Addressing maternal mortality rate in Nigeria
In Year 2000, WHO ranked 187th in overall performance in health among 191 member states. This unhealthy ranking has since made stakeholders in the health sector devised several means to reverse the trend. This includes strengthening the operations of Traditional Birth Attendants, TBAs, for safer delivery of newborns and as a strategy to reverse the country’s maternal mortality rating.
Globally, Nigeria is the country with the highest contribution to annual maternal deaths with 14% of 289,000 global annual maternal deaths. Nigeria has achieved only an average of 1.2% reduction per year in under-five mortality since 1990. The rate required if Nigeria was to be on track for achieving Millennium Development Goals (MDGs) then was 10%.
In Nigeria (Lagos state inclusive), a high percentage (more than half) of deliveries still happen at home without the support of certified medical professionals due to the variation between urban and rural areas as well as some age long customs and confidence reposed in TBAs overtime. In addition, majority of Nigerians still lives in remote villages where access to proper Medicare facilities could take a whole day.
The use of TBAs and home delivery were preferable for some community members despite the availability of the village midwife in such communities. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries.
Perhaps a stronger argument in support of the traditional way of deliveries is the fact that the practice has been in existence decades before the present day medical practice. Conversely, modern day medical way of deliveries also argues that deaths of infants and mothers during birth in the ancient days were often ignorantly linked to evil spirits etymology and in some cases the deaths were attributed to ancestral misfortunes whereas their inability to handle those cases with modern medical knowledge was just the responsible factor for those avoidable deaths.
Research has shown that the leading causes of newborn deaths occur during delivery (baby not breathing), complications of birth as well as severe infections – which could be prevented through healthy home practices and community-based care made possible even in hard-to-reach areas.
Community awareness and behaviour change can save a lot of our neonates, infants, Under-5 children and mothers from untimely deaths. Undoubtedly, majority of those who deliver babies outside maternities, clinics and hospitals do so at TBAs. Others are those who take deliveries in faith-based organizations as well as traditional healers’ facilities.
As the cost of living in urban areas is increasing, large numbers of residents are moving to rural communities where they would end up relying on TBAs as their major health care providers for deliveries. With this, ignoring the contributions of these categories of healthcare givers could spell a doom for a society like ours.
Community Health Workers (CHWs) and TBAs will continue to be part of service delivery models in the coming years, especially in those countries where there are severe deficits in the number of professional health workers. In communities where CHWs and TBAs hold respected positions, they can influence women’s use of midwifery care and can provide basic health information about healthy pregnancy, safe birth options, newborn care, nutrition, breastfeeding support, family planning and HIV prevention.
This informed the decision of the Lagos State Government to continually train TBAs on international best practices while also cautioning them of their limitations. In addition to the establishment of a Traditional Medicine Board to oversee the affair of TBAs, training is usually provided for thousands of these healthcare givers on a regular basis. The State government through this initiative, created a professional synergy platform for the TBAs to refer extreme cases of deliveries to government hospitals where such patient would be professionally attended to before sever complications set in.
In India, for instance, similar strategy is being used to address maternal mortality rate where trained midwives are not available. In Ethiopia, there is a similar practice but the nomenclature used is ‘extension workers’ where they receive training on assisting pregnant women, conducting uncomplicated deliveries, and managing uncomplicated postnatal clients and neonates.
A ban on TBAs, which has been in place since 2007 in Malawi was effectively lifted by Malawi’s then President, Bingu wa Mutharika. Malawi has one of the highest rates of maternal and neonatal mortality in the world, with a maternal mortality ratio of 675 deaths per 100,000 live births and a neonatal mortality ratio of 31 deaths per 1000 live births.
In Lagos, the overall intention of the State Government is safe delivery of newborns regardless of means of delivery, be it through modern day doctors or through TBAs who have been certified to operate by the State Ministry of Health and licensed. While this is quite commendable, adequate monitoring mechanisms should be put in place in ensuring compliance with standard practices and professionalism.
Also, medical issues that require professional medical attention should not be attempted by TBAs but referrals be made appropriately to government hospitals anytime there is need for such. Also, TBAs should be periodically celebrated for their contribution to human existence. They should not be allowed to practice in fear and in secret or under unfriendly legislations as such may worsen access to care and result in worse outcomes if women deliver at home without support of TBAs.
As I draw to a close, let me bring to mind the position of former Malawi’s President, Bingu wa Mutharika on the subject: “We need to train traditional birth attendants in safer delivery methods, we should not completely stop them, because their work is very important. We should train them to assist us in addressing the health challenges that we are facing.”.
Afuwape is of the Ministry of Information & Strategy, Alausa, Ikeja.