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The Practice Of Traditional Birth Attendants And Women’s Health In Nigeria1

Abigail Olu Imogie2

Senior Lecturer, Institute Of Education, University Of Benin, Benin City. Nigeria.
Tel: 234-052-600654 Fax: 234-052-602370 E-mail: dvcacad@uniben.edu

Key words

Practice of Traditional Birth, Women’s Health, Urban and rural Communities, Oredo Local Government Area (LGA) in Nigeria.

Abstract

The practice of traditional birth has a lot of impact on the health of the mother and child. Despite the introduction of modern health facilities, available statistics shows that the majority of children are born by traditional birth attendants (TBAs) especially in rural areas. The care given during the prenatal, postnatal period and the environment in which the women find themselves to a very great extent can determine the state of the health of women. This study was to determine the type of services rendered, the facilities used and the influence of their services on the health status of women.

A total of 250 TBAs and women of child bearing age were drawn from Oredo Local Government Area for the study. A validated questionnaire and structured interview were the tools employed for data collection. The study findings indicate that some women resort to TBAs because they have no other alternative while others believe in the effectiveness of the TBAs. However poor hygienic measures and late referral of complicated cases have been indicated as major causes of maternal health problems and death.

Introduction

Nigeria is a nation with a population of over 100 million and the majority of the people live in rural areas. In any society, there are usually measures to ensure the good health of individuals. In some places the health care system is purely orthodox

while in others it involves the combination of orthodox and traditional ways. In Nigeria, the later is prevalent and as a matter of fact, this measure is common in Africa. According to Martey et.al (1998) the health system in Ashanti Region as it operates in the rest of Ghana is also made up of three sub-systems, namely, public, private and traditional. The public sub-system is made up of essentially what is referred to as orthodox medical services provided in government health facilities while the private sub-system refers to orthodox medical services provided in private (including missionary) hospitals, clinics, maternity homes, chemists shops who are all profit oriented. The traditional sub-system refers to medical services provided by herbalists, traditional healers, traditional birth attendants, bone-setters, spiritual healers and many others. For example, in Ashanti region of Ghana, the public sector provides 60% of health care followed by the traditional sector which provides 30% and the rest by the private sector (Martey et al, 1998). By implication, some serious amount of medical service is provided by the traditional sector to which Traditional Birth Attendants (TBAs) belong.

The most enigmatic among God’s creation can be classified as the woman. It is a known fact that right from the Garden of Eden, the woman was assigned with the travail of childbirth. Thus, from the beginning of the world, it became necessary that the woman be assisted before pregnancy, during pregnancy and after pregnancy. This is where the knowledge and practice of Traditional Birth Attendants (TBAs) become relevant even today, especially in areas where public health facilities are either non existent or insufficient. TBAs are non-professionals who assist women during pregnancy and deliveries and in some cases advocate some form of family planning. Majority of TBAs are females in most areas. Some of the TBAs do not feel free to perform their duties because of the conflicts they encounter with orthodox medical personnel and the fear of non-registration by the establishment. The doctors believe that the TBAs are not trained, skilled nor knowledgeable about the delivery of babies whereas the TBAs on the other hand hold on to the “authoritative knowledge” as they are the ones that deliver majority of children of people in areas where there are public and private modern hospitals and health facilities, and even of people who are too poor to pay the fees in hospitals. The practice of TBAs in the rural context cannot be underrated. It is important to note that in a study carried out in Ghana, (Geurts, 1997) reported that the Ministry of Health has enlisted the assistance of traditional midwives to promote birth as a medical event that should be ‘managed’ by a specialist. What has therefore happened is that TBAs are allowed to handle “routine” births while the complicated pregnancies and deliveries are to be referred to the professionals at the district hospital or a local clinic. Even with this arrangement, most births still occur at home and are attended to by relatives usually made up of predominantly female lineage elders.

The knowledge and practice of traditional birth attendants need to be addressed by policy makers and planners. There is the need to make positive effort through research based on a firm understanding of what TBAs can and cannot do. (WHO/UNFPA/UNICEF). It is also important to know the strengths and limitations in TBAs practice especially as they affect maternal mortality rate (MMR) which in Nigeria is given as 10.5/1000 live births, whereas, it is 3.0/1000 live birth in Sudan while it is 0.1/1000 live birth in England/Wales (Alakija, 2000).

This study examines the knowledge and practice of TBAs in Nigeria, specifically in Oredo. Oredo Local Government Area is one of the 18 (eighteen) administrative/political units in Edo State, which is situated in South-South geo-political zone in Nigeria. Edo State which has a population of about 3.2 million is one out of the 36 States in Nigeria: Oredo Local Government Area is mainly an urban setting with a population of about 900,000. Certain research questions have been raised that would assist in providing solutions to the problem posed. The research questions are:

  • What training is available to TBAS in Nigeria?
  • What are the characteristics of traditional birth attendants?
  • What facilities are used by TBAs in Oredo?
  • Do people believe that the unhygienic ways of taking deliveries by TBAs still persist?
  • Do the TBAs have patronage?
  • What are the problems militating against the practice of TBAs in Oredo Local Government Area?
  • What measures are taken to safeguard the health of the mother and the child in cases with complications?
  • Is it necessary to have government policy banning TBAs from taking deliveries of babies?
  • Should TBAs be trained for effectiveness of services and knowledge?
  • What are the measures of evaluation of the effectiveness of TBAs in Oredo Local Government Area.

Methodology

Study Design

A survey design was used for the study. The population consisted of TBAs and women of childbearing age in Oredo Local Government Area (LGA). A sample of 50 TBAs and 200 women of childbearing age were randomly sampled and used for the study. Out of the 200 childbearing age, 44 women have used the services of TBAs while the remaining 156 are non-users. A total of 250 respondents were used.

A validated questionnaire for the study structured interview and focus group discussion (FGD) were used in gathering information for the study. In addition, concealed tape recorder was used for accurate information retrieval at the researcher’s convenience. The interview helped to supplement the responses made in answering questions raised in the questionnaire.

There were three parts to the questionnaire. Section “A” had to do with the demographic data of respondents. Section “B” was to identify those who have actually used the services of TBAs and those who have not while section “C” was on the knowledge and practice of TBAs. On the whole, there were 25 questions to this effect.

Techniques for Data Analysis

The responses to the twenty-five (25) questions were collated and frequency counts, percentages and T-test were used to analyse them as shown in Tables 1 and 2 as follows:

Results

Table 1: Responses by Users and Non-users of TBAs Services & Practices in Oredo Local Government Area (LGA)

Questions

Users
N=94

Non-Users
N=156

Yes

%

No

%

Yes

%

No

%

1. Heard of TBAs Services?
2. Used TBAs Services?
3. TBAs Services effective?
4. TBAs Services cause problems?
5. TBAs effective?
6. Know user(s) of TBA Services?
7. Was user(s) satisfied?
8. TBAs Services expensive?
9. TBAs patronised/cheap?
10. TBAs patronised because no alternative?
11. TBAs should continue?
12. TBAs have facilities?
13. TBAs knowledgeable?
14. TBAs cope with birth cases?
15. TBAs exist in villages/rural
16. TBAs exist in urban areas
17. TBAs render pre-/post-natal services?
18. I will continue to use TBAs
19. TBAs cause birth complications.
20. Train and assist TBAs
21. TBAs cause child-birth death
22. TBAs helpful to pregnant women.
23. TBAs services unhygienic.
24. TBAs services sub-standard.
25. TBAs should be banned?

94
94
94
16
86
94
94
08
70
55
70
16
86
08
94
78
86
24
70
78
39
86
70
70
24

37.6
38.0
37.6
6.4
34.4
38.1
37.6
3.2
28.0
22.0
28.0
6.4
34.4
3.2
37.6
31.2
34.4
9.6
28.0
31.2
15.6
34.4
28.0
28.0
10.0

00
00
00
78
08
00
00
86
24
39
24
78
08
86
00
16
08
70
24
16
55
08
24
24
70

0.0
0.0
0.0
31.2
3.2
0.0
0.0
34.4
9.6
15.6
10.0
31.2
3.2
34.4
0.0
6.4
3.2
28.0
10.0
6.4
22.0
3.2
9.6
10.0
28.0

130
0
117
117
104
130
104
0
104
104
130
13
117
52
143
143
117
13
25
156
91
143
117
130
25

52.0
0.0
46.8
46.8
41.6
52.0
41.6
0.0
41.6
41.6
52.0
5.2
46.8
20.8
57.2
57.2
46.8
5.2
10.0
62.4
36.4
57.2
46.8
52.0
10.0

26
156
39
39
52
25
52
156
52
52
25
143
39
104
13
13
39
143
130
00
65
13
39
25
130

10.4
62.0
15.6
15.6
20.8
10.0
20.8
62.4
20.8
20.8
10.0
57.2
15.6
41.6
5.2
5.2
15.6
57.2
52.0
0.0
26.0
5.2
15.6
10.0
52.0

A t-test value was calculated to determine whether there was any significant difference in the views of users and non-users of TBAs as shown in Table 2.

Table 2: Test for Users and Non-users of TBAs Services and Practices

N= 250 (Users =94; Non-Users = 156)

X (Users)

y (Non-Users)

Df

Tabular
t

Calculated
t

X

SD

y

SD

24.97

46.7

25.03

34.49

248

1.960

-0.071

P>0.05

Table 2 shows that the tabular value of 1.960 is greater than the calculated value of –0.071 at 0.05 level of significance. This implies that the users did not differ significantly with the non-users in their perception of the TBAs services and practices in Oredo Local Government Area of Nigeria.

Discussion

The knowledge and practice of Traditional Birth Attendants in the improvement of maternal and child health cannot be under-rated. Traditional Birth Attendants have remained at least as one of he alternative health resources in Oredo Local Government Area in Nigeria. It is interesting to note that 38% and 57% of users and non-users of Traditional Birth Attendants (TBAs) respectively have testified to this. Also, TBAs services are not only in rural areas, but also acknowledged in the urban areas as agreed by 31% of users and 57% of non-users). However, it has been observed by Owigar (2000) that the introduction of biomedicine and Western education has in one way or the other sidelined the knowledge and skills of Traditional Birth Attendants. This is why Imogie, Aluko and Agwuibike (2000) noted that the war being waged between trado-medical and orthodox medical professionals remains unabated. They also suffer disrespect from local health officials. Owigar (2000) further noted that what would help to reduce the maternal and mortality rate is the purposeful utilization of the wealth of experience of Traditional Birth Attendants in the effort to complement the good health status of women during pre-natal, ante-natal, post-natal services.

In this study, the result has shown that 34.4% of users and 57.2% of non-users agreed that TBAs are of assistance to pregnant women. The problems, however, are in relation to the availability or provision of facilities. This awareness has been expressed by 31.2% of the users of TBAs and 57.2% of the non-users. It is obvious that in the rural areas, the services of TBAs are heavily dependent upon as about 37.6% and 57.2% of the users and non-users respectively agreed that they know that TBAs render services in the villages while 37.2% and 57/2% agreed that the services they render are not only in the villages (rural) but also in urban areas. These findings are supported by the result of the T-test that indicates that the respondents, (the users and non-users of TBAs) do not vary significantly in their views concerning the services, practice and knowledge of TBAs in Oredo Local Government Area in Benin City.

There still exist people who would not for cultural and ethnographic reasons go to the maternity wards to have their babies. Although they are in a minority, it is an indication that the facilities used by TBAs are not attractive and, therefore, need to be improved since there are women who would always depend on them, especially as 9.6% of the respondents agreed that they would continue to use the services of TBAs while 28% agreed that they would continue to serve as TBAs.

The non-users are convinced of their opinion because 52% of the respondents actually know of people who have used the services of TBAs with some measures of satisfaction. Reasons have been advanced by the focus group discussion (FGD) why some women default in attending maternity clinics or hospitals. To some of them, cultural affinity remains as one of the strongholds on why people will continue to patronize TBAs. Other reasons include the high and sometimes “illegal” hospital fees, the distance of the hospitals or maternity homes to the people, lack of good roads and lack of qualified personnel in such public facilities. These views are in line with the study carried out by Stock (1983) who in a similar group (FGD), revealed that rudeness of staff, persistent shortage of drugs and waste of time were found to be responsible for he non-utilization of health services. In another study, Martey et al (1989) found that some of the inhibiting factors to usage of modern health services include:

  • Prohibitive hospital fees;
  • Illegal fees and bribes;
  • Irregular transport and un-cooperative drivers;
  • Poor and uncomfortable roads;
  • Lack of drugs and essential supplies and
  • Negative staff attitudes.

It appears from the findings in this study, that the practice of TBAs remains attractive and convenient to both users and non-users because it is relatively free of all of the foregoing inhibiting factors. From all indications the patronage of TBAs would continue especially in the rural areas and in this study even the non-users would not support the banning of their practices as indicated by 52%. However, something has to be done in areas where they are lacking to assist them in reducing maternal and mortality rate. Both the users and non-users of TBAs realise the fact that they do not have proper and adequate facilities. Most of them are not (literate) educated, as shown in this study where the highest educational background of users and non-users was primary six (elementary level). The need to provide good hygienic conditions (measures), assistance in form of provision of facilities and training have been noted by 31.2% and 62.4% of the users and non –users respectively. TBAs are very much in short supply of modern facilities and most of the time they are forced to use whatever is available which, as can be seen in this study, they are regarded as being substandard by 28% of those who have used their services and 52% of those who have not but feel the same way. The good thing, however, is that their wealth of experience has been acknowledged (Owigar, 2000). What is, therefore, left is to encourage TBAs through training, moral and material support.

Conclusion And Suggestions

The knowledge and practice of Traditional Birth Attendants (TBAs) in the improvement of maternal and child health cannot be ignored in Nigeria. TBAs remain a major alternative health resource in Oredo Local Government area, Edo State in particular and Nigeria in general, where TBAs services are felt in both rural and urban areas. The factors militating against the practice of TBAs in providing effective maternal health care in Nigeria have been highlighted in this study in broad categories of education, facilities, funds, and social recognition. The practice of Traditional Birth Attendants (TBAs) needs to be encouraged through training, provision of enabling facilities and funds. It is important to recognize their services and give them the social recognition they deserve in the communities. A lesson can be learnt from Ghana when between 1980 and early 1990s the Ministry of health organized, trained and provided materials to the locally recognised village midwives (Geurts, 1997). There is need to foster interaction between TBAs and orthodox maternal health workers/government agencies especially Ministry of Health through broader education programmes. Finally, from the findings of this study, the following suggestions for improvement in the practice/services of TBAs in Nigeria have been made:.

  • TBAs should be recognised and trained by the government.
  • They should be financially and materially supported.
  • The various governments in Nigeria should let the TBAs know their limitations through continuous interaction/education.
  • Operators of TBAs centres should be encouraged and recognised to keep records of birth and mortality.
  • The various governments in Nigeria should encourage the co-existence of traditional and orthodox child bearing practices.

References

1. Alakija, Wole (2000) “Maternal and Child Health Care and Family Planning” in

2. Essentials of Community Health Primary HealthCare and Health Management Ambik Press/Medisuccess Publication, Benin City, Nigeria.

3. Geurts, K. L. (1997) Well-Being and Rural Ghana: Local Realities and Global

4. Mandates. A paper presented at the Fifth Annual Penn African Studies Workshop, October 17, 1997.

5. Imogie, Aluko, Agwubike. Assessing the Role of Traditional Birth Attendant

6. (TBAs) in Modern Medicare in Edo State Nigeria. A paper presented at Gender and Science and Technology (GASAT) Association African Regional Conference, 29th October – 2nd November 2000, Abuja. Nigeria.

7. Martey, J. O., Djan, J. O., Twum, S., Browne, E. N. I. And Opoku, S. A. (1998)

8. Referrals for Obstetrical Complications from Ejisu District, Ghana. West African Journal of Medicine. Vol. 17, No.2 April-June 1998, pp.58-63

9. Owigar, Rosemary Akiniyi (2000) Traditional Birth Attendants (TBAs): An

10. Alternative Health. Resource in the Book of Abstract, Gender and Science and Technology (GASAT) 29th October – 3rd November, 2000 p. 50.

11. Stock, R. (1983) Distance and the Utilization of Health facilities in rural Nigeria.

12. Social Science and Medicine. 17(19): 563-570

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