Assessment of Antenatal Care Services Giving to Pregnant Women by Traditional Care Attendants
Chapter One
Objectives of the Study
General Objective
The general objective of this study is to assess the antenatal care knowledge and practices of traditional birth attendants (TBAs) in Ibadan, Oyo state, Nigeria.
Specific Objectives
The specific objectives of this study are to:
- compare the knowledge of formally trained with untrained
- compare the practices of formally trained with untrained
- determine any knowledge- practice gap among the
- compare the practices of faith -based with non faith-based
- compare the practices of regularly supervised TBAs with those who are
- compare the knowledge of TBAs with formal education with those without formal education.
CHAPTER TWO
LITERATURE REVIEW
Definition
Traditional birth attendants (TBAs) are persons (usually women) who assists mothers at childbirth and who initially acquires her skills by delivering babies herself (self taught) or by working with other TBAs (apprenticeship) (Verderese, Turnbull, 1975). Traditional birth attendants (TBA) – trained or not – are excluded from the category of skilled health-care workers. The term “skilled attendant” refers to “an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” (World Health Organization, 2004).
In south western Nigeria, they are called ‘agbebi’ (Yoruba language) and in south eastern Nigeria ‘ndi ne nime’ (Igbo language). In Guatemala, they are called ‘comadronas’ and in Afghanistan ‘dai’, in Spain ‘empirica’ and ‘daya’ in Palestine. (Plan, 2008).
In most parts of the world, one of the criteria for assuming the office of a traditional midwife is experience as a mother. Many traditional midwives are older mothers; many are post- menopausal. In Palestine, many of them are divorced or widowed and needed to become economically independent to support their children (Wick, 2002, Verderese, Turnbull, 1975). They often serve as a bridge between the community and the formal health system, sometimes accompanying women to health facilities (Verderese, Turnbull, 1975). TBAs are also known as traditional midwives (TM) or community birth attendants (CBAs).
TBAs are more commonly found in rural than urban areas. They may work at considerable distances from health facilities. Most traditional midwives travel to the pregnant woman‟s house to provide care; women may also travel to them to obtain care. They are usually assisted by the birthing woman’s relatives (Verderese, Turnbull, 1975). They may be paid in cash or kind. Some assist with a small number of births per year; others do frequent deliveries. TBAs are not usually licensed but after receiving training, could be certified by the training body (Cochrane Update, 2007).
Historical Background
Traditional Birth Attendants have been valuable members of the birthing process, long before the advent of modern medicine, and its institutions (Mufutau, 2008). In the Bible times, reference was made to Shiprah and Puah who were midwives in Egypt (Thomas Nelson Inc, 1982). Women have given birth for millennia, usually attended by other women who have given birth themselves and/or have helped other women during birth and in the arts of self-care. The primary arts of the traditional non-medical labor companion, or midwife, were devoted nutritional education, herbal wisdom, hygiene, physical mobility techniques, meditative guidance for the psyche of the laboring woman, and newborn parenting support. There have always been traditional midwives in native and/or rural peasant cultures varying in their specific arts according to cultural beliefs that were faith-based, and often involved meditations and prayer formulas. Traditional birth attendants typically had longstanding social relationships with birthing women often elderly midwives had helped two generations or more in one family (Ceallaigh, 2009).
In Nigeria, history of traditional birth attendants could be traced from the pre-colonial period: an era of traditional medicine in its full course. Health care was basically provided by the traditional bonesetters, traditional surgeons, traditional birth attendants, diviners, Quranic healers etc. During the colonial period, the colonial authorities provided health care to colonial administrators and their families only. A vast majority of the people had no access to orthodox health care. They depended largely on traditional medicine. But the postcolonial period witnessed an era of independence and strategic development plans that culminated in the provision of basic health facilities and services, especially in urban centers (Godwin, 2001).
CHAPTER THREE
METHODOLOGY
Study Design
The study was cross sectional in design. It involved the use of semi-structured questionnaires. A direct observation of practices was also done in order to verify data collected with questionnaires.
Target Population
The target population comprised of TBAs resident and practicing within the 11 LGAs in Ibadan. The TBAs were divided into two; TBAs registered with any of the 3 available TBA associations (association of local government trained TBAs, association of church based TBAs and association of midwives who practice in herbal homes) and those who were not registered.
Inclusion criteria:
- Any TBA in Ibadan who consented to participate in the study, whether trained or
Exclusion criteria:
- Auxiliary nurses, community health officers/extension workers, registered nurses/midwives or other skilled health workers who take deliveries were not considered as TBAs.
CHAPTER FOUR
RESULTS
Background characteristics
Four hundred and seven TBAs were interviewed, from the 11 local government areas in Ibadan. The age of participants ranged from 25 to 79 years, with a mean ±SD of 47.0 ±10.8 years. Figure 4.1 shows the age distribution of respondents. TBAs within the age group of 40-49 constituted the majority (31.2%), while those within the age group of 70-79 were the fewest (2.2%). Majority were females (84.8%), the remaining 15.2% were males (M: F=1: 5.6). Eighty seven percent of respondents have had one form of formal education or the other. Figure 4.2 shows the highest level of school attended by respondents. Majority of the respondents attained secondary education (45%).
CHAPTER FIVE
DISCUSSION, RECOMMENDATION AND CONCLUSION
DISCUSSION
Eighty five percent of the TBAs in this study were women, with a mean ± SD age of 47±10.8 years. This agrees with Verderese et al (1975), who stated that in most parts of the world, TBAs were usually women with experience as mothers and are often post menopausal. According to Wick (2002), many of the TBAs in Palestine were also women, many of whom were divorced or widowed and needed to become economically independent to support their children. Khattab et al (2000) and Wick (2002) stated that one of the reasons why TBAs were preferred by women in labour was because they were of the same sex. However, in Salako‟s study in Ogun state Nigeria, more of the TBAs interviewed were men (84.3%). This could be as a result of a relatively small sample size of 51 TBAs, selected for his study.
Unlike some other literatures that reported a high level of illiteracy among TBAs (Matthew et al, 2005, Cochrane update, 2007), 86% of TBAs in this study had at least primary education. This could be a reflection of the relatively high literacy level in the south western Nigeria where the study was conducted (Ogunwale, 2008). Majority (92.2%) of the formally educated TBAs in this study have had formal TBA training as opposed to 43.1% of those without formal education. Also the formally educated had a significantly higher antenatal care knowledge score. This shows that the better educated a TBA is, the more likely she will seek formal training and the more likely she will comprehend and retain what was taught.
This study revealed that a significant proportion of TBAs in Ibadan have had one form of formal training or the other (78.4%). This was contrary to the findings of Matthew et al (2005) and HRH (2008) who observed a low level of training among TBAs in Uyo, Akwa Ibom state, Nigeria(13%) and Mkuranga District of Tanzania (13.5%) respectively. The high level of training among TBAs in Ibadan could be attributed to concerted training efforts that have been made by UNICEF, the state ministry of health, the LGA PHCs and relevant NGOs in the past. It is in fact on record that training has been on for over 30 years in the study area (Ministry of health, Oyo state).
The trained TBAs in this study had significantly higher antenatal care knowledge and practice scores compared with the untrained ones. Also a significantly higher proportion of the trained TBAs reportedly practiced 35 out of 38 antenatal care indicators compared with their untrained counterparts. Several other studies had similar findings (Akpala, 1994, HRH, 2008, Goodburn et al, 2000, Edem, 2005 and Abdul et al 2005). Akpala (1994) while evaluating the Sokoto State government TBA training programme observed that in contrast to the trained attendants, none of the untrained TBAs offered antenatal care, advice on immunization of children or their mothers during pregnancy, and family planning. HRH (2008) reported that trained TBAs in Mkuranga
District of Tanzania were more knowledgeable on danger signs during pregnancy and childbirth and were more likely to refer women with complications to a health facility, compared to untrained TBAs. Goodburn et al (2000) also reported that trained TBAs in a rural community in Bangladesh were found to be significantly more likely to practice hygienic delivery than the untrained TBAs (45.0% vs. 19.3%). In Edem‟s (2005) experimental study conducted in Akwa Ibom State, Nigeria, the knowledge and practice of referral increased significantly after TBA training. Also in the randomized controlled trial conducted by Abdul et al (2005), perinatal and maternal mortality was less within the intervention group where the TBAs were trained as opposed to the control group that had untrained TBAs.
Trained TBAs in this study had relatively better referral practices than those in Sindiga‟s study. In this study 51.1% of the trained TBAs reported always referring primigravida to hospitals as opposed to 16% in Sindiga‟s study. Also 89.7% of TTBAs in this study reported always referring pregnant women with hypertension compared with 14% who refers pregnant women with convulsions in Sindiga‟s study. However there were similar findings in both studies with regards to TTBAs who recommend family planning for clients; 96.6% and 97% respectively.
Majority of the untrained TBAs in this study were traditional healer midwives (92%), most of them without regular supervision and with poorer practices than their trained counterparts. This is in line with the finding of Oyebola (1980) who reported lacunae in the knowledge of traditional healer midwives stated that it could be responsible for the high morbidity and mortality associated with their practice, and might also explain their unscientific and sometimes magico- religious approach to management of perinatal health problems.
Only 49% of the overall respondents had regular supervisory visit by a skilled health worker. Even among the trained TBAs, only 63% had regular supervisory visit by a skilled health worker. A significantly higher proportion of the regularly supervised trained TBAs reported always referring high risk pregnant women compared with trained TBAs who did not have regular supervision. According to Rana (1999) and UNFPA (1996) some of the problems yet to be addressed concerning TBA training include; a lack of an organized system to supervise trained TBAs and availability of basic supplies, such as cord care kits. Primary obstacles to good supervision that were enumerated included; a shortage of supervisory health personnel, inadequate transportation systems and insufficient financial resources. The effectiveness of a training programme in Burkina Faso was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport (Dehne et al, 2005).
There was a knowledge-practice gap among the trained TBAs in this study. This may agree with the statement made in World report (2007) that TBA training, has not led to significant reductions in maternal mortality rates worldwide. Inadequacy of training, lack of persistence of training, monitoring and evaluation, poor supervision, concrete referral facilities and inadequate transport systems could be responsible for these. Thayaparan (1998) stated that by just training
TBAs we cannot solve all the problems, but by providing all the backup services we certainly can reduce the high maternal mortality in developing countries. Most training programmes have focused on training the traditional midwives with little attention paid to the environment in which they work. In line with this, according to Wick (2000) planned home birth with a skilled birth attendant, available transport and a back-up hospital in the vicinity has been shown in many countries to be equally safe for healthy low-risk pregnant women as birth in the hospital. Abdul (2005) also reported that training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. Teaching and equipping traditional birth attendants made a difference in women’s health in Pakistan. Birth kits which contained sterile gloves, soap, gauze, cotton balls, antiseptic solution, umbilical cord clamp and a sterile blade were given to them, and this reduced the perinatal death rate from 1.2% to 0.8% (Rlaan, 2008).
A significantly higher proportion of the trained non faith-based TBAs in this study had regular supervision and reportedly referred high risk patients compared with the trained faith-based TBAs. There is a dearth of literature comparing the practices of faith-based and non faith- based TBAs. However, Etuk et al (1999) had a similar finding where perineal tear, primary PPH, prolonged labour, birth asphyxia, birth trauma, maternal deaths and perinatal mortality were found to be associated more with deliveries in church than hospital deliveries, home deliveries or deliveries by other TBAs. This can be corroborated by lot of complicated cases of obstructed labour found by Edem et al (2005) to be associated with deliveries in spiritual churches. Reliance on other tools of trade by faith- based TBAs such as prayer, fasting, weekly baths and guidance from the Holy Spirit (as enumerated by Adetunji, 1992) at the expense of obstetric knowledge could be a reason for not referring certain high risk patients to hospitals. Matthew et al reported religious beliefs as part of the identified obstacles to proper treatment of obstetric emergencies by TBAs.
There was a strong correlation between the practice scores obtained through questionnaires and that obtained through direct observation of practices. This ensures reliability of data obtained through questionnaires.
Conclusions
From the study, the following conclusions can be made;
- A significant number of TBAs in Ibadan are untrained. Majority of these are traditional healer midwives.
- Trained TBAs had better practices than their untrained
- Among the trained TBAs a knowledge- practice gap was
- TBAs that were regularly supervised had better practices than their counter parts that were not regularly supervised especially in the area of referral of high risk pregnant women to
- The trained non faith-based TBAs had better supervision compared with their trained faith-based The trained non faith-based TBAs were also found to have better practices compared with their trained faith-based counterparts, especially in the area of referral of high risk patients.
- Trained formally educated TBAs had better antenatal care knowledge than trained TBAs who were not formally educated.
Recommendations
- There is the need for the health staff of the State Ministry of Health, Local Government Area Primary Health Care departments and relevant non-governmental organizations to mobilize more TBAs for training, especially the traditional healer midwives.
- Regular refresher courses for previously trained TBAs are also
- Supportive supervision of the practices of the TBAs is needed. This should involve the provision of back up services such as concrete referral facilities, adequate transport systems, equipments and financial resources.
Limitations of the study
- Respondent‟s sincerity in divulging information may not be 100% accurate. Some information may have been inaccurately reported.
- Inability to observe the practices of not more 10% of the respondents for logistic
- During direct observation of practices, there is the tendency for TBAs to adjust their practices to the meet the expectations of the observer, knowing fully well that they were being observed.
REFERENCES
- Abdul Halim M.D and Monira P. 2003. Report on District Skilled Birth Attendant Training, Coordination, Supervision and Training Follow up: Barisal, Bangladesh Skilled Birth Attendant Training Pilot Program.
- Abdul H.J, Heather R.W and Kar K.C. 2005. An intervention involving TBAs and perinatal and maternal mortality in Pakistan. New England journal of medicine. 352:2091-2099
- Abioye-Kuteyi, E.A, Elias, S.O, Familusi, A.F, Fakunle, A and Akinfolayan K. 2001. The role of traditional birth attendants in Atakumosa, Nigeria. The Journal of the Royal Society for the Promotion of Health. 121.2:119-124
- Adetunji, J.A. 1992. Church-based obstetric care in a Yoruba community, Nigeria. Social Science and Medicine. 35.9:1171-1178
- Bailey, P.E, Szászdi, J.A and Glover, L.2002.Obstetric complications: does training traditional birth attendant make a difference? Pan American Journal of Public Health. 11.1:15-22.
- Brennan, M. 1988. Training traditional birth attendants reduces maternal mortality and morbidity. Tropical journal of obstetrics and Gyneacology. 1.1:44-47
