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Pre, Post Natal Care: Traditional Birth Attendants To The Rescue

Delivering of babies outside conventional hospitals is fast becoming an acceptable trend across the country as Traditional Birth Attendants (TBAs) continue to receive more pregnant women. AGBO-PAUL AUGUSTINE (Abuja), ODIRI UCHENUNU-IBEH, (Lagos) Bernard Tolani Dada (Uyo) and Hussaini  Hammangabdo (Yola) write on the factors responsible.

As family members, friends and relations share in the joy of the arrival of little Anne Terngu, to the world of Mr and Mrs James Terngu, the feeling was mutual, love and happiness, as food and drinks passed from one person to the other.

Their small house in Gwazulu, on the outskirts of Suleja, Niger State, seven days earlier, welcomed an additional permanent member, little Anne, who was delivered by a Traditional Birth Attendant (TBA), Madam Mary Nimba, who was also present at the naming ceremony.

It only cost the Terngu family about N3, 500 and a few delivery items, saving them between N15, 000 and N150, 000, depending on whether they had chosen a government or private hospital.

“This is my third baby and all of them were delivered by Madam Mary. It has been smooth all these while and far cheaper with no complications. I can tell you that many children in this locality were delivered by the birth attendant,” Terngu said.

Just like Terngu, many Nigerians have continued to patronise traditional birth attendants for delivery of their babies in spite of the fears expressed by some medical experts on the professionalism in these category of healthcare persons.

That hitherto obscure aspect of the healthcare delivery, is fast becoming an economic power within the health sector, as more Nigerians are entrusting the delivery of their babies in the hands of TBAs.

TBA, First Hope Of Lagosians

As the Terngu family celebrated the arrival of the newest addition to the family, LEADERSHIP WEEKEND investigation has shown that TBAs have, over the years, been the first hope of most Lagosians, who patronise both the TBAs and Hospitals when it comes to healthcare.

It was also discovered that those living in the rural areas and hard to reach or riverine areas within the state, only remember government hospitals when the case has become critical.

This has led to more preventable deaths as statistics by the United Nations Children’s Fund (UNICEF) show that a woman’s chance of dying from pregnancy and childbirth in Nigeria is 1 in 13, due to the fact that quite a number of women shun the hospitals and rather patronise Traditional Birth Attendants (TBAs).

The foregoing is a reflection of the attitudes of pregnant women in some communities in Lagos State. LEADERSHIP WEEKEND, in its efforts to un-ravel the mystery behind it, visited some of these communities and found out that some of the TBAs are very expensive in terms of cost, when compared to what they will spend at government hospitals.

Agboyi-Ketu local council development area (LCDA), in Lagos State, is one of such communities. LEADERSHIP WEEKEND visited the LCDA, a community that comprises of Agboyi 1, 2 and 3 and is surrounded by water, with no bridge to link with neighouring communities like Alapere and Ogudu. The only means of transportation is canoes, which are very few when compared with the over 40,000 people that live in the community.

Worse still, it was learnt that though the LCDA has a functional Primary Healthcare Centre (PHC), offering maternal health services like prenatal, antenatal and counseling services, with little or no cost, a large number of pregnant women still prefer the TBAs.

The chief nursing officer, who refused to disclose her name, said most pregnant women patronise TBAs, adding that some of the women only come around to take injection/immunisation and then go back to TBAs for antenatal and delivery.

She said, “They seem to have a strong relationship with TBAs because they patronise them and some of the women use church maternity. The few that access ANC at the PHC, usually make arrangement with someone that will carry them across the water to the PHC where they would deliver, should they fall into labour at night.”

Some reasons pregnant women gave for patronising TBAs included the fact that the PHC doesn’t run for 24 hours; is not well equipped with medicines and it lacks medical doctors and other quality services.

Ayo, a 33-year-old woman did not hide the fact that she patronises TBAs. “I don’t have any problem at all delivering my baby at Mama Agoro Nurat’s place. I am eight months pregnant with my third child. I prefer her because she gives herbs and can detect if there are complications.”

Shakitat Yakubu, said she has three children and heavily pregnant, adding that she intends to deliver at TBA. She said, “I am eight months pregnant and I had my three children in this TBA and God has been helping me as I have never had problem.”

When asked what Mama Nurat normally gave her, Yakubu said, “I used to collect ‘agbo’ and medicine from Mama Nurat, but I used to go to health centre to collect injection. I go to Mama Nurat every Monday for my antenatal, where she tests me and gives me medicine depending on the issue I present to her. When it is time for me to deliver, she does not collect so much money; she collects N5,000 only. I also bring along the cloth my baby will wear, dettol, spirit, cotton board and other baby things.”

On the other hand, Mrs Aishat Moshood, from Ayetoro community in Ikorodu, said when she was pregnant, she registered with Olorunda PHC, which has been in existence since 1982, but only started renovation last year and is still not completed.

Despite the fact that Olorunda PHC does not provide 24-hour service and is closed during weekends, hence, patients have to travel for about 45 minutes to Imota community, which is the closest health center, Mrs Moshood said she did register for her antenatal and child delivery (just in case she falls into labour during the day time), because it is cheaper than the TBAs or private hospitals.

She said the hospital didn’t collect much from her. She only paid N4, 000 for everything, including registration.

According to Moshood, “I prefer going to Olorunda PHC because they attend to us well. But the PHC doesn’t run 24 hours. Unfortunately for me, I fell into labour at night and my husband took me to general hospital. I didn’t like the way we were treated and I left there and my husband took me to Mother’s Pride, a private hospital, where I paid N12, 000.

Traditional Birth Attendants, Toast Of Akwa Ibom Women

Despite the presence of modern healthcare facilities, there is a rising patronage of traditional birth homes in Akwa Ibom State.

With a population of about 4 million people, the state records about 10 per cent maternal deaths in the country. Despite the existence of modern health facilities, over 80 per cent of deliveries still take place at home whereas only 20 per cent take place in hospitals.

In the rural community, traditional birth attendants are commonly thought to be a poor substitute for care by skilled birth attendants such as doctors, midwives, or nurses) in a government healthcare facility.

Pregnant women in rural communities in the state, still prefer traditional birth attendants to hospital midwives for several reasons.

Uduak Ebong, a community leader in Ikot Okoro, Oruk Annam local government area, told our correspondent that one major reason is poverty, largely common in rural areas where the poorest people live and there is lack of basic socioeconomic infrastructure, medical facilities and good roads.

Also, medical care is not free in some of the few hospitals situated in rural areas. For this reason, poor pregnant women are unable to afford the cost of going to the hospital to deliver. Their only option is to seek the services of the readily available traditional birth attendants whose charges are relatively cheap and accessible.

“In the rural communities where majority of us are peasant farmers, our women patronise the TBA because we do not have   money to enable us take them to the government or private hospitals. TBA services are relatively cheap compared to the orthodox hospitals, but if modern healthcare services were made more accessible and affordable, they would not patronise TBA’s services.”

“Also, since these traditional birth attendants reside in the same community, it is easier for pregnant women to access them compared to midwives in the hospitals located at a very long distance, especially at nights,” Ebong said.

Rachael Udoh, a smoked fish trader and traditional birth expert from Mbo local government area, explained that she has been in the business for over 40 years. According to her, “their services are very cheap and affordable, besides, we are very close to the women, since we live within the same community.

“Most of our drugs and medicines are basically herbs from the bush, trees and shrubs around us, although, I inherited the art of birth attendant from my late mother who, herself, was a renowned herbalist.

“We do not charge much money like the orthodox hospitals, we regard our services as helping our community since the children given birth to are also our children.”

Ekaete Udofia, a six-month-old pregnant mother of four, from Ikot Ekpene local government area of the state, said she had never put to bed in a government hospital but she only patronises TBA not far from her home.

Another mother of two, Janet Okorie, who hails from Etim Ekpo, said that the attitude of some of the nurses in the government and so-called private hospitals, are just appalling.

“Few of us, whose husbands, could afford the money and are lucky to be taken to the conventional hospitals, get harsh treatment from the midwives, with less care and disrespect for no reason.

“We also fear death during delivery, especially when told that we are to be delivered through caesarean section. With many cases and stories of other women who died from caesarean operation during pregnancy, many pregnant women in rural communities are afraid of hospitals and midwives.”

“I am afraid of being delivered in a hospital. Two of my friends died in hospital during childbirth and I don’t want to die too. Besides, those midwives in the hospital are very harsh; they shout at you and scold you as if you don’t know anything. They never use kind words on us despite the pain we experience during labour. I know the traditional birth attendant that will deliver me. She is within my community, she has delivered me of these four children and they are all alive,” said another petty trader, Mrs Mercy Akpapan of Afaha Ofiong in Nist Ibom local government area.

Speaking in vernacular, Mabel Ekanem, another 22-year-old pregnant woman from Eastern Obolo, a rural community in the riverine area of the state, says she has already made an arrangement with a traditional birth attendant in her community to deliver her of her baby when she is due, vowing never to visit any government or private hospital.

Pregnant women in some parts of Nigeria, especially those in rural communities, have to walk or drive long hours to the nearest clinic to be delivered of their babies. This poses a serious risk to their lives, as the lack of immediate medical attention for several hours in the face of painful and exhaustive labour could lead to death. Even when they get to the hospital, there are inadequate medical facilities to take care of these women. As such, these women do not see the need to stress themselves in travelling long hours to these hospitals, coupled with the harsh treatment they normally receive from midwives in the hospitals.

It is typical in Nigeria for hospitals situated in rural areas to request that pregnant women coming for delivery purchase all the sanitary items necessary for the delivery like towels, disinfectants, soaps, sanitary pads and many more. This puts a strain on these women and scares them away from hospitals because they are poor and unable to purchase all the items needed.

All these factors put together make pregnant women in rural communities opt for traditional birth attendants instead, because they are sure the traditional birth attendants will not be harsh on them during delivery of their babies.

But a medical expert, Prof Etete Peters, former chief medical director of University of Uyo Teaching Hospital (UUTH) said that, although TBA maternal health care has been reported to be affordable, accessible and more culturally acceptable as evidenced in its high patronage, studies have shown that many of their practices have adverse effects on the health of mothers.

According to him, in evaluating the cost-benefit importance of TBA-provided maternal health care, it is important to examine its impact on mothers and the children. A report in 1997 from Akwa Ibom, posits that 72 per cent of maternal mortality occurred among women who were either unregistered for hospital antenatal care or were registered but nevertheless attempted deliveries with TBAs

  According to him, “the link between maternal mortality and TBA-provided maternal care, has been investigated. Studies have revealed that TBA-provided maternal health care poses a risk to maternal and child health, as it increases vulnerability of pregnant women and or their newly-born to infections. TBAs lack sufficient knowledge in obstetrics and thus are not able to handle most potentially fatal complications during pregnancy and at delivery.

He said, “A typical TBA is an illiterate and may lack the potential to recognise birth complications. Therefore, TBA-provided maternal health services are unsafe to the health of mothers and the babies.

“However, the training of TBAs can be employed as a strategy to improve maternal and child health care in developing countries where availability and access to proper health care is lacking.”

TBA: Declaration Of Emergency On Health, Changing The Narrative In Adamawa

The Adamawa State Ministry of Health, has said the house-to-house sensitisation by ‘mama-to-mama’ group of women trained to enlightene pregnant women on the need to patronise hospitals, has drastically reduced Traditional  Birth Attendant (TBAs)’s practices in the state.

Dr Fati Atiku Abubakar, commissioner for health in the state, explained that the training, in collaboration with UNICEF, is aimed at strengthening the capacity care for pregnant women in rural communities.

Abubakar said the ministry is de-emphasising the TBA practice in the communities, due to the danger associated with the practices, especially in remote communities.

According to her, the state of emergency declared by the state government in the health sector, has improved the health service delivery in the state.

Dr Abdullahi Dauda Belel, chairman, Primary Health Care Development Agency (PHCDA), said 403 health centers have been rehabilitated in the 226 wards, and operate 24-hour services, providing the minimum package of health needs recommended by the Federal Government.

Belel said, the state came first, in the facilities rate of one PHC per ward revitalisation. “We are far ahead of most of the states and we are still strengthening PHC services delivery in the state.”

He said that in Mayo-inne community, the coverage for institutional delivery for pregnant women to deliver in hospitals, rose from 10 per cent to 100 per cent.

He noted that the effort, attracted the global attention and people are trooping in and around the world to come to the community and see things for themselves.

“That attracted investors to our services as we got support from the World Bank, European Union and also our development partners the WHO and UNICEF, among other donors.