16 July 2018

Nigeria: Traditional Birth Attendants - Friend or Foe?

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The young mothers in the community fondly call her "Aunty Dada"

Her first attempt at helping a woman deliver a baby was in a forest while escaping from insurgents. She had already seen several pregnant women die in childbirth in the forest and so at that point, she felt she had only two options. She could either let this pregnant woman suffer and die like the others before her, or she could try and help even with her limited knowledge. She chose to help and continued in the practice and at some point, during their escape, she helped a woman whose baby was already dead in the womb to deliver her baby. She said she only trusted her instincts to be able to do it.

Today, her practice inside a two-room unpainted building is no longer just informed by intuition, but by the experience she gained subsequently and, more importantly, by the skills and capacity she has developed through training by the Kabash Love Foundation (KLF) which targeted Traditional Birth Attendants (TBA) practicing in Internally Displaced Persons (IDP) camps across Abuja.

Dada Nguru is regarded fondly in the Kabusa camp for IDPs off the Abuja Airport road for her work helping over five hundred pregnant women deliver their babies successfully, in the four years since she was forced to relocate from the northeastern town of Gwoza due to the Boko Haram insurgency.

Liyatu Ayuba, another TBA in the Gwoza and Bama IDP camp northeast of Abuja, relocated in 2012 after her policeman husband was killed by insurgents and her son was maimed by a bomb blast. Liyatu watched her grandmother practice as a TBA and picked up the skills from her.

At the camp, Liyatu tried repeatedly to get treatment for her son, without any luck. Surrounded by young women who were getting pregnant, without easy access to primary health care, Liyatu decided to help these young women to deliver, relying on the knowledge acquired from watching her grandmother. Like Dada, she trusted her instincts and prayed to God to help her take deliveries successfully. Like Aunty Dada as well, she later received training in helping pregnant women deliver successfully, boosting her confidence and expertise.

The efforts of these women and others like them, though largely unregulated and seen by some nurses and midwives as encroaching on their professional territory, helps women deliver safely in areas such as IDP camps where healthcare services are sparse, and women and children are often vulnerable to illness.

A dire situation complicated by insecurity

In many parts of Nigeria, access to health services is already poor during peace time. The outbreak of diseases and conflict brings an almost total disintegration of the health system. When camps are set up for people fleeing from conflict, health services are often not considered and many IDPs find themselves reliant on sporadic outreach medical missions from NGOs and other humanitarian organizations for any healthcare.

A 2015 statistics brief by the United Nations Population Fund (UNFPA) shows that maternal mortality in humanitarian and fragile settings is 1.9 times higher than the world average. This means that if the global maternal mortality ratio is 216 for every 100,000 live births, countries with insecurity challenges have a ratio of 417 for every 100,000 live births. This is worse in West and Central African countries facing insurgencies or other humanitarian emergencies, where the maternal mortality rate is as high as 746 per 100,000 live births. Latest Nigeria Demographic and Health Survey (NDHS) 2013 data shows Nigeria's maternal mortality rate is 576 per 100,000 live births. Even without the present insecurity challenges, there is much work to be done in Nigeria to reduce the maternal mortality rate. To reverse this trend, former UNFPA Executive Director, the late Professor. Babatunde Osotimehin, recommended an improvement in the number of midwives and other health workers with midwifery skills.

Adaptive solutions for safer deliveries

Keturah Adams, founder of Kabash Love Foundation and her team designed an intervention to reduce maternal mortality in IDP camps across Abuja. She said the original idea was "to get women to go to health facilities and have their babies, so they can have safe and infection free procedures with trained personnel."

Their sensitization efforts targeted pregnant women in Bwari area council, about 20km off the Abuja - Kaduna expressway, focusing on educating them about the dangers of home deliveries. They used baby delivery kits as incentives to get women to visit health facilities for deliveries. However, they found that the women would take the delivery kits ahead of their delivery dates promising to return when they were ready to give birth, because they didn't trust the primary healthcare facility staff to give them the kits when they were ready to deliver.

Adams and her team found out when they came back to evaluate their initial intervention that only one out of the 200 women they had worked with gave birth at the health facility. The majority had gone to traditional birth attendants like Aunty Dada and Liyatu. On probing further, they learned the women resisted going to the health facility to give birth for several reasons. These included the way they were treated by the health workers and the cost of care at the facility. The women also preferred the TBAs who understood their culture and way of life.

The KLF team then came up with a new solution- bringing all the TBAs practicing in 23 IDP camps around Abuja together, to build their capacity in performing safe deliveries. The training took place in the Gwoza and Bama IDP camp in Durumi, and the TBAs were taught modern delivery methods.

Adams said the training involved first unlearning some of the harmful practices by the TBAs like using toothpaste for the umbilical cords, tying umbilical cords with clothes and vigorously shaking the newborn after delivery.

They also provided basic delivery materials like hand gloves, chlorhexidine cream and cut clamps for the umbilical cord and taught the TBAs how to use them. The TBAs were trained by a nurse who volunteers for the organization.

Replacing guesswork with training & evidence

Fatima Mohammed, who resides in the Kabussa camp has successfully given birth to two children since relocating from Gwoza three years ago. Describing giving birth to five-week-old Aliyu and two-year-old Aisha as seamless, she said she was home in less than 20 minutes after both deliveries. Fatima said she prefers using Aunty Dada for her deliveries because she charges little to nothing and treats her with respect.

Rakia Adamu, another camp resident, is currently pregnant. She says Aunty Dada delivered her last two babies, and her satisfied smile makes it clear that she plans to come to her when she goes into labour.

Aunty Dada admits that in the past she would get scared if the pregnant woman had suspected postpartum haemorrhage, this is where women bleed profusely after giving birth. Now, thanks to the training by Adams and her team, she is more confident handling certain levels of post-partum haemorrhage with drugs contained in the delivery kit presented to her after training.

The training also provided her with skills on identifying the danger signs before delivery and referring these women to health facilities early. She has had over 100 successful deliveries since she started practicing in the camp.

A stop-gap measure, not the ideal

Even though her success handling deliveries has spread fast by word of mouth and many pregnant women from distant locations come to her for assistance, Liyatu Ayuba says she is honest with the women and advises them on the dangers of home delivery.

She said most home deliveries occur in unsanitary conditions, exposing the new babies, the mothers and even the TBAs to infections. She has taken deliveries without gloves in the past, before the training, and shared the story of delivering a baby inside a tent during a thunderstorm. On that occasion, just as the baby emerged, the storm blew the tent away and they all got drenched, - baby, mother and Liyatu.

On her own part, Aunty Dada confidently declares that she has never recorded any death since she started her practice, information which she shared with the KLF team when they carried out a needs assessment prior to the training.

While this is commendable but perhaps hard to believe, it is difficult to prove or refute due to poor record-keeping practices. Dada said the records she had kept were taken away by organizations who visited the camp, to make copies. The records, she says, were never returned and the organizations never came back with all the things they promised. Adams said many TBAs struggle to admit any deaths because they believe it spoils their reputation.

Dr. Godwin Ntadom, a Gynaecologist and Chief Consultant Epidemiologist of the Federation in the Ministry of Health, strongly believes TBAs have increased the maternal mortality rate in the country rather than reduce it. He says outcomes are better when pregnant women are assisted by skilled birth attendants and maintains that the Federal Ministry of Health has not adopted their practice as a line of action in maternal care.

"The TBAs have this fake confidence in themselves that they can always do it. By the time they are referring that baby or mother, it's already too late," He said, adding that most of the TBAs are old and untrainable.

A senior member of staff at the Head Office of the Nursing and Midwifery Council of Nigeria, who preferred not to be named, said the council is not concerned with regulation of TBA practice and that she personally knows nothing about it.

Important questions to ask are: What would the outcomes have been for the women and babies assisted by these traditional birth attendants if they had not been there? What is the evidence on the balance between the harms and benefits of using TBAs?

The Lagos State Government recently disclosed that TBAs accounted for 14,536 deliveries in 2015, lower than the previous year when there were 23,229 deliveries from 809 registered TBAs. The state government is now working to regulate and monitor their practice through the Traditional Medicine Board which issues practicing licenses to the TBAs.

The ideal situation would be for every pregnant woman to have access to a skilled birth attendant in a properly equipped health facility. Where this is not possible, and access to healthcare is unreliable, such as in the IDP camps, we must examine the best available options taking into account the evidence of effectiveness, the risk of harm and the importance of keeping the patient with their unique contexts and cultural peculiarities the focus.

Could training TBAs like Liyatu and Dada to help women deliver safely be one way of providing a stopgap measure until the health system is able to break down the barriers that prevent women from accessing care? Or should the resources and energy being put into these initiatives be focused on improving access to healthcare and the quality of healthcare provided in facilities? We at Nigeria Health Watch would love to hear your views.

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