‘Women who patronize TBAs have poor health-seeking behaviour’




Women waiting their turn to see the TBA.

Despite availability of robust healthcare services in Lagos, preference for Traditional Birth Attendants (TBAs) remains high. TBA Homes continue to thrive despite the attendant risks those that patronize them often face. In this special report, JULIET UMEH examines the different perspectives of women that patronize the TBAs at the expense of the Primary Health Centres (PHCs) where at the required facilities, personnel and medication are available for the welfare of pregnant women and their newborns.

In several ways, it could be hard to contemplate that in 2017, with all the medical advancements and breakthroughs in science, there are women who still prefer the traditional ways of giving birth. One could ask if it was not in the medieval years that emphasis on tradition and custom was stressed? But several women in Lagos State, a megacity appraised as ‘Centre of Excellence,’ still rely on Traditional Birth Attendants (TBAs). To some, it is incredible.

 A large number of women, particularly rural dwellers, wholly embrace traditional birth practice despite availability of state-of-the- art primary and secondary healthcare facilities within easy reach. Some women that patronize TBAs told Nigeria Health Online (NHO), that the practice is an age-long custom they are not in a hurry to stop. Others attributed their preference of TBAs to the morbid fear of surgery, and their almost unshakeable confidence in TBAs.

 For Mary Ekeh, a resident of Ishaga area of Lagos, whose husband is an indigene of Enugu State, the practice holds sway from Ogwashiuku in Delta State where she hails from. The mother of three said she went to a TBA in Ikorodu, Lagos because medical doctor told her she would need to undergo a Ceasarean Section (CS) to have her second baby.


According to Mary, it was a friend who was in a similar situation previously that reminded her of the custom back home where women are not encouraged to give birth through CS.

“I went to the TBA because the doctor said I have a small pelvis, he told me that my pelvis is 9cm and that the hospital only allows women with at least 10.5 cm pelvis to push. I wanted to try it but was warned not to try. Then a friend that had a similar problem previously, directed me to a TBA, an Ijaw woman that successfully delivered her.

“After I started visiting the TBA, I saw different things happening to me that convinced me that I would deliver on my own. It was not as if she gave me so much medicine, all she did was cook unripe plantain and fish with some other materials. She did everything in my presence. After the meal I returned home. On another day, she cooked something else.

“I visited her place about five times. I was there once in three weeks. I started going when my pregnancy was like five months. On my last visit, two weeks before my delivery, she told me to pound a collection of leaves, squeeze out the juice and drink it. After I drank it I began to feel a sensation of my pelvis opening. At the end of it all, I had a successful delivery.”

Mary confessed that she actually regrets undergoing surgery to have her first baby and that but for the risk of traveling with the advanced pregnancy she would have resorted to her village. She noted that she paid the sum of N12,000 for the services of the TBA, pointing out that it was much less than what she paid to undergo the CS.




Mr. Olusesei, National President, Association of Traditional Midwifery of Nigeria

Mary is among women that live to tell their stories. Unlike her, Bukola Ayeni, a broadcast in Lagos told Nigeria Health Online that she is particularly worried that many of the deaths of women during child birth while being attended to by TBAs are not recorded. Bukola is also concerned that women who patronize these TBAs at the rural level, appear to have strong faith in them than even the hospitals.

“I know of two women at least in my area who lost their babies. One of the women died in the process. She had a General Hospital card but when she wanted to give birth, she opted for the TBA and the unfortunate happened,” she disclosed.

In the view of Dr. Yusuf Oshodi, a lecturer and Consultant Obstetrician & Gynaecologist at the Lagos State University Teaching Hospital, (LASUTH), activities of TBAs are a headache.

His words: “TBAs are known to mismanage patients, collect their money and later push them

out. We review maternal deaths on monthly basis because all government hospitals must keep record of maternal deaths. In the review we did two years ago, looking at three consecutive years, TBAs contribute over 60 percent of maternal deaths.”

Giving instances, Oshodi noted: “Some of them connive with the auxiliary nurses to carry out unwholesome medical practices. Next, they administer injections in unregulated manner and before you know it, the baby is affected. “What I am telling you happened less than two weeks ago in Isolo.


Both the woman and baby died. So, that kind of story is always repeating itself. The relatives don't complain. I won't like to reveal identities but they are loyal to the TBAs as if they swore to an oath. It makes it difficult to follow up with the persons responsible.

“Although some TBAs who are certified and registered claim there are quacks among them, what they ought to do is liaise with relevant government agencies to weed out the quacks because the fact remains that all patients that come from TBAs are regarded alike, whether or not the TBA is registered.”

Oshodi said patients with badly managed complications from TBAs are encountered daily and is worried that people that are quite enlightened and educated patronize TBA homes. He termed the development “poor health seeking behaviour”. He said some of the affected women die within 10-20 minutes on arrival at the hospital. “It’s as if they come to collect their death certificates,” he added.

Medical personnel often wonder why some women prefer TBAs for antenatal care and delivery? What benefits do they enjoy there and why won’t they go to the health centers or hospitals? The reasons are varied according to findings by NHO.

Adeyinka Olabisi, a 68-year-old Akwa Ibom-based woman who spoke in defence of TBAs noted: “It is because the services of traditional people are cheaper. Hospitals charge a lot of money and they will prescribe too many things to buy.”




TBA, Dotsey, Director of SAKDOS TRADOMEDICAL ENT.

Speaking at a herbal home in Ikorodu, Lagos, she disclosed that her first baby was born at tha Home and that she has continued to patronize the place with approval of her husband. Another woman, Ikilima Ismail remarked: “I was going to hospital but I discover that they are not taking good care of me, so I stopped going there. I started coming here when my pregnancy was 18 months. We just came from Abuja and we discover that many people are coming here and that their services are very good and as I come here, things are going well with me.”

A visit to a TBA centre in Badagry was a revelation. Women seeking antenatal care services trooped in one after the other. One of them, Bukky Durosimi, spoke to NHO. “I am here for my antenatal. I got married last year. It was my husband that asked me to come here. I did not register in any other hospital because this is the place my husband and my mother-inlaw want me to come. This is where my mother had her last born.”

As for 28-year-old Bose Abiodun, the TBA Home is more of a safe haven. “It’s been long I started coming here. This is where I had my first baby and I like the treatment here. I was ill when I was about having the baby, and in the hospital they told me that I would undergo surgery, but when I came here, I delivered the baby normally,” Abiodun said.

39-year-old Loretta Nzute, told NHO that she had been married 10 years, and that she came for fertility treatment, hoping to join the antenatal section later because her friend, Ify, who introduced her to the place put to bed and three other women she introduced also had positive stories to tell.

Sadly, despite the campaign against maternal death, Nigeria still has one of the worst maternal mortality indices in the world and is second only to India. In the days of old, the use of TBAs and home deliveries were preferable for the local community due to dearth of healthcare facilities, long distance from facilities and financial limitation. These were the three major constraints that prevented community members from accessing and using trained midwives and institutional deliveries.

 According to the World Health Organisation data on maternal mortality, in 2013, there were 560 deaths per 100,000 births in Nigeria. That figure includes women who die during or within 42 days of giving birth. Figures for Nigeria published by the World Bank in 2011 show that 49 per cent of births were attended by trained healthcare workers.

 Similarly, the National Demographic and Health Survey (NDHS) in 2013, the maternal mortality ratio is 576 deaths out of every 100,000 live births. The figure is as high as 1,100 deaths per 100,000 live births in northern Nigeria and in rural communities where women have little or no education, and access to essential health services is low, according to the NDHS 2013.

Mrs Veronica Olawunmi Tewe, onwer of Winners Healing Maternity



 With about seven million annual births, the number of women who die is about 58,000 each year. Maternal mortality rates in West Africa are among the highest in the world. One in every 30 Nigerian mothers die in childbirth compared with one in every 30,000 in Sweden. In Sierra Leone in the early 1990s, more than 2300 women were dying for every 100,000 babies that were born alive.

In Nigeria, 1100 women were suffering the same fate. The situation in both countries has improved dramatically in the past 25 years. Sierra Leone has more than halved the number of maternal deaths to 1100 for every 100,000 births, just as in Nigeria where the rate is 576 women for every 100,000 births. But this is a far cry from what obtains in developed countries. In Sweden, there are four deaths for every 100,000 births. In the US, there are 28 for every 100,000 births.

During a media interaction on the 2017 Maternal, Newborn and Child Health init6iative, Special Adviser to the Lagos State Governor on Primary Health Care, Dr. Olufemi Onanuga, stated recently that the maternal health bursen for the state is 555 per 100, 000 live births.

Olawole Abiola, health education officer at Amuwo Odofin LGA, also told NHO that Ori Ade LGA records the highest maternal mortality figures in Lagos. Most of the deaths are traceable to TBAs, he noted.

“Like we heard, not all of them are registered, possibly it is those who are not registered in riverine areas, because Amuwo Odofin and Ori Ade have a vast riverine landscape and I think because of that the unregistered TBAs thrive more there,” he said.

 Prince Mare Tajudeen Olusesi, National President, Association of Traditional Midwifery of Nigeria told NHO that he was trained by his late father, who was renowned in the practice. He said TBAs are doing a great work in the country, noting that his Centre takes up to 50 deliveries in a year. “We do everything possible to make sure we have safe delivery,” he added.

 He expressed displeasure over the uncooperative disposition of government and the medical  personnel.  “We don’t get support when there are complications that are referred to the General  Hospital.  They don’t attend to such referrals immediately; you start hearing different stories and queries like: Where are you coming from? Who ask you to go there? All these will not help our health system.

 “Instead of saying what is not about us, they need to embrace us and continue to train and retrain our members because the WHO advises every nation to establish a Board of Traditional Medicine and grow it with their peculiarities. 

 “What the Lagos State government needs to do is to include us in their own health system database so that when they are taking records of maternal mortality they will not be passing the blame on the TBAs.  “The irony of it is that the births of most of those in government or working in general hospitals today were mid-wifed by TBAs.

 “If they said people should not come to us, how many can PHCs and General Hospitals attend to? Go to the health centres now,you will see many pregnant women are waiting to be attended to while the nurses just shout at them. That is why some of them will not patronize government health facilities. So, when they come to us, we pamper them, talk to them and we rub minds together.”



However, Olusesi also pointed out that most of the bad outcomes of childbirths are from auxiliary nurses not TBAs. “The Lagos state government warned most of the private hospitals not to train auxiliary nurses but they still engage in such. Until all the quack nurses tagged auxiliary nurses are fished out, there is likely not going to be headway,” he submitted.



Mrs. Adeyinka Olabisi, TBA user at Ikorodu

Samuel Komi Dotsey, the TBA chairman in Badagry zone, who has been practicing for over 48 years said, “to ensure due diligence in our work, we usually inspect the premises of any intending practitioner before the person will think of going to the traditional medicine board for registration.

“Before I attest for any intending member, I always visit their premises so that certificate will not be issued wrongly by the Board. Without visitation, I cannot sign because the Board has to see my signature before giving approval. Some people are using two rooms, others, one room; provided it is very neat. The person must be ready for inspection anytime.”

Advancing reasons why TBAs are patronized by so many women, Dotsey said: “When you counsel, psychologically you are healing the person. When they come, we don’t demand money first, we start by counseling. That is why I don’t have a signboard. Patients do that for me.”

In corroboration of Dotsey, 45 year-old Veronica Olawunmi Tewe, leader of a faith-based organisation in Ikorodu, said women flood TBA Homes because they have cultural appeal, are affordabile, and have flexible payment methods (pay as you go) among other attractions. She said patients pay as little as N200 per antenatal visit, unlike in the private hospitals where the demand could be as much as N20, 000.

“In terms of availability or proximity, we are closer to the people. So, it is a lot more flexible than private hospital that will tell you to go and bring this or that, you can easily go and knock on the door of any TBA, there is one-on-one approach,” she asserted.

“In the orthodox system, the nurses are too hostile to patients, they don’t have their time, and it is too formal. An average TBA would go and visit patient at home but nurses don’t do that. We even attend their naming ceremony, she remarked.”

All the TBAs that spoke with NHO claimed they had never experienced incidence of death in their clinic. In a response, Tewe said: “When we have what we can’t handle, based on our orientation and training from the Lagos State Traditional Medicine Board, we send them to General Hospital.”

She said TBAs know their limit, noting that the indicatiors include delayed labour beyond 12 hours and if the baby is bridged, or there is High Blood Pressure, or the legs are swollen, or if the woman has previous history of CS.

The TBAs in Lagos are regulated by the state government. Speaking while presenting certificates to some TBA graduates in 2016, Governor Akinwunmi Ambode noted: “One of our policies in the health sector is to empower our traditional medicine practitioners and make them an integral part of our healthcare delivery system.

Lagos State has a functional Traditional Medicine Board that has strategic programmes targeted towards regulating, monitoring, promoting and integrating traditional medicine into modern healthcare system based on the 1978 Alma Alta Declaration of WHO. “The objective is to streamline traditional medicine and change public perception of traditional medicine as a religious and spirit-magical practice by virtue of their proximity and accessibility to the rural dwellers.” Ambode noted that the State decided to train TBAs to protect the health of mother and baby; care of women during pregnancy and child birth; and to refer women and newborns to higher care when conditions arise beyond their scope of practice and capabilities.

 But the latent questions in the minds of many are whether the TBAs have requisite training to address the cases they come in contact with as most of them claim to have learn the craft from their parents and have also gone for further trainings?  Are they really adding value to the health system?

Onanuga, however, told NHO that the TBAs are actually adding value to healthcare delivery system because they are very well-trained and they actually understand why they are there and they know their limits.

Dr. Oshodi, Consultant at LASUTH

“For instance last year, 400 of those we trained were awarded certificate by Governor Ambode. This year, we are also training another 400. What we are preaching to them is that they should internalise the training we are giving them and that they should also know their limit. They should know all the danger signs; they should know when to refer to PHCs and the secondary health facilities. So, they add value to the health system.”

 He, however, added : “We also need to do a lot of enlightenment on health education very well, so that they know what to do. So, like I have said, I am sure we can always have checkers and then we move forward to reduce maternal mortality.”

Conversely, Oshodi explained that TBAs have no business takingdeliveries and his reason is simple: “When you talk about skilled birth attendant, what does that mean? That means the person must have the requisite training, be certified knowledgeable and skilful using the competency-based test.

“So TBAs are not recognized as skill birth attendants in the balance of obstetrics practice, they are not, because if they are, tell me a patient that is in labour, and has had two deliveries before and suddenly the labour was not going on, may be the uterus was not contracting again: What will they do? Is it incantation, or would they give the drugs inside drip to enhance the womb to contract so that the labour can continue and the woman deliver? How will they do that? They don’t know.”

On how to make health care services attractive, Oshodi identified some key points.  “Yes, if we can make health care services delivery free, it will be an incentive. Two, if health workers should be more accommodating; because patients are complaining that healthcare workers are rude and not compassionate. If health personnel change attitude and become more receptive, patients will stop seeking alternative.

“Importantly, the wherewithal that the doctors and health workers need to work should be provided along with adequate healthcare personnel like doctors and nurses. More so, there is need for legislation that will include sanctions to deal with quackery. When people are made to face the wrath of the law then it will serve as deterrent to others and the others will not want to do it,” he suggested.

 Further, he suggests massive health education and campaign involving grassroots levels, all stakeholders – market women, opinion leaders, traditional rulers and religious leaders; professional associations as well such as tricycle operators, i.e. Okada riders, hair dressers, and pepper sellers. Interestingly, Oshodi wants Ondo State approach adopted in Lagos where TBAs were asked to stop taking deliveries and were tailored towards acting as “community scavengers”. This involves taking pregnant women that approach them to government hospitals, and for that they get compensated. He is of strong conviction that if it works in Ondo State, it can work elsewhere.