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.
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| 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.”
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| 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.
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| 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.
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| 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.
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| 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.
Infant mortality rate has dropped to 70 per 1000 live births from 97 in 2011 in Nigeria according to the 5th Multiple Indicators Cluster Survey (MICS5), conducted in 2016 and 2017. The National Bureau of Statistics (NBS), UNICEF and other key partners officially released the survey results that showed that deaths among children under age five have also dropped to 120 per 1000 live births from 158 in 2011. 
