By Vivian Chime
Calabar, Cross River: At Palm Street in Calabar, the capital of Cross River State, Idoreyin Sayo-Ajayi is full of smiles on the morning of January 19 this year.
She grins from ear to ear as she prepares to leave the home of a Traditional Birth Attendant or TBA at 137 Palm street, where she had given birth to a healthy baby three days before.
“It wasn’t stressful,” Sayo-Ajayi, whose two out of three children were delivered by TBAs, said of her delivery process, “so I thank God for safe delivery.”
Like Sayo Ajayi’s, testimonies of how TBAs have helped women deliver successfully abound in Nigeria.
But, for the ugly side of this traditional practice, which is that many expectant mothers die in the hands of TBAs, Sayo-Ajayi’s Cross River State government has moved to ban TBAs completely through legislation, a move some experts believe is inappropriate at a time the state’s healthcare system is not well-equipped to fill the gap TBAs would leave behind.
“We have come to seek the support of the state House of Assembly to pass bills against the traditional birth practices (that) endanger our women during childbirth,” Janet Ekpeyong, state director-general of Primary Healthcare Development Agency or PHCDA, had said to lawmakers last October. “TBAs have become a menace to the society…and do not know their limits.”
Most TBAs are unskilled, often learning their craft either through observation or apprenticeship to a relative or a non-family member. When complications arise during labour, they are unable to handle, often leading to the mother’s death.
For example, 40-year-old Essienowan Emmanuel-Abi, the TBA that catered for Sayo-Ajayi, has been in the trade for 10 years but never had any formal training.
“It is a gift from God, I did not learn from anyone or any hospital,” She declared proudly. “I don’t have a certificate.”
Despite the risk, forcing out TBAs could lead to more maternal deaths because: “The TBAs are simply filling a vacuum that has been created from the shortcomings of the (states’ poor) orthodox health system,” says Lawal Onyeneyin, a chief consultant obstetrician and gynaecologist at the University of Medical Sciences in Ondo State.
At least 55 percent of Nigerian women use TBAs, only 36 percent use skilled birth attendants or SBA. Overall, 23 percent of all maternal deaths happen in Nigeria.
Cross River is one of Nigeria’s most MMR-burdened states. Data from Maternal Figures, a database for maternal health interventions in Nigeria, shows that the state has 820 deaths per 100,000 live births, nearly 37 percent higher than the national rate of 512 deaths per 100,000 live births.
So why is patronage to TBAs high?
One major problem is the costly out-of-pocket expenditure required to deliver at a hospital or clinic.
A 2020 study observed that obstetric care – the professional care women receive during and after childbirth – in a public health facility in Nigeria costs a minimum of N43,000 ($113).
That is significantly high in a country where over 83 million or 40 percent of the population live in extreme poverty.
The cost could be over 200 percent higher at private healthcare facilities. Many TBAs charge way lower than public clinics. Emmanuel-Abi, for example, charges N5,000 (about $12) to deliver a baby.
A second reason is a heavily underfunded healthcare that lacks adequate facilities and a shortage of skilled personnel, especially in rural settlements where TBA patronage is highest.
In 2018, for example, only four percent of the national budget was allocated to health, which fell significantly short of the 15 percent all African countries agreed to allocate to health yearly during a joint Declaration in Abuja about 20 years ago.
In 2019, the nation’s healthcare budget increased to 5.66 and later shrunk to 4.1 percent in 2020.
Regarding the shortage of health personnel, estimates from the World Health Organization show that Nigeria has 0.4 doctors per 1,000 people and 1.2 nurses and midwives per 1,000.
Those numbers, put together, are way below the 4.45 doctors per 1,000 population recommended by the World Health Organization.
TBAs are among those filling the gap the shortage of health personnel has left; that is why experts feel forcing out TBAs could be risky.
The government should create an incentives-enabled referral system that would keep TBAs involved in the fight against MMR, they argue.
Ondo and Lagos examples
Such an inclusive approach applied in the past in some parts of Nigeria proves that TBAs could be instrumental in getting more expectant mothers to begin delivering their babies at health clinics and with the help of skilled birth attendants.
For example, before 2009, the MMR rate in southwest Nigeria’s Ondo State was 742 per 100,000 live births.
To beat down this number, the state government introduced an initiative called “Agbebiye” in Yoruba, a language spoken in most parts of Nigeria’s Southwest region. It translates to Safe Birth Attendant initiative.
Under the programme, TBAs were offered N2,000 ($5.25) for every pregnant woman they referred to a medical facility.
To further encourage the TBAS to stop their traditional baby-delivering practice, the programme also offered small loans to TBAs to start small businesses after taking them through livelihood training, including in bead making, catering, soap production, tailoring, and others.
Through Agbebiye, in combination with Abiye or safe motherhood – another government-introduced initiative where a community health extension worker called “health ranger” was appointed to monitor 20 pregnant women in their local areas, health rangers were able to help pregnant women in labour reach health centers in time using government-provided motorbikes and ambulances.
In addition to setting up new healthcare centers in underserved communities, refurbishing existing ones, and equipping them with professional health personnel, the government also provided pregnant women with cell phones for ease of communication with health rangers during emergencies.
In the end, most TBAs in the state stopped their baby-delivering practice. They focused more on referring women to health centers.
By 2016, two years after Agbebiye kicked off, nearly 95 percent of all pregnant women in the state delivered their babies at health clinics and by skilled health attendants.
Consequently, the state’s MMR dropped from 742 to 112 deaths per 100,000 live births.
In Lagos State, where the MMR stood at 800 per 100,000 live births as of 2008, the government did not ban TBAs nor insist that they refer pregnant women to health facilities.
Instead, it set out to achieve safe delivery for women and their babies regardless of the place of delivery by revisiting a 1980 law and broadly incorporated TBAs as necessary health partners in the law.
This created room for the health ministry to provide training to TBAs and strictly monitor their activities and compliance based on laid out rules.
A 2017 government-set-up task force had asked TBAs to register with the health ministry to receive training (including on how to stabilise a mother during complications) and operational licenses, with a threat to fine or ban those who failed to register.
The task force also regularly visited the registered TBA premises to enforce operational compliance, including maintaining a clean environment and having the needed kits and information to operate.
The strategy worked as the state’s maternal deaths now stand at 165 per 100 000 live births, a 79 percent decrease in maternal deaths.
Experts say the Ondo and Lagos models should be replicated across Nigeria to bring down the national maternal death numbers.
“States should be willing to adopt the Agbebiye model by removing the impediments militating against the populace referring TBAs to government hospitals, like hospital fees, attitudinal improvement of staff and equipping facilities,” says Onyeneyin, the consultant obstetrician.
However, in replicating these solutions, states must avoid mistakes made by Ondo and Lagos states to cut MMR to the lowest level possible.
For example, in Ondo, as more and more pregnant women started visiting health centers across the state because the government did not adequately prepare for what was coming, the available health facilities became overcrowded with expectant mothers, further leading to a shortage of qualified health personnel.
Many women had to wait for long hours before attention at the centers. According to Ajewole Fadekemi, an Ondo-based mother who benefitted from Agbebiye, the exhausting administrative procedure women were observing when they visited health centers could, on average, be two hours.
Also, since the Agbebiye initiative was a mere policy without any legislative backing, when the term of Olusegun Mimiko, the then governor of Ondo who started the Agbebiye initiative, ended in 2016, the new administration of Rotimi Akeredolu did not continue the programme as vigorous as the Mimiko government did.
In the end, some traditional birth attendants returned to their trade, and since expectant mothers had to spend long hours at health facilities due to a shortage of personnel, they went back to patronizing TBAs.
Consequently, the MMR in Ondo has surged from 112 deaths in 2016 to 253 deaths per 100,000 live births in 2019.
For Lagos state, despite having trained over 7,000 TBAs, Olorunkemi Kadiku, Coordinating Director of the Lagos State Traditional Medicine Board or LSTMB, said the state “is like scratching the surface” as a lot more TBAs still abound who have not received any form of training or are not even aware of its existence due to inadequate publicity. It implies that a lot more needs to be done to inform TBAs and persuade them to enroll.
Back in Cross River, as criticism increased over the proposed plans to ban TBAs with no proof of any clear-cut plans to handle the gap TBAs’ absence will leave, the government reversed course and started considering the option of using TBAs as referral agents.
But the state is likely to encounter challenges in the improvised referral system because Ekpenyong, the head of the state’s Primary Healthcare Development Agency, has ruled out any monetary compensation to TBAs, the very thing that helped the Ondo model – which Cross River is now hoping to replicate – succeed.
“It will be a huge burden because considering all the other competing priorities, we are still working on how we can fix the health sector, so giving money to TBAs from the (health) ministry might not be possible,” Ekpenyong said.
Ekpenyong’s excuse is flimsy at its best, argues Oyeneyin, the obstetrician. Paying a TBA N2000 (less than $5) to refer a pregnant woman to a health facility for safe delivery is “actually very economical” compare to the state having to spend more every time “a woman in labour faces complications resulting from either a mismanagement by a TBA” or from any such cases like “excessive bleeding or ruptured uterus (that is when the womb is torn),” Oyeneyin said.
Meanwhile, some TBAs say they would work with the Cross River State government to reduce maternal deaths if compensated. Compensation is important because for some TBAs, delivering children is their only source of livelihood. If cut off from this source of livelihood, they might struggle to feed their families.
“Who am I to question the government? If they say I should stop, I will stop; I have hand-work to do, referring to her small-scale vegetable farming that gives her N6,000 or $15 every week. I’m just doing this to help (pregnant women),” said Emmanuel-Abi.
Sixty-seven-year-old Enang Etim-Nyong, a TBA who has been in practice for 45 years, said she would not participate in any proposed referral system if she is not compensated.
“They (the government) have to pay me for me to stop doing my job because pregnant women will still come to me. So [if they pay me compensation], whenever they [pregnant women] come to me, I will refer them to the hospital,” she said.
Etim-Nyong is correct; if even the government creates a referral system, women like Sayo-Ajayi would always patronise TBAs because, from TBAs, they get the extra care that healthcare workers might not be ready to provide
“Can a nurse boil water and massage you?” Sayo-Ajayi asked. “They [nurses] would not have time for that. But this woman (referring to Emmanuel-Abi) will take proper care of me, bathe me, make sure she heals the wound. That is a mother for you.”
If anything, Sayo-Ajayi’s resolve shows that Cross River State and, indeed, other states have a great deal of work to do to tackle maternal mortality.
This story was produced with the support of Maternal Figures.