Traditional birth clinics: Old practice in need of modernisation

Despite controversies trailing the practice, traditional birth attendants (TBAs) are still enjoying patronage. Low socio-economic status, illiteracy, poor awareness of modern maternal health (MCH) facilities, strong family influence and easy access to TBA services are some of the strong factors promoting traditional midwifery,especially in rural areas.

Some doctors, who are against the practice, have said studies show that more than 80 per cent of TBAs are older women, who also have other occupations on the side. About 54 per cent have no designated room for deliveries, while 80.8 per cent would not consider a pregnant woman to be at high risk. A little over 11 per cent perform intravaginal examinations during labour and only a few recognise complications. Also, 46.2 per cent never refer patients, while nearly all clients interviewed started using TBAs at the age of 25 and 50 per cent had used TBAs for all of their deliveries.

Also, 77 per cent of the TBAs handle not less than five clients per month, while 61 per cent of the clients said they would patronise TBAs for future delivery, and 49 per cent would recommend TBA care to other women.

However, others have argued that if adequately trained, equipped, supported and supervised, TBAs could significantly contribute towards safe maternity in the country.A visit to the clinic of a traditional birth attendant in Lagos revealed that people in this field are trying to be as professional as possible. Some of the tools on display included masks, gloves, amniotic hooks, speculums, forceps, vacuum, scissors, hemostats, sponge holders and herbal mixtures (agbo), among others. All of which were situated at the entrance of the room.

What are the challenges being faced in the sector and what can be done to improve the practice?
Raheed Razaq, who has a clinic in Mushin area of Lagos, while explaining the basic duties of a TBA, said just like the orthodox healthcare, TBAs are also facing some challenges.He said: “Many of our clients are poor, and poverty frustrates efforts to deliver good services. Government can help in this regard by empowering citizens financially through job creation and ensuring there is cash flow in the society. I assure that TBAs service will improve significantly, if this is done.

“Also, some of our clients are unable to adequately prepare for childbirth or cater for their babies later. They are often unable to set aside money for emergencies. All these factors often undermine the good works of TBAs. Such clients do not often eat well and are not healthy. Therefore, they frequently experience complications for which TBAs get blamed.

“In the course of our job, we support and relate with pregnant women in the community. We also provide women with advice and information on contraceptives, as well as antenatal and postnatal care. We help to obtain birth certificates, mediate between women and their husbands, and organise schemes that women can rely on to deal with health emergencies.”He explained that they treat minor childhood ailments, as well as advise families on a range of issues, including nutrition during pregnancy and preparation for childbirth.

“We offer counselling services to single women, organise prayer sessions for pregnant women, take their babies for vaccination, arrange money and other materials for indigent pregnant women, and sometimes visit them at home to help with their household chores during pregnancy and afterward,” he said.Another TBA, Tomiwa Adeola, said they are only filling the vacuum created by inadequate or lack of care at hospitals, occasioned by non-availability of drugs and personnel.

He said: “The fact that some women still patronise us is an acknowledgment of the quality services TBAs are providing. Women come to us because they trust our capacity. They only go to hospital, when they know they will develop complications that we can’t handle their case.

“The hospitals are good and we are equally good. They prefer us because some of them allege that they are insulted or ignored at orthodox clinics and hospitals. But because I value my work, I treat my clients with respect and provide quality services. Sometimes, medical personnel don’t have time to take care of clients or have tight schedule, which has led to some women delivering their babies elsewhere.

“So, rather than waste time going to the hospitals, some of these women prefer coming to us. There is also the cultural aspect to the issue.”Alhaji Gani Oke, a TBA at Oshodi, Lagos, said he has been in the business for more than 20 years. He explained that nurses working for him have undergone required professional training.

He said: “Our services are very cheap and affordable, which is why people come here. Our herbs are very effective. When a pregnant woman is about to deliver, our herbal mixtures help her deliver safely.

“We do not have issues of pregnant women delivering through operations, unlike hospitals, where a growing number of pregnant women are delivered through Cesarean Section, just because they want to make money, as the method is more expensive than the natural one.

“The major challenge we face is the misconception circulating about us, which frequently accuses us of providing services we know nothing about.“The hospital care providers look down on us because they feel they have been to school to study. They sometimes also treat our referral cases badly. For instance, if we refer a case to them, they would tell the patient: ‘if you knew TBAs were better, why are you here now? You women wait until you have problem, then you rush to us for help.’

“But there is need for cooperation between us and orthodox doctors and nurses, so that we are able to work together for the good cause of saving lives.”In his view, government is also part of the problem, as it demoralises TBAs rather than train, equip and encourage them.A female TBA, Mrs. Kafayat Mohammed, said her greatest challenge is the inability of most of her clients to pay their bills.

“Our services cost between N15, 000 and N20, 000, depending on the condition of the pregnant woman and her complications. But despite these low charges, many of these women find it hard to pay,” she said. Shedding light on why she patronises TBAs, Mrs. Kate Duru said she stopped attending hospitals because the doctors and nurses insult and neglect pregnant women.

“I was told at a hospital that I was giving birth to children anyhow without planning. So, I decided to be having my children elsewhere,” she explained.While Duru has been quite fortunate, the same cannot be said for Mrs. Kate Henry, 22, who lives in Isolo area of Lagos. She developed vesico vagina fistula (VVF) after patronising a traditional birth attendant and also lost her baby in the process.

She told The Guardian that she gave birth when she was 17 years old and had prolonged obstructed labour. Ever since, she has been suffering from urine leakage, and is currently undergoing fistula repair and other medical treatments.But regardless of what women patronising TBAs may say, it is still argued in some quarters that TBAs should be boycotted to reduce cases of VVF, maternal mortality and other related issues.

Prof. Oladosu Ojengbede, Master Trainer of Fistula Surgeons, and consultant gynaecologist at University Teaching Hospital (UCH) Ibadan, advised pregnant women to stop attending traditional birthplaces to avoid prolonged obstetric labour, which is the major cause of maternal mortality and morbidity in the country.He said for every woman that suffers mortality from prolonged obstetric labour, there are more than 20 near misses with serious morbidities. The commonest is the obstetric fistula.

So, to reduce these health conditions, pregnant women should go for antenatal care and deliver at the nearest registered primary healthcare centres. He said: “Injuries TBAs might cause include a syndrome involving multiple organ systems with constellation of injuries. Other parts of the body that might be affected include, urinary system, genital and reproductive system, gastrointestinal system, musculoskeletal system, neurologic system, dermatology, mental health and psychosocial issues. A more holistic obstetrics care is required for the devastating consequences on the quality of life of affected women. More importantly, there is need to prevent these dangers and effects.”

Other problems that might be caused by TBAs, according to him, include paralytic ileus following sepsis, acquired rectal atresia from excessive scarring rectal prolapse, anal sphincter incompetence with flatus and or faecal incontinence, stress, depression and low self-esteem, among others.

But Dr. Ezekiel Sofela Oridota, a senior lecturer and consultant, Public Health Physician, Epidemiology and Biostatistics Unit, Department of Community Health and Primary Care, College of Medicine, University of Lagos and Lagos University Teaching Hospital (LUTH), said boycotting traditional birth attendants is not the solution, as a large number of pregnant women still deliver their babies there.

He said: “What we should do is to make it safer by training and retraining TBAs and giving them support. The training and workshop would help them to know their limits and danger signs, as well as take right steps at the right time. But to stop them completely is not encouraging, because they are the ones at the rural level and most pregnant women there prefer TBAs to primary healthcare workers.

“Therefore, government should work towards organising workshops and training for TBAs, because what we need is qualified and experienced health workers to undertake safe deliveries.“Pregnant women are more familiar with these traditional health workers in the rural communities. So, if one advises them not to patronise them, they will not understand.”

He said community health workers at primary health care centres should partner with traditional birth attendants to curb prolonged and obstructed labour, while TBAs should recognise when there is danger and invite a qualified medical doctor.

“We need to value health by investing more in the health sector because many people cannot afford hospital bills, and many people die because of poverty. We need experienced and qualified health workers to take delivery and not just anybody. “Government needs to reduce poverty and ignorance, as well as provide health education, because many Nigerians die as a result of this. There is also need for every community to have health notice boards, where health issues should be reported, as this would help to improve healthcare awareness.”