A narrative qualitative study of maternal and perinatal death surveillance and patient referral practices among Traditional Birth Attendants in East Central Uganda

Abstract

Introduction: Maternal and Perinatal Death Surveillance and Response (MPDSR) and referral systems are critical for improving maternal and neonatal outcomes. In rural Uganda, Traditional Birth Attendants (TBAs) remain key community actors but are rarely formally integrated into MPDSR processes. Objective: To explore the roles, practices, and challenges of TBAs in MPDSR and referral processes in Mayuge District. Methods: A narrative qualitative study was conducted among 15 TBAs using in-depth interviews, observations, and document review of community and facility records related to maternal and perinatal deaths. Data were inductively coded and thematically analysed, with document review findings triangulated to enrich interpretation of reporting and referral practices. Results: TBAs contributed to maternal and perinatal death notification primarily through informal community networks, with frequent delays and limited engagement in formal MPDSR processes. Document review confirmed gaps in formal reporting and inconsistencies between community and facility records. TBAs rarely participated in structured death reviews due to exclusion, fear of blame, and limited system integration. Referral practices were adaptive and included referrals to health facilities, other TBAs, and traditional healers, shaped by logistical, cultural, and social factors. Conclusion: Traditional Birth Attendants in rural Uganda play an important but often informal role in the MPDSR process and referrals. Despite the lack of formal training and integration within the health systems, TBAs contribute significantly to maternal and perinatal death notifications and provide vital feedback on death reviews. Improving training on danger sign recognition, establishing structured community death notification pathways, and strengthening referral linkages between TBAs and health facilities could enhance MPDSR effectiveness while maintaining the national emphasis on skilled birth attendance.