Traditional Birth Attendants and Nigeria’s Maternal and Infant Health: Lessons from the Field

By: Oluwakemi Gbadamosi

Over the past one month, various states in Nigeria have marked the Maternal, New born and Child Health week; popularly referred to as MNCH week. The MNCH week is an essential part of the Integrated Maternal Newborn and Child health (IMNCH) strategy, which was adopted at the National Council of Health in 2007 to strengthen access to quality health services, in order to improve maternal health and reduce child mortality in line with the millennium development goals (MDGs) 4 and 5. The MNCH week is implemented by providing a combination of proven interventions; which includes Immunization, Antenatal Care, Nutrition, HIV Counselling and Testing, long lasting insecticide-treated nets distribution, health promotion (hand washing, early initiation and exclusive breast feeding, hygiene and sanitation etc.

A strategic intervention like the MNCH week has become very vital over the years in addressing Nigeria’s high maternal and child mortality rates, and high mother-to-child transmission of HIV.  Although Nigeria has made great progress in maternal and child health, current statistics are still very unsettling. According to UNICEF, Nigeria loses about 2,300 children under five and 145 women of childbearing age daily; making Nigeria the 2^nd largest contributor to the maternal and under-five mortality rate globally.  Nigeria also accounts for about 30% of the burden in mother-to-child-transmission (MTCT) of HIV in the world, which is also very high compared to most African countries. It is very important to note that beyond MTCT, HIV/AIDS is also one of the largest contributors to infant mortality in the country.  Recently, WHO declared Cuba as the first country in the world to eliminate-mother-to-child transmission of HIV, a very enviable feat. While countries like Botswana and South Africa have reduced transmission rates to 3% and 7% respectively, according to the 2013 UNAIDS global progress report.

Various factors have been identified as responsible for Nigeria’s poor maternal and child health statistics; such as low access and utilization of quality healthcare services, low literacy level, poor healthcare practices, inadequate skilled human resource, funding issues, low awareness and distance from healthcare centers-especially in hard to reach communities, among others.  However, a recent visit to the field, specifically primary healthcare centers in very remote areas highlighted another contributory factor, which may not be receiving the desired attention in our quest to drastically reduce maternal and infant mortality rates – Traditional Birth Attendants (TBAs).

In virtually every community, facilities recorded high Antenatal Care (ANC) attendance, but recorded abysmal delivery figures. In one of the facilities, ANC attendance for the month of April was over 20 women but delivery was just 3.  The facility head explained that 17 of their women delivered with the Traditional Birth Attendants and the women only visited the facility for immunization or when complications arise. The great disparity in delivery figures is also supported by a report from UNICEF which reveals that only 35% of deliveries are attended by skilled birth attendants. Further discussions revealed that issues of complications and transmission of HIV to children are recurrent. While some facilities explained that integration between them and TBA’s have been quite successful and helpful (TBA’s refer pregnant women to facilities after delivery for the necessary examinations and follow-up); others decried the underutilization of the healthcare centers and risks women are exposed to when they visit TBAs.

TBAs have been defined by the WHO “as a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or through an apprenticeship to other TBA’s”.  They are often not formally trained, but are usually respected elderly women in their communities.   TBA’s play a very pivotal role in maternal and child health; because they somewhat bridge the gaps in supporting women with deliveries especially in communities where the closest health center is many miles away.  The potential of TBA’s cannot be underestimated, which has necessitated research studies and training programs to improve their skills.  Unfortunately, my visits to these communities reveal that more needs to be done.

Deliveries with TBA’s have been tainted with use of unsterilized tools, unskilled personnel, poor environmental conditions, and little or no knowledge of PMTCT, hence contributing to high maternal and infant mortality and MTCT of HIV rates. Interactions with facility workers also revealed that most of these women are influenced by religious leaders in their communities and cultural beliefs; leading to high patronage of TBA’s.  The issues raised in these facilities reveal that TBAs and the role they play in maternal and child health needs to be revisited and necessary strategies put in place across the entire country, to ensure that women and children are not at risk.   The following may be considered:

• Integration of health facilities and TBAs should be made compulsory – TBAs should refer pregnant women to facilities for delivery and counselling. Facility personnel can also be invited to provide support for TBAs, where distance to the facility is a huge issue.

• Every local government secretariat should have a TBA desk and make it mandatory for TBAs to be registered and accredited for easy monitoring.

• TBAs should be constantly trained and carried along in various health programs and thematic areas, at state and local government levels.

• Communities should be provided with mobile vans and head TBAs provided with mobile phones, to enable mobility and communication for effective transfer of women in labor to health centers.

• Community awareness, door-to-door education should be revitalized to encourage women to visit health centers and the benefits.

• Above all, quality service delivery in health centers and healthcare workers needs to be strengthened and sustained.

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