Progresses and challenges of utilizing traditional birth attendants in maternal and child health in Nigeria

1. Background and Objectives

Nigeria is comprised of 774 local governments and 374 ethnic groups, thus setting the stage for great variability in customs and traditions regarding childbirth and postnatal practices.[1] Table 1 describes Millennium Development Goal 5 (MDG 5) and the factors that influence maternal health in Nigeria. The MDG 5 goal set by the United Nations is to improve maternal health by reducing the maternal mortality rate (MMR) by three-fourths by 2015.[2] Nigeria was identified as one of the countries that needed to achieve MDG 5 due to the high maternal mortality rates occurring in the country.[2] The 2013 Nigerian National Demographic and Health Survey (NDHS) reported the maternal mortality ratio was 576 deaths per 100,000 live births. Exposure to hemorrhages, infections, unsafe abortions, obstetric emergencies, HIV/AIDS and meningitis leave women at risk of mortality due to unsafe practices.[3] Lack of access to quality health care, lack of skilled health workers, education and poverty are some of the structural factors that have contributed to maternity and infant mortality rates in Nigeria especially in rural areas, leaving women and children at higher risk of exposure to dangerous delivery practices that contribute to high mortality.[3] Before modern medicine, mothers and mothers-in-law often assisted their daughters with delivery and would depend on Traditional Birth Attendants (TBAs), if issues or complications were to arise.

Traditional Birth Attendants (TBAs) in Nigeria have the potential to contribute significantly to maternal health outcomes because of their high utilization within the country. TBAs are defined as providers who are traditionally independent of the health system, and are community-based providers of care during pregnancy, childbirth and the postnatal period.[2] TBAs do not receive formal medical training when compared to other health professionals such as obstetricians and gynecologists. However, TBA’s are much more affordable and accessible than skilled birth attendants (SBAs) in most parts of the country. Most TBAs are middle-aged or older women and are highly respected in their roles as midwives to rural communities.[3,4]

Nigeria has an estimated population of over 100 million and about 80% of the population live in rural conditions.[5] Women living in rural areas are 77% more likely to give birth at home than in a health facility, which contributes to the high demand for TBAs.[6] Nigeria has made slow but progressive results in reducing maternal mortality rates since 1990 with a baseline figure of 1000 deaths per 100,000, 545 per 100,000 in 2007, 350 deaths per 100,000 live births in 2012 and then 243 per 100,000 live births in 2014.[6] However, maternal mortality rates remain high compared to other developing countries and it is important to address structural factors that are contributing to the high MMR witnessed in Nigeria.

In this paper, a purposive literature review examining the role of traditional birth attendants (TBAs) maternal health in Nigeria was conducted. An emphasis was placed on identifying the maternal health progresses and challenges, in order to examine the association of the utilization of TBAs and attainment of MDG. In examining the literature, the relationship between maternal health in Nigeria and current healthcare practices was explored to identify strategies that can aid in the reduction of maternal mortality through interventions that include TBAs. In addition, the current review sought to 1) compile current practices of TBAs in Nigeria and 2) to provide effective implications to policy pertaining to traditional birth attendants in order to improve the health of women and children in Nigeria.

2. Methods

Electronic databases (PubMed and EBSCOhost) were utilized to identify published empirical studies, review articles and policy briefs in order to: 1) compile current practices of traditional birth attendants in Nigeria 2) evaluate the progress of Nigeria’s plan according to Millennium Development 5 goals, and 3) provide effective implications on policies pertaining to traditional birth attendants in order to improve the health of women and children in Nigeria. Figure 1 illustrates the PRISMA model used for article selection.

Close

Figure 1

Illustrates the PRISMA model for the literature review conducted on TBA and MDG 5

Export to PPT

3. RESULTS

4. DISCUSSION

An analysis of the literature reveals an immense public health need for quality health education and training of TBAs in rural communities. Although Nigeria has reached its target regarding reducing maternal mortality rates, other indicators such as reducing maternal morbidity and increasing access to antennal care have not been met. Recommendations for improvements include: the recruitment and retention of skilled birth attendants, balancing the maldistribution of skilled health workers and encouraging women to deliver in a health care facility.[25]

Prior published research has focused on either: promoting skilled birth attendants, omitting TBAs from rural communities or additional training of TBAs. The research presented in this paper details what efforts are needed to improve the care of pregnant women and mothers and the need to accelerate progress in field of maternal health through a collaborative approach. In order to achieve this, policy makers, professional midwives, medical practitioners and funding organizations involved in the provision of maternity services must develop collaborative opportunities with TBA’s that encompasses mutual trust and respect for each other.[26]

Future research should focus on evaluating the impact of TBA trainings to ensure improvements in maternal health. Models have existed before in which Western-trained professionals work well alongside TBAs.[26] Even without training, TBA’s provide services that are beneficial to women that is founded on the intimacy of the relationships with mothers. Increases in trust between mothers and trained health professionals can build relationships similarly to those shared with TBAs. In addition, providing adequate health education and training to TBAs can have the potential to increase access to skilled birth attendant services through referrals.[27]

5. Conclusions and Global Health Implications

Training TBAs has been shown to increase the utilization of prenatal, antenatal, and postnatal healthcare of women who otherwise are unable to seek treatment from a skilled birth attendant.[28] Without formal training, TBAs are unable to identify the signs of a critical pregnancy or labor and delivery danger signs which can significantly put a mother’s life at risk.[29] Training of TBAs is recommended in addition to an increase of hospital births and informing women who utilize TBAs to request that they refer them to a health facility if they are unable to care for them properly.[1]

Providing quality maternal health training to TBAs will help them recognize their scope and limitations, and possibly refer mothers and their infants for immunization, family planning, and emergency services as needed.[7] TBAs, in addition to other community members who are influential in decision making, should be included in educational and communication activities. An example of this includes community mobilization to recommend oral misoprostol to prevent postpartum hemorrhaging, which has been effective.[19]

A lack of comprehensive maternal and child health infrastructure and a need for policy improvements were found as factors that influence maternal health in Nigeria. A reason for the high utilization rates of TBAs in rural areas is due largely to lack of access to health care facilities. Eliminating the utilization of TBAs in rural areas will not alleviate mortality rates but may actually exacerbate rates as it would leave mothers without access to any form of assistance. Policy makers, such as the International Confederation of Midwives (ICM), can advocate for the inclusion of TBAs as an important bridge to health care without excluding them. [27] WHO and the United Nations have acknowledged the importance of integrating TBAs in health care interventions and training TBAs in an aim to reduce mortality rates. Furthermore, government agencies should provide support in the strengthening of relationships between skilled health workers and TBAs. To improve the quality of care for women, cooperation and communication is needed between TBAs and health care workers. The communities’ input and participation can help improve programs and health service delivery. Policies that incorporate an ecological systems view, which acknowledges and recognizes the contributions of TBAs and socio-historical factors that encourage their utilization, is a step forward. This highlights the relevance of the important cultural and social roles that TBAs fulfill in their communities.

To reduce maternal mortality and improve maternal healthcare in Nigeria, an increase in quality health education for women and their family is essential. Additionally, the inclusion of culturally appropriate and sensitive health care practices is warranted.[10] With improvements in education for both men and women, in addition to improving the overall economic status of the families; a reduction in maternal deaths in communities is possible and likely.[27]

Paternal attitude is an important factor that influences many women when it comes seeking quality care due to negative outlooks within the health system. When men gave their wives more permission to go to a health care center, health care utilization increased.[18] Increasing the focus on the role of men in the pregnancy and postpartum period can be done by providing education, incentives, and support that can be instrumental in reducing maternal mortality and increasing health care usage among both men and women.

It is important to note that westernized medicine is often viewed as the preferred form of care which has contributed to the role of TBAs being devalued. Western medical knowledge is often used as the standard of acceptable medical practice, intentionally ignoring the cultural perspective and tradition into utilization thus perpetuating the roles of TBAS as inferior and unsafe. Reasons for the recent devaluation of TBAs role is also due to lack of evidence based literature and research that can support utilization of TBAs positively. Though there is no direct link to high utilization of TBAs and mortality rates in infant and mothers, researchers tend to attribute the use of TBAs to morbidity and mortality in countries where they are heavily utilized.

The high utilization rates of TBAs in rural areas and developing countries are not solely due to comfort level mothers but also to lack of access to health care facilities. Therefore, eliminating TBAs in rural areas will not alleviate mortality but may exacerbate rates as it would leave mothers and children without access to any form of assistance. When establishing goals for MDG 5, there should be more of a positive lens that highlights TBAs that have good intentions but are limited in skills and knowledge. TBAs are the bridge to reaching the community and providing the quality care needed for mothers.