Muzalema Mwanza is reducing neonatal and maternal mortality in Zambia by positioning Traditional Birth Attendants (TBAs) as the drivers of standardized and quality care at the point of birth.
The New Idea
In Zambia, 53 percent of births are unattended by a skilled professional but generally aided by experienced but unskilled Traditional Birth Attendants (TBAs) in communities. Muzalema positions these TBAs to help ensure safe births by empowering them to address three of the drivers of maternal mortality – lack of information, lack of access to health clinics, and use of non-sterile supplies. The TBAs become skilled practitioners trained by the Ministry of Health (MoH) and serve as a bridge to the public clinics, with which they build relationships and communication channels, and ensure that mothers have access to the right sterile materials they need for a safe birth.
Safe births in Sub-Saharan Africa are a challenge because women don’t have access to, or choose not to access, clinics – a main reason is that mothers are mandated to bring their own sterile material for the birth, which they may not have access to. Muzalema began equipping TBAs and mothers with a baby delivery kit, comprising of essential sterile material needed at the point of birth. The kit includes items like cotton wool, bleach, cord clamps and surgical gloves. Distributed by the TBAs to the mothers at clinics and communities, the kits form an integral part of Muzalema’s inclusive business model, as well as offering TBAs additional income opportunities.
In this context, Muzalema is upskilling and professionalizing these attendants to improve safety in both clinic and home births across urban and rural Zambia. Her training (conducted in partnership with MoH) enables them to use the birth kit as a starting point for a deeper conversation on safe birthing practices pre, during and post birth. TBAs also build relationships with fathers, to enable family communication on birthing and child-rearing. Understanding that maternal anxiety over childbirth can often lead to mothers falling back on unsafe and superstitious practices, Muzalema is removing the anxiety from the birth process, and rebuilding trust between communities and clinics. As such, she is ensuring that mothers do not compromise their own safety and that of their newborn children in under-resourced clinic environments as well as at their homes.
When Muzalema was pregnant, she realised that she would have to provide the materials for her own delivery, like all Zambian women have to do. After going shop after shop to find these materials, she found herself frustrated and wanting a more convenient solution. At the same time, she saw the number of women who were choosing to have babies at home (more than 50% childbirths happen at home). This started her journey towards making a baby delivery kit, localised to the needs of Zambian women, available for the population. The first kit, the baby delivery kit, includes all the essential material recommended and endorsed by the National Department of Health. Seeing the uptake, Muzalema also created a new-born kit - to keep the new baby comfortable in birth; a menstrual kit, including sanitary napkins made of banana fibre; and a post-partum kit, to support mothers in breastfeeding, vaccination and baby registration.
Her different kits present the opportunity for Muzalema to have important conversations with a range of stakeholders on the quality of healthcare available for rural and poor-urban Zambians. With the Department of Health, she has signed an MoU which allows her to use the 3500 health clinics in the country to distribute the kits. In the process, she is able to converse with them on issues of infrastructure and personnel – and showcasing the local resources available to address these issues. The TBAs now not only distribute the kits and earn income from them; but also play a role in supporting nurses and clinicians now in facility-based deliveries.
Zambia has a maternal mortality rate of 470 (per 100,000 live births) and a neo-natal mortality rate of 22.2 (per 1000 live births). 30% of the neonatal deaths in Zambia occur due to complications during birth (preventable if the birth is in a facility or assisted); and 17% occur during Sepsis, when infections occur during birth. There is also little evidence to show geographic disparity as well - children born in the most developed province of Lusaka had as high of risk of dying as those from Luapula, a province with a history of extremely high mortality rates in Zambia.
At the same time, only 47 % of child births are attended by a skilled health worker at health institutions. With health care facilities few and far in between, and a doctor-patient ratio of 1:12000, the 47% are also still required to provide their own birthing materials, unless they go to a private hospital (which less than 1% do). When women come to the clinic to give birth, and don’t have the material, they risk being turned away, or being treated as a burden by the clinic staff, who then have to source the material from other departments. The birth experience becomes fraught with anxiety, at a time when both the mother and child are already vulnerable.
Thus, women often find themselves deciding to have babies at home, either attended by experienced family members, or Traditional Birth Attendants (TBAs or untrained community midwives). Although experienced with births, TBAs also do not have the right, sterile material to support a mother at this point. Further, they often use local herbs and roots, propagate superstitious behavior; and more importantly, do not have the linkages to the clinic, when there is an emergency situation in the birth.
Ultimately, if the mother has attended an ante-natal session (comprising of a health-talk, followed by checking of vitals, from the nurses at the clinic), and received the list of materials from the clinic, and she goes out to look for the materials, she finds herself having to go not only to the chemist, but also to the hardware store to find the required items. The time and transport cost of doing this is often high enough that many mothers do not do this. Knowing that traveling to the clinic is also a cost, and one where they will not be respected, it becomes a space of fear, and mistrust, and a space to be avoided. Underlining all of this is the fact that maternal health is not a priority of the national government, which is stretched thin on issues like tuberculosis, and regular epidemics including cholera leading to maternal health wards often running short of essentials like cotton wool, gauze, and surgical gloves as well.
Muzalema’s simple solution seeks to equip clinics, mothers and traditional birth attendants with the materials, the capacity and most importantly, the dignity, to deliver babies safely – in the clinics and their homes.
The core of Muzalema’s strategy lies in developing a professionalized cadre of skilled birth attendants who provide the bridge between the clinic and the home. Muzalema identifies trusted and experienced TBAs from the communities where she is working. In agreement with the Ministry of Health (who provides a trainer), she trains these attendants on modern birthing practices, as well as in entrepreneurship skills, and in building and maintaining relationships of trust. The TBAs are then equipped with pre-packaged birth kits containing essential sterile material (cotton wool, gloves, bleach, maternity pads, cord clamps, scalpel blade), packed and provided by Muzalema’s organization Safe Motherhood Alliance, which they are able to sell in the community as well as in the local clinics, and earn a commission. Muzalema is able to leverage the TBAs ability to communicate with mothers in ways that nursing staff are not; where they not only counsel but have been able to support and deliver babies at home using this training and material when the mother has not been able to go to the clinic on time. The TBAs also stay with the mothers post the birth, to provide support and advice post-partum, including topics like breast-feeding, vaccinations and birth registration of the child.
In parallel, Muzalema has also partnered with local clinics, supported by an agreement with the National Ministry of Health. At the clinics, the TBAs use the platform provided by the health talk during the Ante-natal visit to dispel myths about pregnancy, and to encourage women to choose a facility birth, as opposed to a home birth. They are also able to talk about the baby delivery kit, allowing the mothers to purchase them, and reduce the anxiety of having to find the materials for themselves later on. Very often, the conversation is also had with the male partners (who are the holders of the purse-strings), to not only talk about the kit, but about creating familial ownership over the birth process. Sometimes, the TBAs are able to offer the kits for free to those women who registered early; to incentivize more early registrations from other mothers in the community.
The clinic staff and the TBAs are able to build a relationship of support; where the TBAs are able to support them with tasks like taking the vitals of the mother; as well as assisting in birth. Should the mother be giving birth at home and there is an emergency, the TBA knows who to communicate with at the clinic, give them advance notice of the emergency and ensure that once the mother is at the clinic, she get the attention and care she needs to save the life of herself and her baby. Muzalema is currently developing a feature phone app, leveraging on a USSD code provided by the National Ministry of Health, to support TBAs at the time of birth by automating diagnosis, send treatment reminders, and further allow for ease in communication between TBA and clinic. In the future, Muzalema envisions that this data bridge between TBA and clinic will give the clinic essential information to prevent stock-outs of materials and medication, know when to call in specialized help for emergency situations and know where to send their community health workers for maximum support.
Since the launch of the birthing kit, Muzalema has assisted in “delivering” over 1,000 babies safely in 5 health centers and clinics, working with 30 traditional birth attendants. Muzalema is seeing evidence of impact in preventing cord infection and puerperal sepsis, both leading causes of neo-natal and maternal mortality globally. Newborns of mothers who used the clean delivery kit were about 13 times less likely to develop cord infection. Women who used the kit were about 3 times less likely to develop puerperal sepsis. Further qualitative outcomes were observed:
I5% increase in the number of people attending antenatal visits due to increased canvassing by TBAs. 
Increase in the community knowledge on safe birthing practices
Demystification of unsafe traditional practices e.g. faith-led disbelief in vaccinations.
Social connections of expectant and new mothers improved – both in the family and with the clinic
Further, Muzalema provides the bridge between the TBAs on the ground, and the Ministry of Health guidelines. For instance, formaldehyde had been mandated as part of the list, but the TBAs feedback on formaldehyde to clean the baby’s umbilical cord showed that the nurses and mothers were using too much of it, leaving the area vulnerable to infection. When informed of this by the SMA team, the MoH agreed to drop the item from the list; and started recommending clean water instead.
Through the agreement with the Ministry of Health, Muzalema is able to work in all 3500 clinics in the country. Towards enabling her capacity to reach rural women, she is currently focusing on dropping the price of the kit (from USD 10 currently – to USD 2) so vulnerable rural women are also able to afford it. She has already experimented with localized production of the material as opposed to imports, to reduce the cost (she has replaced the maternity pads with that made from banana fiber). Further, she is using local and international partnerships to augment the capacity of the clinics in rural Zambia – through a partnership with RREAL a US-based solar company, she was able to support 5 rural clinics that are off the grid, with solar batteries, so that mothers are not delivering their babies in torchlight.
Muzalema is a civil engineer, a solar project developer, and a social entrepreneur. She has designed construction projects, consulted on a utility scale renewables project, worked on an innovative women’s aquaculture project, mentored girls in STEM, and started her own construction company.
At the ante-natal visits for her first child in 2016, Muzalema was given a list of items to bring with her in order to give birth at the hospital. As a first-time mother, and having had difficulty getting pregnant, Muzalema was consumed with anxiety and fear. At the time, she was in rural Zambia. Not finding the items she needed in her vicinity, and not getting support from her husband, she moved back to Lusaka, where she found the same situation. She had to visit the chemist, the supermarket and the hardware store to find the items. At the hardware store, she was confronted by a smirking clerk, who seeing that she was pregnant, threw down a roll of dusty, black plastic (used for a birthing mat) even before she asked him for it.
When talking to other mothers, family and friends, Muzalema was surprised to find that everyone had just accepted that this was the way things were. Why should women have to run around for their own birthing material, she asked. Why should they be subjected to judgment and stigma in doing this? When she investigated further, she realized that this situation was leading to many mothers deciding to give birth at home, using whatever material they had on hand (rusty blades and knives, plastic bags for gloves) making them vulnerable to infection and disease during birthing. This led her to develop the baby kit and put her on a journey to create safe spaces for birth.