Traditional birth attendant training in Nohana, Lesotho.

Rural clinics in the southern African country of Lesotho used to deliver an average of three or four babies per month, with most mothers delivering their infants at home, risking the possible severe health and disease transmission threats.

Now, some of those same clinics are delivering over two dozen infants each month thanks to a fast-expanding project, which provides mothers with prenatal care, HIV testing, treatment, pre-birth accommodation and nutritional support.

The daunting challenge facing the Ministry of Health in this poor, mountainous country is that roughly one in four adults is living with HIV; many of whom are co-infected in an epidemic of TB and MDR-TB that has swept through its villages.

With one of the world's highest rates of maternal mortality, pregnant women here are among the most vulnerable – physically separated from clinic services by crumbling dirt roads and rugged terrain, and often at risk of passing HIV to their infants.

In 2009, a partnership between Partners In Health, the Lesotho Ministry of Health, and the Elton John AIDS Foundation launched a pilot project at a newly renovated clinic in Bobete to retrain 100 of the country's traditional birth attendants (TBAs) to bring pregnant women access to services at the center. 

In addition, a waiting house near the clinic was rented so that women nearing their birthing date can make the journey before their labor begins, and move quickly and without risk to the clinic's maternity ward when the time comes. This model is now being extended to six other clinics, thanks to new funding from the UK-based Positive Action for Children Fund.

In the first year of the initiative, the Bobete clinic delivered 150 babies, with more than 80 percent of these mothers brought in by TBAs. Most of these would likely not have visited a clinic for prenatal visits or the delivery, were it not for the new TBA counseling.

Since the project’s inception, 67 percent of these mothers have also stayed at the waiting house before delivery, further increasing their chances of a healthy maternity process.

In addition to training, supervision, and incentives given to TBAs, mothers who make use of the services also receive incentives in the form of baby starter packs.

Receipt of the packs – which include baby clothing, pins, and a bathtub - means that these mothers attended at least three antenatal visits, and also agreed to HIV testing and – if necessary – measures to prevent HIV transmission, and 88 percent of Bobete's mothers qualified.

The project was so successful that it is already expanding throughout the partners' network of remote health centers. In addition to one MDR-TB hospital--Botsabelo--PIH now supports seven health centers in Lesotho's most remote mountain areas, serving a catchment area of 300,000 people.

PIH Lesotho Project Manager Archie Ayeh said a second class of TBAs had completed their training at Nohana Clinic, in Lesotho's southern region. In October, visiting staff from PIH in Boston were amazed to find that 45 of these graduates—some nursing mothers themselves--had traveled on foot for up to two days to attend the training.

Ayeh said Lesotho's traditional birth attendants had previously – “unfortunately” – discouraged pregnant women from seeking care at clinics, while many more expectant mothers previously received no assistance at all.

However, he said the income from home births had been replaced with a PIH cash incentives program, and added that the newly trained TBAs were now committed to a model which sees them counseling and accompanying young mothers to access professional services.

Ayeh said Lesotho's young mothers deserved equal credit, for making the significant effort to negotiate the tough terrain to access their clinics.

“We are really thrilled – even surprised – at how patients and the TBAs have embraced this program to get mothers to the clinics,” he said.

Meanwhile, Ayeh said the waiting house system at Bobete had proved so popular with mothers – and the TBAs so effective – that the four-week waiting period had to be cut to just two in some cases, to accommodate more women.

Rather than renting existing buildings, PIH has constructed waiting houses at two clinics in Lesotho's southern region--Nohana and and Nkau--thanks to a three year grant from the Positive Action for Children Fund grant. This funding will now see further waiting shelters established at four more clinics.