In a bid to reduce
maternal and child death in many developing countries, governments are
partnering with Traditional Birth Attendants, TBAs on how to reduce risks of
infection, mortality rate and generally improve their services. Medinat Kanabe
takes a look at how well this partnership is working, taking Nigeria’s
commercial capital, Lagos, as a case study.
Traditional Birth Attendants are pregnancy and child birth
care providers that have been well-rooted in our society, well before the
advent of modern medical practices. Going by their origin and orientation, they
were not formally educated, as they get their knowledge through apprenticeship
and oral teaching. Usually, they are seen in remote and other medically
underserved areas, where their services are welcome, albeit despite the risks.
It should be noted here that orthodox health practitioners are particularly
against Traditional Birth Attendants, not necessarily because of competition or
neo-colonialism as many want to claim, but according to former Director of
Nursing Services in the Lagos State Ministry Of Health, Mrs. Olubumi A. Raheem,
because of their weaknesses, which “lie in harmful traditional practices, which
may have harmful effects for her clients; unhygienic practices and inexistence
of the referral system.”
Government however recognises their relevance nevertheless,
especially in the remote areas where they are top choices and sometimes, the
only available choice, hence the decision to train them in government hospitals
and imbue them with the power of referral, such that they are able to refer
patients who need special medical attention. They now also get certifications,
licensure and registration.
In a Lagos State Maternal and Child Mortality Reduction
(MCRC) Program released last year, Nigeria is one of the 187 countries that
signed the Millennium Declaration in 2000 with the aim of reducing the 8
identified goals/targets substantially by 2015.
Notably, reducing maternal mortality rates is one of the goals.
However, the country, as at 2015 still has one of the
highest maternal mortality rates in the world, which varies between 800 to
1,000 births based on the geographical location. In 2008, the figure, though
slightly better than the national average of 650/100,000 live births (NDSHS 2008),
was still unacceptably high.
The figures also show that two decades after various Safe
Motherhood initiatives since its launch in Nairobi in 1987, Nigeria has failed
to make any remarkable impact on the maternal health indices.
This may therefore be one of the reasons a state like Lagos
is relaxing its noose on Traditional Birth Attendants, reputed to be one of the
major factors responsible for the poor indices.
Investigations also confirm that more Nigerians prefer the
Traditional Birth Attendants to the orthodox health facilities. In 2013,
154,304 attended antenatal at the Primary health care (PHC) centres, while only
16,699 delivered. The same trend continued in 2014, where between January and
August, 121,451 attended PHCs for antenatal, but only 13,000 delivered there.
Coordinator of Reproductive Health, in the ministry, Taiwo
Johnson also said that the state Ministry of Health reviewed maternal death
records from secondary facilities in certain areas and uncovered the causes of
maternal deaths to find solutions.
“In March, we went to Ajeromi-Ifelodun because we noticed a
high incidence of maternal deaths in cases referred to our facilities from
quacks. Then, we came to Epe, where records showed that a number of maternal
deaths can be traced to TBAs,” she stated.
During the first convocation of the TBAs at the Lagos State
College of Health Technology, wife of former Lagos State governor, Mrs.
Abimbola Fashola said their training is in line with the vision of the state to
reduce infant and child mortality.
Chairman, Lagos State Traditional Medicine Board, (LSTMB),
Dr. Bunmi Omoseyindemi who also spoke at the convocation explained that the
TBAs have been classified as Community Based Health Workers (CBHW) by the
National Primary Health Care Development Agency, NPHCDA. She added that it is
in line with the World Health Assembly, WHA strategy on development of
traditional medicine to improve health-care coverage.
Indeed, for a state like Lagos, with over 21 million people,
it is not surprising that its government has chosen the path of reason, as the
facilities on ground are grossly inadequate to service the huge population.
Besides, the economic situation and phobia for Caesarian section has also
contributed in no small ways to the thronging of people to the TBAs.
However, some states in Nigeria may still be living in
denial, as they continue to outlaw and discourage patronage of TBAs in their
domains.
In a recent report, the News Agency of Nigeria, NAN, quoted
Dr Ngozi Nwosu, the South East Coordinator of the National Primary Health Care
Development Agency, NPHCDA to have said that the TBAs are major threat to
maternal health in the region.
She said the increased patronage of TBAs in communities have
become worrisome; she also claimed that the proportion of women who receive
ante-natal care in health centers is a lot more than those who are eventually
delivered of their babies in those health facilities – a confirmation of the
fact that women opt for the TBAs at the last minute.
However some of the reasons some women opt for TBAs in the
South-East may be a bit vane. Said Dr. Nwosu, “In parts of Anambra and Ebonyi
states, the people believe that women who are delivered of babies in hospitals
are not strong and this is part of the illiteracy problems we face. Pregnant
women who patronise such places are prone to infections, as the TBAs lacked the
requisite knowledge and facilities to take care of deliveries,” she said.
For Mrs. Modupe Kolawole, her reason may however border on
fear of the surgeon’s knife. Mrs. Kolawole registered with a private hospital
where she underwent her antenatal. It was her first child, so she kept all her
appointments until her last weeks when she was told that her baby was
leg-breeched and would therefore be delivered through a Caesarian Section.
After an argument with the doctors and nurses on duty, Mrs.
Kolawole went home to her petty trading. She later told her story to a friend
who introduced her to a TBA. She told the TBA that it was her first child and that
the doctor has said the baby is breeched and will be delivered through a CS. As
is often the case, the TBA assured her that all would be well, and that all she
needed to do was to pay twice the regular fee.
On the day of her delivery, she went to the TBA, who uses a
room in her home to deliver women and the process started. When she was dilated
to the last stage of delivery, one of the baby’s legs came out. The baby’s
other leg however remained stretched inside the mother.
The TBA immediately held the baby’s leg and forcefully
pulled her out. The force caused the baby to tear from between her legs. She
didn’t cry as she was weak and injured. It was then the mother realised she had
made a mistake. Regretting her actions, she immediately took her baby to Ifako
Ijaiye General Hospital, Lagos.
The doctors and nurses on duty did their best to save the
baby, but she gave up the ghost after some days.
Without any gainsaying, one could say that it is for cases
like this and several others that Lagos particularly opted to co-opt the TBAs,
rather than leave them to their practice.
LSTMB chairman, Dr Bunmi Omoseyindemi, who spoke to The
Nation, said the TBAs in Lagos are guided by rules.
First they must be registered by the board and trained by
the board. After that, they are sent to general hospital for 6 weeks
orientation, where they observe procedures and thereafter they can take
deliveries.
He acknowledged that many of the TBAs have been on their own
for many years, and said “they just come to us to refine them.”
Stating what they must have and how the place must look, he
said they must have a delivery bed and the necessary delivery tools like
scissors, and other things that are used in the hospital.
“The environment must be clean and they must have at least
two rooms – one for delivery and one for consulting.”
Asked if it is allowed for them to convert a room in their
homes into delivery room, he said no. “It is not allowed for TBAs to use homes
where they live with their husbands and children as their delivery rooms; but
it is the practice and we are trying to make sure it stops because of basic
hygiene, space and privacy.”
Asked to comment on which is better between TBAs and public
health facilities, he said patients choose between delivering in the hospitals
and going to TBAs; so he could not say categorically that one is better than
the other. “The fact is that two of them complement each other. Many people
prefer the TBAs because of their culture and because they have more empathy
than the hospitals.
“Another thing is that majority of the TBAs reside in the
communities, so they know the person that is pregnant and understand where they
are coming from. It is like a family doctor, they have more confidence in them
and after delivery they can still help out with taking care of the baby.”
On what happens when a TBA that is not registered is caught,
he said the law states that the person is fined and can be jailed for at least
two years.
Asked what happens when a woman is in a critical condition,
he explained that the normal thing for a TBA to do is to refer her to the
nearest general hospital. “That is why we say that they should be trained in
the general hospitals nearest to their local government.
“This is so that they can have interactions with them, to
prevent any delays when they go to them with such cases, and they must not
allow a patient to stay long before they refer.
“Patients that must be advised to go to the government
hospitals include patients who have done CS before, because they have
tendencies to have complications. They must also refer first-time pregnant
women. If they don’t refer and the patient dies or becomes a case of emergency,
they will be sanctioned.”
He advised the TBAs to make sure they are registered with
the Traditional Medicine Board. They should be ready to go for continuous study
at the general hospitals and college of health technology and must take good
care of the patient and encourage them to take their immunizations.”
Several TBAs still not registered
However, when this reporter visited TBAs in Badagry, a good
number of them still operate unregistered, thereby running fowl of the new
government rules.
At Latabas House in Metoho Street, Badagry, a woman uses her
room in a self-contain apartment, where she also lives with her family, as
delivery room.
The place is converted to a delivery room anytime she has a
patient in labour.
She claims that she has a lot of pregnant women, who come to
her, when it is time for them to deliver, and that so far, no case of emergency
has been recorded.
At Cele Bus-stop, Ansar-ud-deen Road, also in Badagry, a TBA
takes delivery in his compound. As the landlord of the property, a ‘face me-I
face you,’ he has a number of tenants. He also has a building to himself where
he lives with his family and takes delivery for pregnant customers. Although
his elder children live outside the building, the compound itself does not look
suitable for a clinic.
Rumour has it that apart from taking deliveries, he also
does abortions in the building.
For Mr. Adenigba Henry of Humanity Family Foundation for
Peace and Development (HUFFPED), in the past there were great improper
operating procedures noticed before their interventions with the TBAs.
“Such practices included unclean environment, inadequate
staff, inadequate equipment, space and lack of skill for referral. But things
have improved, as capacity building of different areas of operations are being
introduced by the government and the Community Service Officers, CSO. Some were
very primitive but have improved over a period of time. Some were ignorant of
what their Terms of Reference (TOR) should be and the limitation of their
activities, as some try to go beyond their permissible activates; but some
adhere strictly to the ethnics of the job.”
He noted that the government has put in place strong
monitoring and evaluation activities to ensure standardization.
Speaking on the TBAs he has worked with, Mr. Adenigba who
claimed he has been working with TBAs for the past 10 years said they have
worked with over four hundred TBAs on several funded projects.
“For instance, on FHI360/LSACA project, we are working with
over 80 TBAs in four local governments – Lagos Island, Agege, Shomolu and
Badagry; and we have worked with over 300 TBAs since inception of the project
three years ago in these four Local governments.”
On what risks a child and mother are exposed to if attended
to in TBAs, he said, there is no risk for a child and mother that attended
registered TBA that follow ethics of the job, but for the TBAs that are not
registered, there are lots of risks, which include the child being infected
with HIV if the mother is HIV positive and is unawares of her HIV status; dirty
environment, dirty water, infection and even death.
Asked to confirm if indeed many women register at TBAs, he
said: “Yes, both educated and uneducated. Some attend because of their
traditional beliefs and nobody can discourage them. Some attend because of the
attitude of healthcare providers and some attends because of funds as the TBA
bills are very moderate and affordable.”
He called on the Lagos State government to reduce the
registration fee to encourage unregistered TBAs to register because many women
go there without knowing whether a TBA is registered or not.
“Lagos State government is supporting the TBAs very well,
especially in capacity building in term of regular training for registered
TBAs, organizations also work with government in area of testing and counseling
for pregnant women during their clinic days. The government also finds time to
hold meetings with registered TBAs. But
there are many TBAs that are yet to be registered. I think government did not
realise on time how many women patronise the TBAs. They were looking down on
them before. But now both are collaborating to save the lives of mother and
child; collaborations between TBAs and orthodox facilities are becoming very
strong now.”
He called on TBAs to embrace change. “They should forget
about what is obtainable during the ages of their grand-parents, which have become
tradition and imbibe new and standard ways of doing things that will be in
conformity with the government and universal tenets.”
Another expert, an Associate Professor, College of Medicine
and Consultant in Primary Health Care, Lagos State Teaching Hospital, LASUTH,
Mrs. Olayinka Abosede who spoke with The Nation seemed to agree with Mr.
Adenigba.
Mrs. Abosede, who started working with TBAs since 1983, said
many more of the TBAs are trained now on conventional method. “We train them on
how to prevent infections, especially with HIV/AIDS challenges. Most of them
are registered now. We train them at the Institute of Child Health and Primary
Care and I also interact with a lot of them.”
She also agreed that a lot of the ones that have been
trained are performing much better than they were doing some years back, adding
that studies have shown that in the North, where there are no midwives, the
community health workers working with the TBAs have reduced the rate of
maternal mortality. “As a matter of fact they refer mothers to the primary
health clinic and they are utilizing these clinics more than before. Although
there is still room for a lot of improvements, with training, they are doing
more than before.”
She explained that a lot of women register with TBAs, saying
if 100 mothers attend antenatal clinic in the government hospital, when it
comes to delivery you find out that 60 per cent of them deliver with the TBAs.
She called on the government to work with TBAs as they
graduate, “For instance, from College of Technology, they are attached to a
Primary Health Care centre within their wards, so that the midwife can
supervise what they are doing.”
She also called on the TBAs to relate more with their
primary health facilities that are well equipped and take their deliveries
there, noting that it can happen in Nigeria just as it has happened in Ghana.
“Primary Health Care centers are also beginning to have
anti-shock garments, which the TBAs normally do not have; so if a woman is
bleeding, she can be taken to the nearest Primary Health Care centre to access
good more adequate health care.”
On TBAs who convert a room in their homes into their
delivery rooms and keep them untidy, she said this is why if they have a link
with the primary health facility, “it will be better for them, because the
nurses and midwife at the primary health facilities will be able to inspect and
see where they are taking those deliveries, and help them to improve the
facilities. The practices must change because they will be supervised.
“Before, they were functioning on their own without the
intervention of the primary health facilities, but now, if they really want to
function in our communities, they must be attached to a primary health
facility. And those that are working there are now responsible for checking on
what standards they are maintaining wherever they are taking those deliveries.
That is in addition to their ward health committee members, because those being
delivered in those untidy facilities are mothers and therefore there must be a
check on what the TBAs are doing.
“I will advice them to make sure they are trained,
registered and must go according to the national standing order that have been
set for them. They should not go beyond the limitation of the standing order
and as soon as they find that there is any problem, they must refer. They must
be close to and link with the primary health facility within their ward.”
First published in The Nation of January 24, 2016
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