasons these women still feel confident in their own ability to give birth were a sign of physical, emotional and spiritual health, and not the opposite. In addition, it is clear that the researcher does not support the work of TBAs because of her explicit discrimination against this group as opposed to the "skilled" ones in the facilities. It's fascinating to me that the technocratic model of birth is accepted as the best and the standard of care. When they can't find a model that fits their bias, they don't know what to make of it!

They conclude that it is more important to convince men to take their wives to the delivery facility through pregnancy and childbirth education than to support their family and home birth systems traditionally in place. It seems to me that instead of wanting to take these women away from their families and homes (where most of them feel safe) at the time of birth, a different model could be put in place. For instance, a combination of in-clinic and at-home antenatal visits performed by both TBAs and SBAs could be the best prevention of bad outcomes during and right after birth. And at the time of birth, the woman being attended by the team of her choice, should complications arise, could be transported into the delivery facility where medication and personnel with more technical skills could take care of the situation.

In addition, it seems to me that ignoring the knowledge and wisdom of the region's TBAs is a big mistake. Instead of pretending they do not exist, these wise elders should be cherished by society for the value of their work and service. If these TBAs don't need to go into hiding and can work together with the attendants who work in the delivery facilities, for instance, in a situation of transport intrapartum or immediately postpartum, results would improve for sure.

This research and its findings are so valuable not to solve the problem the way they wish they could, but because it brings to light a way of living that sounds more respectful of birth as a rite of passage that is still alive today! It is proof that somewhere at some point in time women did not fear childbirth: they gave birth in full surrender to the process, feeling supported by the women in her community: her mother, grandmothers and the wise women there! And men also knew their place when it came to birth: their support role, their trust in the process and in their wives to bring life forth and continue the thriving life process on Earth.

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