My attention was drawn to an article on Nigeria Health Watch (NHW) blog where my BMJ opinion on the managed use of Traditional Birth Attendants (TBAs) in LLMICs, for good reason, was cited (Head To Head - Are traditional birth attendants good for improving maternal and perinatal health? Yes. BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3310
We share the NHW article, below, courtesy of Researchgate (https://www.researchgate.net/profile/Joseph-Ana/stats/report/weekly/2022.... It is very instructive and throws even more light why a formal engagement of TBAs are an essential and necessary option as LLMICs struggle to reduce appalling maternal and newborn morbidity and mortality.
I was excited to note that other state governments in Nigeria have embraced our positive opinion, and that ‘ ----- The Lagos State Government recently disclosed that TBAs accounted for 14,536 deliveries in 2015, lower than the previous year whenthere 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.’.
We look forward to the time when the authorities in the Federal Ministry of Health would reflect on the crucial question in the article and review its current position about TBAs, based on the plethora evidence, that is, ‘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?’.
READ ON –
‘’Traditional Birth Attendants: Friend or foe?
By Chibuike Alagboso . date July 16, 2018
[Extracts below. Read in full: https://nigeriahealthwatch.com/traditional-birth-attendants-friend-or-fo... ]
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 thatpoint, 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 fivehundred 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...
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...
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...
A 2015 statistics brief by the UnitedNations 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...
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.”...
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...
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...
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 inmaternal 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...
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 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 culturalpeculiarities 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 thebarriers 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? ‘.
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Prof Joseph Ana
Lead Senior Fellow/ medicalconsultant.
Center for Clinical Governance Research &
Patient Safety (ACCGR&PS)
P: +234 (0) 8063600642
E: info@hri-global.org
8 Amaku Street, State Housing &20 Eta Agbor Road,
Calabar,Nigeria.
www.hri-global.org
HIFA profile: Joseph Ana is the Lead Senior Fellow/Medical Consultant at the Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria, established by HRI Global (former HRIWA). He is a member of the World Health Organisation’s Technical Advisory Group on Integrated Care in primary, emergency, operative, and critical care (TAG-IC2). As the Cross River State Commissioner for Health, he led the introduction of the Homegrown Quality Tool, the 12-Pillar Clinical Governance Programme, in Nigeria (2004-2008). For sustainability, he established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria. His main interest is in whole health sector and system strengthening in Lower, Low and Middle Income Countries (LLMICs). He has written six books on the 12-Pillar Clinical Governance programme, suitable for LLMICs, including the TOOLS for Implementation. He served as Chairman of the Nigerian Medical Association’s Standing Committee on Clinical Governance (2012-2022), and he won the Nigeria Medical Association’s Award of Excellence on three consecutive occasions for the innovation. He served as Chairman, Quality & Performance, of the Technical Working Group for the implementation of the Nigeria Health Act 2014. He is member, National Tertiary Health Institutions Standards Committee of the Federal Ministry of Health. He is the pioneer Secretary General/Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers. (http://www.hifa.org/support/members/joseph-0 http://www.hifa.org/people/steering-group). Email: info AT hri-global.org and jneana AT yahoo.co.uk
