By Fortunate Ozo

TRADITIONAL Birth Attendants (TBAs), are community-based providers of care during pregnancy and childbirth. Despite their limitation in handling complications, these TBAs who are mostly unskilled and untrained middle-aged women seem to be widely accepted and patronized in most rural communities.

According to United Nations Children Fund(UNICEF), the new global maternal mortality report showed that 82,000 women in Nigeria die from pregnancy and childbirth related complications every year.

While the country’s maternal mortality rate according to the Society of Gynaecology and Obstetrics of Nigeria is 512 deaths per 100,000 live births, which is nowhere near the SDGs target of 70 per 100,000 live births by 2030. There is also a high density of unaccounted death of mothers during childbirth. Some of these deaths occur in the home of traditional birth attendants.

In Ebonyi State, postpartum hemorrhage, which is one of the complications from TBAs, contributed 36 percent of recorded maternal deaths in 2022. There are a number of reasons why these deaths occur and they are rooted in poverty, inequality, religious, cultural and poor knowledge.

Mrs Virginia Ekuma, a housewife and nursing mother, who delivered a set of twins on June 21 2023, at the home of a TBA, narrated her ordeal of bleeding before and after the delivery of her twins which left her unconscious, without the intervention of the TBA who lacks the necessary skills in handling complications.

“I gave birth to my twins at the home of the traditional birth attendant around PDP area, because I don’t have money to go to the hospital. Out of my six children, I delivered only one of them in the hospital and they charged me much money, so I stopped going to the hospital for childbirth.

“Before I went into labour, I started bleeding from my house and after considering how much it will cost me to go to the hospital, I decided to go to the house of a traditional birth attendant because I didn’t have money. The traditional birth attendant charged me 10,000 naira, two fowls and two tubers of yam which I could not afford as well.

“After giving birth, the bleeding started again and continued till I returned home. I was unconscious until around 2 O’clock when I regained consciousness. I was given some drip and injections by a patent medicine owner then I became stable,”she said.

A pregnant woman, Margret Chidume also recounted her experience during her first pregnancy and childbirth at a traditional birth attendant’s house and noted that she was not comfortable with the compound where the TBA conducted deliveries, which she said was a public yard housing other tenants.

“I have two children and this is my third pregnancy. I delivered my first child at a TBA’s house, in Portharcourt, but I was not comfortable with the environment. It is just a compound where you have other tenants living, and it’s just a little room.

“It is not about being cheap, I went there on recommendation. After that pregnancy, I said let me try another method, so I had my second child in a general hospital at Enugwu-Ukwu in Anambra State.

“This is my third pregnancy and I am going to the Alex Ekwueme Federal University Teaching Hospital Abakaliki for antenatal. l think it’s okay to have people that can take care of me very well like in my second pregnancy, I had complication, which if it was not in a hospital, I don’t think a TBA would have been able to handle it. So out of that experience, I said it is better to go to a hospital so that in case of any eventuality, I will be properly taken care of,” Margret said.

Another pathetic story discovered in the course of this investigation, is that of Benedect Nwodom, a mother of 8 children, who sells vegetables in small quantity from which she feeds her children. According to her, she delivered all her eight children including her new born baby at home without anybody’s assistance.

“I gave birth to this baby on June 5, 2023 at home just like his seven siblings because my husband doesn’t have money. After going to Mile Four hospital for antenatal, when labour starts, I normally deliver them at home at our backyard after which I cut their umbilical cord by myself,”she said.

These are just few out of many complications that sometimes lead to the death of pregnant women and their children, which are in most cases, covered by TBAs.

According to data from the Obstetrics And Gynaecology, O & G Emergency, Alex Ekwueme Federal University Teaching Hospital AE-FUTHA Abakaliki, the statistics of unbooked patients referred to the hospital from TBAs when they were unable to handle complications, from 2021 to middle of July 2023 is as follows: 2021= 37 patients. 2022= 61 patients. January to June 2023= 30 patients. Total of unbooked patients referred from TBAs to AE-FUTHA Abakaliki, for 2 years and 6 months= 128 patients.

While some of these patients survived, others lost their lives and their babies on getting to the hospital, said Dorathy Egbo, Chief Nursing Officer, O & G Emergency Alex Ekwueme Federal University Teaching Hospital AE-FUTHA Abakaliki.

This reveals that nearby health facilities often bear the brunt of cases of complications from traditional birth attendants.

Mrs Gladys Njaka, the Assistant Officer in charge of maternal child health care facility MCH Azuiyiokwu, Abakaliki local government area of Ebonyi State, decried that despite the campaign against visiting quacks and TBAs, many pregnant women still patronize them and end up being rushed to their health facility at the dying minute when complications occur.

“We have been having series of them, the cases of people, they will go to TBAs instead of them to come to the health centre where the people working here are trained and qualified. But they will go there, when they go there, when they will come here is when the condition is already bad.

“Their cervix will swell up, when you check the fetal heart rate of the baby, you might not hear the fetal heart rate of the baby that is to say that they have stayed there for three or four days, the baby in the womb has died so we see a lot of them everyday, unbooked patients.

“You know we have a visiting doctor here at times it will lead to surgery or at times it will be the one we will do by ourselves.Then at the end it will lead to a successful story but majority of them lose their babies because of that.

Mrs Njaka called on the government to make a law banning traditional birth attendants from conducting deliveries or provide training for them.

“What I am saying that government should do is that they should have a law banning those TBAs from taking deliveries because they are not trained or if possible they should be trained.

“There is a chairman of a village here that made it compulsory that pregnant women must go to the hospital. If you don’t deliver your baby in the hospital you will not get a share of farmland which is being shared annually. So that made them to be going to the hospital to seek proper care from trained personnel,” Njaka added.

Elizabeth Anakpe, the Chief Nursing Officer, Antenatal Care clinic, Alex Ekwueme Federal University Teaching Hospital AE-FUTHA Abakaliki, said that an average of 300 to 400 women register for antenatal in the hospital every month, but regretted, that some of them, end up delivering their babies in TBA houses or at home.

“It depends, some months, 300 to 400 women register for antenatal here, and we know that there are still some that deviate and go and deliver somewhere else. Some will tell you it is proximity or one reason or another.But the good news is that the hospital management has slashed down so much on our bills.

On the issue of complications from TBAs and handling of delivery for HIV patients, Anakpe said that it is risky for pregnant women who are not sure of their HIV status to deliver at TBAs homes adding that they are not trained on proper skills to prevent mother to child infection during childbirth.

“That Programme is called, PMCT that is, Prevention of Mother To Child Transmission of HIV. So when women come to register for antenatal, the first thing we do, we send them for that test, and it is free of charge. Anyone that her result comes out positive, we sit them down and do a post counseling before we break the news.

“And we always warn them, don’t go to a quack to deliver, why? In the process of delivery, if you are not trained, you don’t have the skills or knowledge, you will not know that the blood of the mother or the product of conception, should not come in contact with the baby. But when they go to TBAs, they will just muffle up everything together and the babies are positive,” said Anakpe.

Although, most women who visit TBAs for childbirth in Ebonyi State, attribute their reason to poverty and high cost of childbirth in health facilities, research shows that the cost of childbirth in Maternal and Child Health Care facility, Azuiyiokwu Abakaliki is 12,000 naira for normal delivery and 112,000 naira for delivery through cesarean section.

Similarly, the Alex Ekwueme Federal University Teaching Hospital (AE-FUTHA) Abakaliki, which recently reviewed the hospital’s delivery rate, charges between 10,000 to 18,000 naira for normal delivery, and between 70,000 to 100,000 naira for cesarean section. As against the old delivery rates of between 35,000 to 40,000 naira for normal delivery and between 150,000 to 200,000 naira for cesarean section.

Despite the glaring dangers and implications of using TBAs during childbirth, a reasonable number of rural women in Ebonyi State still patronize them, giving high cost of hospital bills as one of their reasons.

Ijeoma Igwe is a native of Agbaja community and a mother of six who gave birth to all her children at the house of Helen Nwibo Nwoba, a traditional birth attendant. She insists that traditional birth attendants are closer to rural people and as such, should be supported by government.

“I have never given birth in a hospital before but in this village there is a traditional birth attendant that lives close by. Anytime I went into labour especially at midnight, the woman will be called. Immediately she comes it will not be long I will deliver my child. Even when one of my children died in the womb, that traditional birth attendant delivered me of that dead child safely.

“I am pleading with the government to help these traditionalbirth attendants. It is always good to have the Orthodox and traditional medical practice because many people in this our village are not mobile and cannot afford a motorcycle if their wives go into labour especially at night. .

“Before they will run around to find means of transportation, maybe a car or tricycle any traditional birth attendant living close by will be called to salvage the situation. So they are really helping us in this village,” she said.

Mr Sunday Igwe of Agbaja community, a Retired Correctional Service staff and husband of Ijeoma Igwe, who delivered her six children in the house of a TBA. agreed that it is hereditary in some families that are born as traditional birth attendants, pointing out that their services are quick, accessible and affordable.

“There are families that specialize in traditional bone setting, once they touch you, that bone will heal, likewise there are families that specialize in childbirth (TBAs) especially women. When they attend to you they will attend to you like professional nurses because they are destined by God to work in that area.

“Yes, all the six children we have now all of them were delivered by a traditional birth attendant. Within an hour, my wife had delivered safely no death, no anything since I started living here in 1971.

“Inside the village, before a pregnant woman will be rushed to the hospital it will take up to five or six hours and even transportation is a big problem. But this traditional birth attendants are very close. The women will be rushed there and they will be attended to quickly and they will deliver safely.

“So I am appealing to government at least to assist these TBAs, give them training so that they will be equivalent to those trained nurses in government hospitals,” he said.

No matter the seeming benefits of TBAs, many respondents believe that TBAs lack the requisite skills, structures and equipment for handling child birth as some of them use huts situated in their yam barns and kitchen line rooms as their facility. Some of the traditional birth attendants denied ever encountering complications in their many years of practice. However, it was a difficult task getting the TBAs to speak, as they thought the reporter had come to arrest them.

Elizabeth Mbam of Ndiebor Ofoke village in Ebonyi Council area of Ebonyi State, is a well known TBA who conducts deliveries in a hut inside her yam barn, with some woods she put together and uses same as a delivery couch.

She said that the art of delivery is a family inheritance and noted that she conducts 2 to 3 deliveries in a day or week and sometimes, 2 to 3 or more deliveries per month. Adding that she does not charge much money for childbirth.

“I didn’t learn how to conduct delivery anywhere, it is a gift in our family. But if a woman comes here for delivery, once I look at her and my spirit tells me that I cannot handle it, I will tell the person to go to the hospital. But if my spirit accepts, I will conduct the delivery. I use some prepared herbs that hasten labour.

“I was charging between 1,000 to 3,000 naira per delivery, but now, my charge is 5,000 naira per delivery. And if it is a set of twins, I will charge the person 10,000 naira. It is not everyone that eventually comes back to pay the balance of the money they are owing me, but what can I do to them?,” She said.

Mrs Ukamaka Ogbonna is another traditional birth attendant in Agbaja community, Abakaliki local government area of Ebonyi State, she said that she learnt home delivery from her late mother-in-law and mother who were renowned traditional birth attendants during their lifetime.

According to Mrs Ogbonna, she took over from her mother-in-law after her death, adding that she administers some herbs on pregnant women and they deliver their babies safely. “When I moved into this family, my mother-in-law who was 132 years old before she died was a renowned traditional birth attendant, likewise my own mother who could only touch the belly of a pregnant woman and she will deliver her baby safely.This is the same situation with me.

“This twin youths here were delivered by me and I have delivered more than 30 women of their babies.

Mrs Ogbonna also claims that she uses herbs to prevent bleeding as well as provide cure for convulsion and fever.

“If a woman is bleeding and people rush her to me saying Ukamaka what shall we do? I will go to the bush and get some herbs and give to the person, the bleeding will stop then I will ask them to go to the hospital if it is a situation that requires blood transfusion because I don’t do that.

She further speaks on how she performs female genital mutilation as a legacy from her late mother-in-law and appealed to government, to engage her to assist in conducting deliveries in nearby health centres.

“When my mother-in-law was alive, whenever she was doing female genital mutilation she would call me to be around and learn how it is done. When she became too old and could no longer take charge, I started doing female genital mutilation but you know female genital mutilation is no longer in practice.

“So when a woman delivers a baby girl now, like my son’s wife, I use vaseline to rub and press her clitoris instead of cutting it. “If it pleases the government, they can engage me to render my services in nearby health centres here. If a woman is in labour and there is no doctor around I can help out after that, the government can pay me any amount they deem fit,” she said.

Another traditional birth attendant at Ishieke Ebonyi local government area, Mrs Martina Nworie, who conducts deliveries in a kitchen line room claimed that the keys to the room was lost at the time of visit and the state of the room could not be ascertained. According to her, she started working as a TBA at the age of 11 when a prophecy was given concerning her in the church about God’s calling upon her to be a traditional birth attendant.

“I was a little child just like this child here when I started working as a TBA because it was in the church that a prophecy was given that after my primary school I should not further my studies rather that I should go and understudy and learn how to conduct deliveries that that is the call of God for my life. So after my primary school, I proceeded to Akpugo Nkanu where I understudied a herbalist and learnt a lot about different drugs (traditional herbs). If a pregnant woman comes for delivery, I will just give her some prepared herbs and she will drink and deliver her baby safely, “she said.

Mrs Helen Nwibo Nwoba is another elderly traditional birth attendant in Agbaja community Abakaliki local government area of Ebonyi State, she told NTA news that she was instrumental to the birth of almost all the children in that community. But complains of low patronage these days as she does more of traditional bone setting nowadays.

“Since I started this work, I have never had any case of complication. When a pregnant woman comes she will just deliver her baby and go home in good health. I delivered almost all the mothers of the children in this community of them. There is none that was not given birth to in my house. It’s just that nowadays, hospitals seem to be everywhere and many women are no longer coming to give birth in my house the way it used to be.

“Some people are still coming for herbs but come to give birth if labour starts at odd hours when they cannot go to the hospital,” she added.

His Royal Highness, Eze Sunday Oketa, is the traditional ruler of Nkaleke Echara Unuhu Autonomous Community, Ebonyi local government area, he highlights the efforts of his cabinet in the fight against domestic violence and the need for women to go to hospital when they are pregnant.

“In the area of women delivery and death during childbirth, the only thing that happens in rural areas is lack of nearby hospitals. I have so many educated people in my cabinet. “Whenever we have our cabinet meeting, we discuss such issues to let our women know that they should go to the hospital when they are pregnant and also we have made the law that guides my community that no one should maltreat women.

“No man will likely maltreat his wife. Whenever we hear of such, the man involved will be punished. Then we need government to have more hospitals very closely, mostly in the rural areas. What kills women during delivery is lack of hospitals or lack of health centres. If there are so many health centres in rural areas, it will assist us so that women will not die during childbirth,” he said.

What effort is Ebonyi State government making through its regulatory bodies to check the activities of traditional birth attendants? The Programme Manager, Ebonyi State Emergency Maternal and Child Health Intervention Centre (SEMCHIC), Mrs Aluu Otu highlights some of the complications arising from cases managed by traditional birth attendants, ranging from postpartum hemorrhage, perinatal death among others.

“Yes, all the complications of obstetric complications are coming up from them like postpartum hemorrhage, ruptured uterus, then perinatal death, death of the uterus and then tears and all those things. And even the woman going into shock and being unconscious.

“These are the complications that normally occur from the cases they have handled so resulting to and then you know, bladder rupture, fistula cases are part of the complications, the risk that when the women that they manage, when they come to the hospital they are just at risk of getting such things,” she said.

The Ebonyi State Co-ordinator, Reproductive Health And Safe Motherhood, Maryjane Ikechukwu Nwobodo, highlighted the efforts of the State government in checking the activities of traditional birth attendants, various laws and regulations as well as results achieved so far.

“In the past, we have tried to regulate them through the Maternal and Child Care Initiative (MCCI) law, during Elechi’s administration, but to no avail. They still continued to do what they do. And they are causing so much havoc and the government is aware.

“I just want to have a kind of database for these PPMVs and TBAs. You know why we don’t actually for now train them, I mean the TBAs is because there was a time WHO, organized a training for them and they were of the opinion that, they have trained me.

“Then, some of them, the certificates they were given, they went and enlarged it, hung it, I’m now government person you see, they recognize me. And they were only trained on how to identify danger signs. Identify these danger signs and refer. Then the MCCI law told them not to deliver. If any woman comes to you, take that woman to a facility.

“They have some leaves that when contraction is not progressing, they will give you to chew, and then contraction will start immediately. Some of them, if you’re lucky you deliver, if you’re not, ruptured uterus. One of the complications in delivering with the TBAs, you don’t just have ruptured uterus, as a long term effect the prolapse. Most of our women are living with that uterine prolapse.

“Thank God our present government has health as one of the priority areas. And we are going to bring them out once again, to tell them their limit, because you see, a woman like the one we visited last month when we heard what she did, we went there, though on sighting us, she ran away.

“The report that we got was that this woman (TBA), delivered a woman of her baby and then kept that woman in her home, the placenta did not come out, she did not deliver the placenta. She had retained placenta which if she was to be trained, she would have known what to do. But she kept this woman in her room for 5 days telling the woman that the placenta will gradually come out. And that woman died of infection.

“Another one that we got from the same woman (TBA), was that a woman was bleeding, post partum hemorrhage, she kept the woman, finally, the woman died.

“So when we got this report, because we have our committee at the State level, every death that happens in the state be it in a health facility, be it in the community, the report comes to us and we review it. Those preventable deaths we will now know what to do, recommendations are given.

“So, in our meeting, this report came to us and the recommendation was that a team comprising myself, the Director Medical Services, the Director Pharmaceutical and the Medical Director of a very equipped health facility, Amurt health facility was just close by and this woman was just few meters away. So when we got there, when they saw us, they ran away but we are still on that matter.

Mrs Ikechukwu Nwobodo further stated, that the State is yet to prosecute any traditional birth attendant.

“On December 16, 2020, former governor David Umahi signed into law our Maternal Perinatal Death Surveillance And Response law. He signed it. It is gazetted, we have a copy. It is not a punitive law, that when in the course of managing a patient and you did everything you are supposed to do and the person dies, nobody is going to blame you.

“But where it will be an offence even to you as a health worker is that you have death, and you refuse to report that death,” She added.

Other dangers associated with childbirth through TBAs range from, lack of knowledge of the correct dosage of herbs to administer to pregnant women, lack of skills in identifying and handling HIV patients to avoid mother to child transmission, inability to handle complications such as bleeding, administering of harmful herbs that reduce the size of big babies to pregnant women, inability to conduct CS when a pregnant woman cannot deliver by herself, inability to give necessary immunization to newborns, lack of skills in giving proper medical check up and care to mothers among others.

To overcome these dangers, a retired Director, Nursing Services, Lagos State Primary Health Care Board, Oluwatoyin Adetoun Odukoya recommends that, Ebonyi State government should have a datebase (statistics of TBAs) operating in the state, check the influx of pregnant women that visit TBAs for childbirth ( the statistics) and compare it with the statistics of pregnant women that visit Health Care facilities in rural areas for childbirth. This she said, can be achieved through the Community Health Extension Workers.  

“A survey should be conducted to find out the general cost of delivery in TBAs homes, and then compare same with delivery rates in health facilities in rural areas. If need be, delivery rates should be subsidized in government hospitals in rural areas. While periodic sensitization should be carried out for rural women on the need to visit health facilities for childbirth and bring to their notice, that the cost of delivery has been made affordable in government hospitals.

“Traditional rulers can be used to make laws in rural communities on the issue. Moreover, TBAs must be equipped and trained in identifying danger signs and referring women to health facilities at the first sight of danger sign.

“Ebonyi State government should establish a ‘Traditional Medicine Board to oversee the regulation of TBAs, traditional bone setters and other related traditional medical practice. If the government does not want to scrap the TBAs, the Traditional Medicine Board should be saddled with the responsibility of training, registration and licencing of TBAs( including auxiliary nurses, unemployed trained midwives and community health extension workers who are practicing as TBAs in rural communities).

“But the Primary health care development agency should oversee their overall activities through the Community Health Extension Workers. And give sanctions when necessary.

 “There can be collaboration between traditional birth attendants and hospitals in rural communities, whereby a pregnant woman can register with a TBA and she will encourage her to also register with the closest PHC in the area. At the end of the day, if there is any complication, the TBA can comfortably take the pregnant woman to the PHC from where she can be referred to a general hospital or a higher one, as the case may be.

“The above method, is part of the reform on TBAs as implemented in Lagos State  when I was still in service, and to a large extent, the activities of traditional birth attendants were brought under control in the state.

“Based on the foregoing, it is pertinent that government should as a matter of urgency, checkmate the activities of traditional birth attendants in order to reduce maternal and infant mortality to the barest minimum,” she ended.

 This report was supported by the Wole Soyinka Center for Investigative Journalism (WSCIJ) under its Report Women! Female Reporters Leadership Programme (FRLP), champion building edition.