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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 6, Num. 2, 2002, pp. 94-100

African Journal of Reproductive Health, Vol. 6, No. 2, August, 2002 pp. 94–100

Assessing the Role of Traditional Birth Attendants (TBAs) in Health Care Delivery in Edo State, Nigeria

AO Imogie1, EO Agwubike2 and K Aluko1

1Institute of Education, University of Benin, Benin City, Nigeria. 2Department of Physical and Health Education, University of Benin, Benin City, Nigeria.
Correspondence: Dr (Mrs.) AO Imogie, Institute of Education, University of Benin, Benin City, Nigeria.

Code Number: rh02026

ABSTRACT

This study was conducted to assess the role of traditional birth attendants (TBAs) in modern health care delivery in Edo State, Nigeria. A total of 391 respondents comprising 48 TBAs, 309 childbearing mothers and 34 medical and para-medical professionals constituted the study sample. In-depth interviews and focus group discussions as well as validated questionnaires were the tools used for data collection. The results reveal that respondents believe that TBAs can play meaningful roles in family planning, screening of high-risk pregnant mothers, fertility/infertility treatment and maternal and child care services. Rural dwellers prefer to use the services of TBAs, as compared to their urban counterparts. Reasons for the preference included TBAs, availability, accessibility, cheap services and rural dwellers' faith in the efficacy of their services. There is, therefore, the need to restructure the training of TBAs as well as to fully integrate their services into the Nigerian orthodox healthcare delivery system especially as they affect rural settings. (Afr J Reprod Health 2002; 6[2]: 94–100)

RÉSUMÉ

Evaluation du rôle des sages-femmes traditionnels (SFTs) dans la prestation des services de santé dans l'Etat d'Edo, Nigéria. Cette étude a été menée pour évaluer le rôle des sages-femmes traditionnels (SFTs) dans la prestation des services de santé moderne dans l'Etat d'Edo, Nigéria. 391 répondants au total, y compris 48 SFTs, 309 mères en âge d'avoir des enfants et 34 professionnels médicaux et paramédicaux ont constitué l'échantillon d'étude. Des entretiens approfondis, des discussions en groupe cible, ainsi que des questionnaires confirmés ont servi d'outils pour recueillir des données. Les résultats ont révélé que les répondants ont cru que les SFTs peuvent jouer des rôles importants dans la planification familiale, le dépistage des mères enceintes à haut risque, le traitement `fertilité /stérilité' et les services de soins maternel et infantile. Les ruraux préfèrent les services de SFTs en comparaison à leurs homologues urbains. Ceci à cause des raisons qui comprennent la disponibilité des SFTs, l'accessibilité, les services bon marché et la confiance en l'efficacité de leurs services. Il y a donc la nécessité de restructurer la formation des SFTs et d'intégrer pleinement leurs services dans le système de la prestation de soins de service de santé orthodoxe nigériane, surtout à l'égard des milieux ruraux. (Rev Afr Santé Reprod 2002; 6[2]: 94–100)

KEY WORDS: Traditional birth atendant, childbearing, healthcare, orthodox medical practitioners

INTRODUCTION

Since the dawn of history, mankind has been actively experimenting with a variety of available means to safeguard its health and promote the quality of life. In most developing countries like Nigeria, the two forms of health care that permeate the health care system are the modern/orthodox and the traditional. Due to the popularity of the method, one may be tempted to conclude that orthodox healthcare enjoys a higher patronage and supremacy over its traditional counterpart in most developing countries. However, the fact remains that effort to cope with the existing and enormous health problems in developing countries still lacks necessary corresponding facilities required to come with such problems.

In Nigeria, with an estimated population of over 100 million, the number of health professionals responsible for delivering orthodox healthcare is largely inadequate. Over 80% of the population live in the rural areas. Yet, over 75% of Nigerian orthodox medical and paramedical personnel are concentrated in urban areas that have the large majority of modern health facilities to the detriment of the teeming rural dwellers. Many rural Nigerians, therefore, have not been exposed to the benefits of modern changes in orthodox healthcare system. Consequently, traditional health care system is the principal system used in most rural communities in Edo State.

It is clear from the above that new philosophies and appropriate approaches for conceiving the promotion of health care as an integral part of overall national health and development are relevant. There is need to assess the nature and extent of the complementary and collaborative roles of TBAs towards achieving the goal of modern medicare in Nigeria. The present study, therefore, sets to (1) determine the role of TBAs in health delivery in Edo State; (2) determine the reasons for preference or patronage of TBAs in the state; (3) ascertain the quality and quantity of TBAs' services or health care; and (4) determine the rationale for integration of traditional healthcare with orthodox health care in the state.

METHODOLOGY

Between March and September 1999, we investigated women's perception about the existence and operations of TBAs in Edo State, Nigeria, and how best their services can be integrated into modern health care. Three categories of respondents involved in the study were the TBAs themselves, non-TBAs (childbearing mothers who were potential clients to the TBAs), and the medical and paramedical professionals who render modern childbirth services.

Edo is one of the 36 states in Nigeria, located in the heart of the tropical rain forest. Its land area is 19,281.93 square kilometres with an estimated population of 2.5 million people. It  comprises 18 local government areas (LGAs), five of which have been randomly selected and used for this study.

The TBAs were randomly selected from five local government areas in the State. The TBAs who participated were chosen on the recommendations of other women in the area as experts in traditional birth attendant services. In order to minimise selection bias, the women who recommended the TBAs were requested to simply name some known TBAs in their areas for the purpose of the study. They were informed about the purpose of the study and they were assured of confidentiality of any information they provided. We then visited the recommended TBAs and obtained informed consent to conduct in-depth interviews and focus group discussions with them on the role of TBAs in modern health care. Finally, every willing or consenting TBA was recruited until the sub-sample size (n = 48) was reached.

The second group of respondents comprised 309 childbearing mothers chosen in a stratified fashion to represent a range of socioeconomic clientele, and to cover a mix of ante and post-natal clients of public and private clinics. They were made up of 106 teachers, 48 civil servants, 143 petty traders and 12 members of the armed forces and the police.

The third set of respondents was made up of 34 medical and paramedical professionals (medical doctors = 6, nurses/midwives = 28). They were staff working in the clinics where the eligible childbearing mothers for this study were attending their ante and post-natal clinics.

All eligible or consenting women recruited in the study received a brief discussion of the purpose and procedures for the study. They were then subjected to individualised in-depth interviews. The interviews were tape-recorded. TBAs and other respondents were interviewed either in proper English or Pidgin English. Alternatively, local languages with the help of two trained local interviewers from each of the five distinct local language settings were employed. The recordings in Pidgin English and local languages were later translated into English. All the recordings were then transcribed for analysis.

Early in the interview process, we discovered a substantial lack of interest by TBAs in our study. Consequently, we decided to consider the opinion and views of the TBAs participating in the study. We finally randomly selected 108 “eligible refusers” and invited them to attend one of the three focus group sessions in Benin, Ekpoma and Agenegbode. The three towns are local government headquarters in the study areas. Participants from Akoko-Edo and Etsako East attended the sessions at Agenegbode, those from Esan Central and Owan West converged at Ekpoma, while Oredo participants held theirs in Benin City. Between eight and ten individuals participated at each FGD. These focus group discussions took place within one week of the completion of the initial interviews. Each focus group discussion lasted approximately two hours. The first hour of each session was dedicated to the participants' opinions and was facilitated by an experienced member of the research team. An additional member of the research team served as the recorder.

We conducted the focus group discussions for the purpose of better understanding of the public perception of TBAs in modern health care. Although we encouraged a wide range of responses from our focus group participants, we facilitated the sessions to obtain responses from the main themes.

RESULTS

The results are differentiated in terms of the three categories of respondents, namely, the TBAs who are responsible for rendering traditional birth services; the childbearing mothers who were the real consumers of both TBA and orthodox birth services; and the medical and paramedical professionals who render orthodox birth services.

Reasons for TBAs' Initial Reluctance to Participate in the Study

The TBAs were initially reluctant to actively participate in the study because of their non-acceptance into the orthodox professional family. Moreover, they felt that the information given by them may not be used to their favour, they saw it as a form of exploitation. In addition, they were afraid of being legally prosecuted for their views. After all, they felt that there were no financial gains or remunerations. To the TBAs, their participation may not bring about their recognition by the government; therefore, they would rather keep their practice “secret” and pass it to their offsprings alone rather than divulge it to the public. At the same time, others felt that their participation was a waste of time.

The Role of TBAs as Reported by TBAs and Childbearing Mothers

It was discovered that TBAs' roles, apart from their main role as traditional birth attendants, include family planning, nutritional requirements, recommendations, screening of high-risk mothers, fertility/infertility treatment, determination of ailments or abnormalities relating to reproductive organs and reproduction. They also include care of childbearing mothers during pregnancy, labour, and post-natal periods, care of the infants in health and disease/sickness, recruitment of new acceptors into TBA practice, counselling responsibilities, and preservation and conservation of herbal plants and their derivatives.

The Quantity and Quality of TBAs' Healthcare

The amount and efficiency of TBAs' services are reflected in Tables 1, 2, 3. Table 1 shows TBAs' views on the quantity and quality of their services. Quality is defined in terms of the efficiency and efficacy of their services in relation to an expected standard from the public. Quantity is in terms of the number of clients they attend to and whether the number is enough to earn them public recognition. The table shows that 72.9% of TBAs rated their own services as adequate in terms of quantity while 27.1% disagreed. The quality of service was overwhelmingly rated (100%) as adequate by themselves.

Table 2 indicates that 47.3% of childbearing mothers who are the actual consumers of both TBA and orthodox services (77.6% of petty traders, 50.2% civil servants, 55.6% of housewives, 41.7% of armed forces and the police, and 11.3% teachers) rated the services rendered by TBAs as adequate. On the contrary, 52.72% of them (teachers 88.7%, armed forces and the police 49.8%, civil servants 44.4%, housewives 22.4% and petty traders 58.3%) claimed that the amount of their services was inadequate. As regards the quality of services TBAs render, 53.48% (76.4% of teachers, 77.1% of civil servants, 83.3% of armed forces and the police, 22.2% housewives and 8.4% petty traders) viewed it as inadequate. On the other hand, 46.52% of consumers of the services (petty traders 91.6%, housewives 77.8%, civil servants 22.9%, and 8.4% of petty traders) believed that their services were adequate.

Table 3 shows opinions of medical and paramedical professionals (who are the group that render orthodox childbirth services) on the services provided by TBAs. While 66.6% of them (doctors 50% and nurses/midwives 83.3%) are of the view that the quantity of services rendered by TBAs are inadequate, 33.4% (50% doctors and 16.7% nurses and midwives) approved of their adequacy. However, there was a 100% disapproval of the quality in terms of the efficacy of the TBAs' services by both representatives (doctors and nurses).

Reasons for Patronage of/Preference for TBAs by Childbearing Mothers

The reasons given by childbearing mothers regarding preference for TBAs over orthodox medicare include, among others, it is cheap (relatively inexpensive) to both the practitioners; easily and readily accessible/available; near to the grassroots; they use familiar language; they are rated/regarded as more efficacious, thus more confidence in them; they use natural herbs; and there is mutual trust because of their assumed respect for tradition and custom of the people.

DISCUSSION

The initial resistance by TBAs to participate in the study is obvious, bearing in mind the unabated conflict between them and orthodox medical professionals, which, no doubt, is fuelled by the non-recognition of TBAs by the government. One therefore expects approaching them to elicit information regarding their practice to be received with scepticism.

The obvious preference for TBAs' health care particularly by rural dwellers has both cultural and economic roots. Iweze noted that the TBAs are seen as members of their extended families who also can communicate in their local expressions. It is sometimes argued that TBAs' health care should be merged with modern health care, but Lashari queried their compatibility. It should be argued that the popularity of TBAs and their health care does not mean that they are the best system for healthcare delivery. Basically, it is the faith of the people in traditional medicine that makes them seek the help of TBAs.

There are, however, plausible reasons why such traditional health care may be preferable. Traditional medicine, to which TBAs' health care is an integral part, is an ancient form of health care practiced long before the emergence of scientific medicine in areas where it is being patronised or preferred. It is therefore part of the culture of the people. Moreover, it is accessible to the people in even the most remotest areas, and it is inexpensive, apart from not requiring sophisticated equipment. Such were the attracting factors for TBAs' health care as reported in the present study. Cost has a tremendous influence on choice of health care. In this regard, efforts should be made to reduce the cost of modern scientific treatment, especially in the rural settings where most of the people are poor. This calls for free health care in rural areas and this may be achievable through health insurance schemes. Voluntary organisations also have an important role to play in ensuring that modern medicare is available without undue financial burden.

It should be emphasised that as long as hospitals and other modern health care facilities are located far from towns and villages and not easily accessible to users, such people must seek an alternative means of satisfying their health care needs. Moreover, if doctors, nurses and other allied health workers have been poorly and inappropriately distributed to rural areas, it will be difficult for scientific healthcare to claim superiority and attract more patients in such settings. It is probably on this premise that TBAs gained acceptance in Edo State of Nigeria. After all, the concern of childbearing mothers is safe delivery and good health by whatever means available.

It is not surprising that TBAs rated their own services or medicare as adequate in both quantity and quality as opposed to the ratings of their orthodox counterparts. It seems evident that TBAs are resisting being intimidated based on the value conflict between them and their orthodox medical practitioners. However, the mere fact that such claims are made by TBAs should not exempt them from scientific scrutiny.

The ratings by childbearing mothers seemed to have been influenced by their respective levels of education and enlightenment. Hence, teachers, civil servants, the armed forces and police perceived the services of TBAs as inadequate in both quantity and quality, whereas petty traders and housewives viewed TBAs' services as efficient and effective. Those who rated TBAs' services as adequate claimed that they were direct consumers of TBAs' services and, therefore, their responses were based on their experiences. They supported their claims by citing successful deliveries in the hands of TBAs. They regarded orthodox midwives as young, wicked and inexperienced officers who usually face retirement by the time they are about gaining experience. Some revealed that they prefer consulting both TBAs and orthodox midwives, claiming that their registration in hospitals is necessitated by an event of serious delivery complications and for immunisations, which the TBAs cannot provide.

Whereas TBAs and majority of childbearing mothers opted for an unconditional reliance in or use of TBA medicare over the long term, medical and paramedical practitioners viewed the use or practice of TBAs as a stopgap measure. This divergent opinion seemed implicated in Lashari's contention that all patients in the rural areas of developing countries are initially attended by traditional healers, and only those who do not adequately recover or have serious complications seek hospital treatment. Much precious time is thus wasted, which means that patients are sometimes hopelessly ill by the time they seek modern medical care. The unfavourable outcome then adds to the unpopularity of scientific medicine in such rural communities.

Orthodox medical practitioners opposed the idea of recognising TBAs and merging their services with scientific medicine, while TBAs and childbearing mothers were in support of it. It is the view of Lashari that some “genetic counselling” might be needed to ensure a healthy offspring from a marriage of the two systems and to avoid hostility and misunderstanding between the partners. Certainly, standardising their remedies as well as determining their side effects should refine TBAs' services. TBAs' drugs and procedures should be studied and those that are harmful modified or discarded. Above all, TBAs should have to undergo training in the basic principles of modern midwifery as done in India, China and Bangladesh. In addition, all TBAs should be bound by a code of ethics. Such measures should make it easier to effect integration. WHO Chronicle3 reported that Bangladesh is among the countries that have developed an explicit national “health for all” strategy by using trained TBAs to extend coverage of maternal and child health services. The need for such training has been emphasised by Ejembi. However, Okonofua has a contrary view because, according to him, TBA training has not been a cost-effective intervention for reducing maternal mortality in Nigeria.

CONCLUSION

In spite of the fact that TBAs may still hide a few secrets, only science and research will reveal the full potentialities and intricacies of their practices. It is a matter of intellectual honesty to accept that TBAs have played a very important role in obstetrics and gynaecology in Edo State of Nigeria. Since TBAs' health care is still widely practiced to good effect essentially in rural settings, should it not be officially recognised, encouraged, improved upon and integrated into the contemporary Nigerian midwifery health care system? This calls for extending and improving maternity services of TBAs by giving them scientific orientation and training regarding safe and hygienic midwifery and in providing adequate supervision with referral facilities. Any such training programmes for TBAs should constantly make reference to the local body of beliefs and practices relating to the entire maternity cycle of puberty, pregnancy, childbirth, postnatal period and child care.

RECOMMENDATIONS

Based on the results of this study, the following recommendations are made: It is important for the government, in collaboration with traditional medical practitioners, to set up machinery for evaluating the nature of technologies, knowledge and competence of TBAs. Consequently, accurate and adequate statistics of TBAs in each local government/state of Nigeria should be kept. Also, there is need to assess the nature of the herbs and organic matters used in TBAs' practices or health care. This points to the structural training of TBAs in Nigeria. There is need for registration of all TBAs through a census by the Nigerian government and non-governmental organisations, while legal recognition of TBAs on the basis of tests to evaluate their competence for certification is advocated. Moreover, further research on TBAs is needed.

REFERENCES

  1. Okonofua FE. Integrating TBAs into reproductive health care in Nigeria:  a conceptual model. In: Defining the future role of traditional birth attendants in reproductive health care in Nigeria. Report of a seminar organised by WHARC, Nigeria, in collaboration with UNFPA, 61–66.
  2. Itina SM. Re-training of TBAs:  the anual experience. In: Defining the future role of traditional birth attendants in reproductive health care in Nigeria, 41–45.
  3. Iweze FA. Traditional birth attendants in maternal care: women's experience. In: Defining the future role of traditional birth attendants in reproductive health care in Nigeria, 58–60.
  4. UNFPA. UNFPA support to traditional birth attendants. Evaluation Report 1997; No. 12.
  5. Lashari MS. World Health Forum 5: 175–177.
  6. WHO. The extension of health services coverage with traditional birth attendants: a decade of progress. Chronicles 36(3): 92–96.
  7. Ejembi CL. TBA re-training programmes: experience from northern Nigeria. In: Defining the future role of traditional birth attendants in reproductive health care in Nigeria, 46–57.
  8. Payne AO. How to Remunerate Traditional Birth Attendants in Reproductive Health Care in Nigeria, 92–95.
  9. Abioye-Kuteyi EA, Elias SO, Familusi AF, Fakunle A and Akinfolayan K. The role of traditional birth attendants in Atakumosa, Nigeria. J Royal Soc Prom Health 121(2): 119–124.
  10. Pretorius E. Traditional healers. S Afr Health Rev 1999. <%-6>
  11. Family Care International (FCI) and the Safe Motherhood Inter-Agency Group (IAG). Good Quality Maternal Health Services. New York: FCI.

Copyright 2002 - Women's Health and Action Research Centre


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