Successful TBA Training in the Midst of War

Almost 60-70% of women and their families in the isolated communities of Wardaga and Ismailia prefer and use traditional birth attendants. Over the past ten years, due to illness, old age, insecurity and relocation, the number of Traditional Birth Attendants in Wardaga and Ismailia village in Northwestern Frontier Province has decreased drastically. As the area is conservative and rigorous purdah practiced, women rarely venture outside their own homes. In these areas linking pregnant women up to women within their own community who are knowledgeable about pregnancy and child birth is crucial to reducing deaths from child birth.

4000 was obtained from the Hillman Medical Education Fund and Society of Rural Physician donors to train 30 TBAs. A lengthy consultation with the two communities ensured they were supportive of the plan to improve maternal health services, were willing to have their wives and mothers trained as TBAs and/or visited by the TBAs in their homes and had agreed upon a minimal fee for provision of birth kits and TTBA care. Discussion of the qualities needed for being a TBA lead to development of a set of criteria and identification of suitable candidates for each community. At the end of the process the communities had identified a total of 38 women were needed.

Wardaga’s population is 12,000 while Ismailia’s is 30,000. It was recognized that these female health workers as the only ones in their community would also be important conduits of health information on diarrheal diseases, immunization and nutrition as well as pregnancy and newborn care. Wardaga has a day labour room staffed by two nurses and 3 dais while Ismailia has a basic emergency obstetrical center (EmOC) providing 24 hour coverage with 3 nurses, 1 assistant nurse and 4 dais. So skilled TBAs were an important adjunct to getting services to women and women into the health centers for delivery when needed.

The need for skilled female health workers in the community resulted in the extending the training from four weeks to six weeks. This 50% increase in enrolment and training period were accomplished with cost efficiencies within the original budget with $4000 training 38 TBAs, or approximately $105 per TBA trained. This cost included provision of a supply of individual birth kits containing rubber gloves, soap, razor and tie. The individual kits form a rotating supply that will be sold to pregnant women at cost plus a small amount for the TBA which is agreed in advance by the community, approximately $0.50. In addition each newly trained TBA received a TBA kit with rubber sheet, nail brush, towels, gloves, soap, plastic apron, containers and a supply of oral rehydration packets.

The project did not include an evaluation component and information is available for only 4-6 months following the training but data from the health units show a real impact. Ismailia Health Center, where 38 TBAs were trained, reported a more than thirty percent increase in the number of ANC visits, from 240 to 320 women in the first four months following training of the TBAs and a >200% increase, from 30 to 68 in the number of women delivering at the Health Center. Prior to training. almost half of the women admitted to the obstetric unit did not proceed to delivery prior to training while six months following training less than 10% of the pregnant women who initially admitted were discharged without delivering.

Health Center, where nine new TBAs were trained, ANC visits doubled from 51-106 within six months and the number of delivered women receiving at least two doses of tetanus toxoid rose from 36-51 in three months.

While the follow-up period is short and the data preliminary, these figures suggest that not only do trained TBAs refer more pregnant women to ANC and for delivery but appear to be more appropriate and effective in their referrals. Trained Traditional Birth Attendants in this area are proving to be valuable resources in reaching women in their homes and linking them to appropriate delivery and antenatal care. Their pride and dedication to improving the care to pregnant women.

Photos: TBAs in class; TBAs using models; TBA with certificates

Turner Clegg, My Grandfather

Recently I was rearranging a bookcase in a attempt to organize books by subject and found an envelope stuffed with curious bits of paper that I didn’t at first recognize. 'the turquoise blue booklet jogged my memory and I recognized my father's handwriting immediately. It was the memorial record of my mother’s funeral. For most of my youth a stash of the memorial records were kept in the cupboard where winter coats, curling sweaters and other out-of-season outer clothes were stored. No one wanted to throw them out.

This one however, had in my father handwriting, a note saying, “Mom, If you would like some more of these, let me know. Les”. So I realize this item must have come from my maternal grandmother.

Among the notes were two penciled letters on thin sheets addressed to "Dear Wife" dated June 26, 1917 and Jan 15, 1918 from my grandfather, Turner Clegg, who served in France during WW I. A cropped sepia photo of two young unidentified children was included as well as a handwritten Xmas letter written during WWII from my mother to her father with details about my father’s difficulty completing his degree if he is still working at the cordite plant and if he isn’t not being able to afford it. Handwriting is like a face as is instantly recognizable. My mother’s handwriting feels familair too, although I she died when I was ten. There is as well a letter of reference for Turner Clegg dated May 23, 1899 in elegant copperplate signed by Herbert Mitchell of Holly Bank, Bradford.

Dear Sir, it states, Turner Clegg worked for me for about 6 weeks to get up some young pedigree Hackneys for sale, from what I known of the man he seems honest, sober, industrious, willing and obliging, he left for no fault, namely because we had no further employment for him. I think he is a steady young man.

This, it would appear, must have been the reference letter that my grandfather brought with him when he immigrated as a young man to Canada.

Slowly I recalled that a number of years ago, when my mother’s sister, Aunt Millie Teskey, whom I had kept in touch usually at Xmas, was moving into a small apartment and was clearing out things, she had sent me these items in a letter. She said her sons weren’t interested in these and I might be since I had asked her for info about my grandparents. My Grandma and Grandpa Clegg had moved from Medicine Hat to stay with her family on their farm in Orillia for their final years. She had also given me the name of relatives in the UK, whom she had kept in contact. She had died within the year but I had followed up and visited the relatives where I collected some more information on my family. .

Letter dated 15/1/18

Dear Wife,
Your parcel dated Nov 20 arrived safely on January 13th. The contents gave me much pleasure. In our cellar there are six men and all have had parcels so you can bet we had some time, real bean feasts. Did I tell you they had your watched fixed for me in England & it is going first class. Hope it keeps on doing so feel lost without it was good of them don’t you think so. I had a letter from my sister Annie making all kinds of inquiries how I spent the rest of my time over there. Have you any of those photos which I had taken over here to spare, if so will you send one to the families. I think you have the address you might drop them a line at the same time it would be a good opening, that is if you don’t mind. Well we are having all kinds of weather just now, front, snow, thaw and today it is raining, just the kind that comes across the prairie. Well I hope yourself and the kiddies are well it is with me. I have not heard from Twyford yet so cannot say anything about there so I will close with much love to you all from
Yours
Turner

552255 Pte. T. Clegg
P.P.C.L.I.
Att. Area Commandant 3rd Can Div
BEF France

Letter dated June 26, 1917

Dear Wife
I received your parcel and the contents were fine, also the small note, wish I could say the exact date but am looking forward to it anxiously, wish it was now. I have enough handkerchiefs, sugar and vaseline for a long time & if you have not sent off the milk I should not trouble, you see where I am there are Y.M.C.A.s and Canteens so I can buy most of the things I want, don’t think you are not wanted to send anything. It is nice to have parcels but useless expenditure, buy something for yourself & the kiddies. I would be much more pleased with it & better for yourself. I have more than a hundred dollars credit so if I get a blightly leave shall be jake. I had letter from Twyford this week and your father is well and about again poor old chap he had a long spell of it this time. Yesterday I had my half day holiday so took a stroll down to the village for a change had tea eggs & milk & finished up with a glass or two of beer on Violet so tell her I shall have to collect when I see her. The Thimble Hall people wrote me and they are all well. Willie is in the Punjab at Rawal Pindi lucky for him & Bob is still in England. Well I don’t know of anything very interesting. The weather is not to bad, rain & sunshine and the country looks pretty nice, as for myself I am well and hoping that you are the same. I will close with much love to yourself and kiddies Yours Turner

552255 Pte. T. Clegg
c/o Major Ramsey
Camp Commandant
Can Div
B.E.F. France


Letter from Vi to her father Turner Clegg dated Saturday,

On the back- Read This First Don’t Open Parcel

Dear Dad,
You aren’t supposed to open your present until Christmas and please see that Mom and Millie keep their mudhooks off theirs too.
I hope you are feeling better now. Les says he is going to get some beer delivered here for Christmas but he never gets time to get a permit. It would keep nice and cold down our cellar. It’s too bad you couldn’t be here to celebrate. Les gets the day off unless anything happens.
We are maybe going to move from here in the Spring. If Les is still working at the plant he won’t be able to go to summer school & if he isn’t, we won’t have the money or else, he’ll be in the army-so his degree will be away off again. Still- it can’t be helped, and if he can stick to this line of work after the war, he’ll be O.K. Defense Industries Ltd is a subsidiary of Canadian Industries Ltd (CIL) and they in turn are supposed to be connected with Vickers. They make all sorts of things so maybe he’ll stand in good with them or the gov’t because the gov’t is interested in (DIL) so perhaps it was a good change.
Well, hope you have a nice time. Wish I could be home or you folks here.

Merry Christmas.
Vi

It moves me to read these handwritten notes from so long ago, some handwriting I recognize and all somehow linked to me with information from so long ago and so far away. To learn about a relative who served in Rawalpindi, so close to the NGO project I work with near Peshawar in North West Frontier Province of what is now known as Pakistan. And the degree my father was unable to complete; the camaraderie between my mother and her father along with antiquated expression which feel somehow familiar, such as mudhooks. As I put the priceless notes into plastic covers to preserve them, I decide to post them on my blog on the internet so the rest of my family and even those still to come, also will know they exist. It is one thing to have a genealogy chart and quite another to have some handwritten notes, some of them more than a hundred years old. Now I must track down the identity of those two kids in the photo. And for those interested, Hackneys are a pedigree horse bred by country gentlemen.

photos: 2 young children; memorial record of Vi; reference letter for Turner Clegg, 1899