Killers or saints: Examining TBA’s role in maternal health care (Part 11)

• They contribute 60% of maternal deaths in Lagos State  – Gynaecologist

Dr. Oshodi

In part 1 of this story,  NHO reporter Juliet Umeh visited some traditional birth attendants  (TBAs) in some Lagos communities  and discovered that quite a large number of women, especially in communities without modern facilities, still rely on them for their antenatal care and deliveries. To some of this women, the TBA’s are God-sent even with the dirty surroundings and glaring unwholesome practices in some of the centres.  In this concluding part, Juliet spoke to a gynaecologist  in a public hospital and some healthcare practitioners who believe some of the TBAs are sending many women and their children to early graves and should be checked. Enjoy it.

NHO investigations revealed that it is not all pregnant women who patronise the TBAs that come out smiling with their babies. Many have reportedly entered, not to come out alive- a story you are not likely to be told at any of the TBA centres.

Bukola Ayeni, a Lagos-based broadcaster indeed expressed her worry about this trend to  NHO. According to her, many of the deaths of women during child birth while being attended to by TBAs are not recorded.  Yet, several women who patronize these TBAs, especially in rural areas.  appear to have so much confidence in them than the hospitals.

“I know of two women at least in my area who lost their babies. One of the women died in the process. She had a General Hospital card but when she wanted to give birth, she opted for the TBA and the unfortunate happened,”  Ayeni  disclosed.

In the view of Dr. Yusuf Oshodi, a lecturer and Consultant Obstetrician & Gynaecologist at the Lagos State University Teaching Hospital, (LASUTH), activities of TBAs are a headache.

His words: “TBAs are known to mismanage patients, collect their money and later push them out. We review maternal deaths on monthly basis because all government hospitals must keep record of maternal deaths. In the review we did two years ago, looking at three consecutive years, TBAs contribute over 60 percent of maternal deaths.”

“Some of them connive with auxiliary nurses to carry out unwholesome medical practices. Next, they administer injections in unregulated manner and before you know it, the baby is affected.

“What I am telling you happened less than two weeks ago in Isolo. Both the woman and her baby died. So, that kind of story is always repeating itself. The relatives don’t complain. I won’t like to reveal identities but they are loyal to the TBAs as if they swore to an oath. It makes it difficult to follow up with the persons responsible.

“Although some TBAs who are certified and registered claim there are quacks among them, what they ought to do is liaise with relevant government agencies to weed out the quacks because the fact remains that all patients that come from TBAs are regarded alike, whether or not they are registered.”

Oshodi  is particularly worried that people who could be said to be enlightened and educated patronize TBA homes. He termed the development “poor health seeking behaviour”.  According to him, some of the affected women die within 10-20 minutes on arrival at the hospital.

“It’s as if they come to collect their death certificates,” he added.

But most women at the TBA centres say the hospitals are not perfect either.

Adeyinka Olabisi, a young pregnant woman seen at a TBA centre in Ikorodu  took serious exception to the notion that TBAs are responsible for a large number of death of mothers and children during pregnancy and delivery. “No, that can’t be true,” she said, shaking her head.

“Women go to traditional people  because their services are cheaper. Hospitals charge a lot of money and they will prescribe too many things to buy.”

She told NHO that her first baby was born at that Home and she has continued to patronize the place with the approval of her husband.

Another woman, Ikilima Ismail remarked: “I was going to hospital but I discover that they are not taking good care of me, so I stopped going there. I started coming here when my pregnancy was 18 months. We just came from Abuja and we discover that many people are coming here and that their services are very good and as I come here, things are going well with me.”

Sadly, despite the campaign against maternal mortality, Nigeria still has one of the worst indices in the world and is second only to India. In the days of old, the use of TBAs and home deliveries were preferable for the local community due to the dearth of healthcare facilities, long distance from facilities and financial limitation.

These were the three major constraints that prevented community members from accessing and using trained midwives and institutional deliveries. But a lot has changed since then. Although still below what the country should have, there has been an increase in the number of facilities, especially in the urban centres

According to the World Health Organisation data on maternal mortality, in 2013, there were 560 deaths per 100,000 births in Nigeria. That figure includes women who die during or within 42 days of giving birth. Figures for Nigeria published by the World Bank in 2011 show that only 49 per cent of births were attended by trained healthcare workers.

Similarly, in the National Demographic and Health Survey (NDHS) in 2013, the maternal mortality ratio is 576 deaths out of every 100,000 live births. The figure is as high as 1,100 deaths per 100,000 live births in northern Nigeria and in rural communities where women have little or no education and access to essential health services is low.

With about seven million annual births, the number of women who die is about 58,000 each year.

Maternal mortality rates in West Africa are among the highest in the world. One in every 30 Nigerian mothers die in childbirth compared with one in every 30,000 in Sweden. In Sierra Leone in the early 1990s, more than 2,300 women were dying for every 100,000 babies that were born alive.

In Nigeria, 1,100 women were suffering the same fate. The situation in both countries has improved dramatically in the past 25 years. Sierra Leone has more than halved the number of maternal deaths to 1,100 for every 100,000 births, just as in Nigeria where the rate is 576 women for every 100,000 births. But this is a far cry from what obtains in developed countries. In Sweden, there are four deaths for every 100,000 births. In the US, there are 28 for every 100,000 births.

During a recent media interaction on the 2017 Maternal, Newborn and Child Health initiative, Special Adviser to the Lagos State Governor on Primary Health Care, Dr. Olufemi Onanuga, stated that the maternal health burden for the state is 555 per 100, 000 live births.

Olawole Abiola, health education officer at Amuwo Odofin LGA, also told NHO that Ori Ade LGA records the highest maternal mortality figures in Lagos. Most of the deaths are traceable to TBAs, he noted.

“Like we heard, not all of them are registered, possibly it is those who are not registered in the riverine areas, because Amuwo Odofin and Ori Ade have a vast riverine landscape and I think because of that the unregistered TBAs thrive more there,” he said.

                          Oluesesi                                                                            Dotsey

But Prince Mare Tajudeen  Olusesi, National President, Association of Traditional Midwifery of Nigeria disagree with the view in the medical circle about the activities of the TBAs. To him, the TBAs are doing a great work in the country, noting that his Centre takes up to 50 deliveries in a year.

“We do everything possible to make sure we have safe deliveries,” he added.

He also  expressed displeasure over the uncooperative disposition of government and the medical personnel.

“We don’t get support when there are complications that are referred to the General  Hospital.  They don’t attend to such referrals immediately; you start hearing different stories and queries like ‘Where are you coming from?’  ‘Who ask you to go there?’  All these will not help our health system.

“Instead of saying what is not about us, they need to embrace us and continue to train and retrain our members because the WHO advises every nation to establish a Board of Traditional Medicine and grow it with their peculiarities.

“What the Lagos State government needs to do is to include us in their own health system database so that when they are taking records of maternal mortality they will not be passing all the blame on the TBAs.

“The irony of it is that the births of most of those in government or working in general  hospitals today were mid-wifed by TBAs.

“If they said people should not come to us, how many can PHCs and General Hospitals attend to? Go to the health centres now, you will see many pregnant women waiting to be attended to while the nurses just shout at them. That is why some of them will not patronize government health facilities. So, when they come to us, we pamper them, talk to them and we rub minds together.”

However, Olusesi  also pointed out that most of the bad outcomes of childbirths are from auxiliary nurses not TBAs. “The Lagos state government warned most of the private hospitals not to train auxiliary nurses but they still engage in such. Until all the quack nurses tagged auxiliary nurses are fished out, there is likely not going to be headway,” he submitted.

Samuel Komi Dotsey, the TBA chairman in Badagry zone, who has been practicing for over 48 years said, “to ensure due diligence in our work, we usually inspect the premises of any intending practitioner before the person will think of going to the traditional medicine board for registration.

“Before I attest for any intending member, I always visit their premises so that certificate will not be issued wrongly by the Board. Without visitation, I cannot sign because the Board has to see my signature before giving approval. Some people are using two rooms, others, one room; provided it is very neat. The person must be ready for inspection anytime.”

Advancing reasons why TBAs are patronized by so many women, Dotsey said: “When you counsel, psychologically you are healing the person. When they come, we don’t demand money first, we start by counselling. That is why I don’t have a signboard. Patients do that for me.”

45 year-old Veronica Olawunmi Tewe,  leader of a faith-based organisation in Ikorodu agreed with Dotsey.  She told NHO that women flood TBA Homes because they have cultural appeal, are affordable, and have flexible payment methods (pay as you go) among other attractions. She said patients pay as little as N200 per antenatal visit, unlike in the private hospitals where the demand could be as much as N20, 000.

“In terms of availability or proximity, we are closer to the people. So, it is a lot more flexible than private hospital that will tell you to go and bring this or that, you can easily go and knock on the door of any TBA, there is one-on-one approach,” she asserted.

“In the orthodox system, the nurses are too hostile to patients, they don’t have their time, and it is too formal. An average TBA would go and visit patients at home but nurses don’t do that. We even attend their naming ceremony, she remarked.”

All the TBAs that spoke with NHO claimed they had never experienced incidence of death in their clinic.

“When we have what we can’t handle, based on our orientation and training from the Lagos State Traditional Medicine Board, we send them to the General Hospital,” Tewe told NHO.

She said the TBAs know their limit, she added, listing  indicators such as  delayed labour beyond 12 hours, if the baby is bridged,  there is High Blood Pressure,  legs are swollen, or the woman has previous history of CS as conditions that should make a TBA refer a patient to a government facility.

Mrs Veronica Tewe, Proprietress, Winners Healing Maternity home, Ikorodu

NHO investigations revel that The TBAs in Lagos are regulated by the state government. Speaking while presenting certificates to some TBA graduates in 2016, Governor Akinwunmi Ambode noted: “One of our policies in the health sector is to empower our traditional medicine practitioners and make them an integral part of our healthcare delivery system.

Lagos State has a functional Traditional Medicine Board that has strategic programmes targeted towards regulating, monitoring, promoting and integrating traditional medicine into modern healthcare system based on the 1978 Alma Alta Declaration of WHO.

“The objective is to streamline traditional medicine and change public perception of traditional medicine as a religious and spirit-magical practice by virtue of their proximity and accessibility to the rural dwellers.”

Ambode noted that the State decided to train TBAs to protect the health of mother and baby; care of women during pregnancy and child birth; and to refer women and newborns to higher care when conditions arise beyond their scope of practice and capabilities.

But the latent questions in the minds of many are whether the TBAs have requisite training to address the cases they come in contact with as most of them claim to have learnt the craft from their parents and have also gone for further trainings?  Are they really adding value to the health system?

Onanuga believes they are, saying the state government has invested a lot in training them and ensuring that they add value.

“For instance last year, 400 of those we trained were awarded certificate by Governor Ambode. This year, we are also training another 400. What we are preaching to them is that they should internalise the training we are giving them and that they should also know their limit. They should know all the danger signs; they should know when to refer to PHCs and the secondary health facilities. So, they add value to the health system.”

He, however, added: “We also need to do a lot of enlightenment on health education very well, so that they know what to do. So, like I have said, I am sure we can always have checkers and then we move forward to reduce maternal mortality.”

However,   Dr.  Oshodi believes that TBAs have no business taking deliveries and his reason is simple: “When you talk about skilled birth attendant, what does that mean? That means the person must have the requisite training, be certified knowledgeable and skillful using the competency-based test.

“So TBAs are not recognized as skill birth attendants in the balance of obstetrics practice, they are not, because if they are, tell me a patient that is in labour, and has had two deliveries before and suddenly the labour was not going on, may be the uterus was not contracting again: What will they do? Is it incantation, or would they give the drugs inside drip to enhance the womb to contract so that the labour can continue and the woman deliver? How will they do that? They don’t know.”

On how to make health care services attractive, Oshodi identified some key points.  “Yes, if we can make health care services delivery free, it will be an incentive. Two, if health workers should be more accommodating; because patients are complaining that healthcare workers are rude and not compassionate. If health personnel change attitude and become more receptive, patients will stop seeking alternative.

“Importantly, the wherewithal that the doctors and health workers need to work should be provided along with adequate healthcare personnel like doctors and nurses. More so, there is need for legislation that will include sanctions to deal with quackery. When people are made to face the wrath of the law then it will serve as deterrent to others and the others will not want to do it,” he suggested.

Further, he suggests massive health education and campaign involving grassroots levels, all stakeholders – market women, opinion leaders, traditional rulers and religious leaders; professional associations as well such as tricycle operators, i.e. Okada riders, hair dressers, and pepper sellers.

Interestingly, Oshodi wants the Ondo State approach adopted in Lagos. According to him, TBAs in Ondo state  have been stopped from taking deliveries.  Rather, they now act as “community scavengers”. This involves taking pregnant women that approach them to government hospitals  and for that, they get compensated.

Oshodi  says if this is working in Ondo state, it can also work in Lagos.