A Dangerous Alternative
By Chinenye Eseke.
In spite of its dangers, many Nigerian women still patronize untrained traditional birth attendants, for reasons ranging from poverty to ignorance and inadequate primary health care facilities writes Chinenye Eseke.
Didikankide Joseph, a Traditional Birth Attendant (TBA) in Bomadi, Delta State, is one of the few trusted by the locals in that community. And he is ever ready to flaunt his “great exploits”. In fact Joseph fancies himself as a lifesaver. For instance, he says he once came to the rescue of a woman whom doctors had told could not deliver except through Caesarean section, when her husband could not afford the N40,000 hospital bill. Confronted with such a dilemma, he says the couple came to his makeshift clinic where the delivery will not cost more than N10,000.
His clinic is a small hut without mattresses or other equipment, apart from a pair of gloves and needles. There is no ventilation. It is so small that it can barely contain two pregnant women at a time. Others would have to wait outside for their turn regardless of the fact that they may be in labour.
In spite of that, Joseph has been a TBA since 1991, and his business appears to be waxing stronger by the day. Curiously, he says he was never taught by anybody “except God”. Joseph’s popular mantra has always been that, “your mama gave birth to you without operation; so you too must give birth without operation”. With those words Joseph encourages the women who daily throng to his makeshift clinic.
He has recorded several successes over the years but he has also had his fair share of failures. And when failures occur, it always leaves a sad taste in the mouth, particularly for the family of the patient. Perhaps the most traumatic was when a birth attendant had to deliver a set of twins who medical doctors said could only be delivered through Caesarean section. The attendant took the woman into his small hut and tried to bring out the baby manually. In the process of delivery, the TBA discovered that the first baby was trying to come out with the legs first rather than the head. “I tried carefully to drag out the baby with the legs but unfortunately, the head came off from the body and went back into the mother’s womb. The remaining part of the baby’s body came out. It was a most horrifying experience”, he says.
At this stage he says, the terrified husband of the pregnant woman burst into tears. But all the TBA could do was to console the distraught husband while hoping for a miracle to save the life of the second baby and the mother. Fortunately, when the woman went into labour for the second baby, the dead baby’s head came out before the second baby, who was delivered successfully. “It was only God who saved the woman’s life and that of the second twin,” Joseph admits.
Such terrifying experiences do not however stop women living in such communities from patronising TBAs. For some it is a case of blind trust, while evidently for some others it is just the most affordable option. For instance, within the first nine months of 2014, Joseph delivered 68 babies. “Sometimes [the women who come to the clinic] are so many that I don’t have chance to attend to them. I tell some of them to leave my house but they choose to wait,” Joseph says. He further claims that, “If any one of them starts experiencing labour pains, I command the baby to wait for its turn and the labour will stop for a while. When I am through with the first woman, I will now come back to others”.
When it is eventually her turn, the pregnant woman is taken to the ‘labour room’ and positioned for delivery. Joseph wears hand gloves and uses his finger to probe the woman’s genitalia to measure the dilation and centimetres left before the baby will come out. He keeps checking the progress until he is sure it is time for delivery. Then he lays her on the floor of the room and asks her to push while he assists her efforts with his hands. When the baby eventually comes out he uses a razor blade to cut off the placenta. Then he gets a sewing thread or plaiting thread to provide any stitching necessary. He then cleans up the baby with water and hands it over to the mother. At that stage, his job is done.
So how does he handle complications? His usual response is a resort to mysticism or an appeal for divine intervention. In any tough situation, Joseph prays to God for assistance. There are times when a woman’s labour ceases after waiting tirelessly for her turn. In such a situation, Joseph claims that he commands the woman to start labour when it is her turn to be attended to.
Regarding how he sterilises his equipment and environment, Joseph says the expectant mothers come with disinfectants of their choice to sterilise and clean up the baby and mother. And since there is not much equipment other than the new sets of needles and razors, there is no need for any serious attempts at sterilization.
As poor as his facilities are, Joseph is obviously overworked. He delivers at least 50 per cent of Bomadi’s babies. Does he deliver his own babies? “I have six children. Three were delivered by other TBAs because my wife doesn’t believe in me; when she saw that more women in the community are delivering with me, she allowed me to deliver the other three,” he reveals.
Joseph relies heavily on his predictions and intuition for the deliveries he handles. He says he once told a woman who was in her ninth month of pregnancy that she would still have to stay extra two months before delivery; she doubted him and went to the hospital, but her labour never came until after exactly the two months he predicted. Perhaps this is one of the reasons most women in the community trust his sense of judgment, sometimes even at great risk to themselves.
He is not alone. Joseph is just one of many TBAs who operate in Nigeria. Salamotu Jubril, 47, is a birth attendant fondly called “Amiria” in North-central Nigeria. Like Joseph she operates from her house, an uncompleted building, in Idah, Kogi State. She has been in the business for more than 20 years. In her own case, she recites certain incantations to deliver babies.
Indeed, her modus operandi is quite strange. “When a woman is in labour, I take her to the back of my house where I have a plantain farm. She would sit on a [log] facing the river where her blood would be flushed during delivery. Then I will start some incantations. When the baby is ready to come out I will cut the leaves of the plantain and place them on the floor; that would be where I would keep the baby when it is delivered. I will then dig a small hole in the ground where I would bury the placenta,” she reveals.
Like Joseph, she too believes that no woman should give birth through Caesarean section, because she can attend to her. When there are complications during childbirth, like bleeding or not being able to push out baby due to a narrow pelvis or other causes, Jibril simply mixes a drink from some native herbs for the mother to drink. After that she gently pushes a stick into the woman’s mouth three times. On the third push, she claims that the woman will naturally deliver her baby. TELL Magazine, however, did not witness this spectacle.
Carol Nwankwo, a birth attendant in Nibo, Anambra State, south-east Nigeria, has a different mode of operation. She takes her clients into her room where she delivers the pregnant woman’s baby and, with the aid of a razor, cuts off the placenta and massages her with herbs. Next she gives her a herbal drink which, she claims, will help her body to heal pretty fast. In recent times, however, Nwankwo says she has limited her services to her immediate family members, because of the risks she had faced over the years. She fears she could contract deadly infections from women she doesn’t know.
On the other hand, some churches also have birth attendants who deliver babies. Elijah Iloana, evangelist at The Church of Jerusalem, Abagana, Anambra State, said his church prays until a pregnant mother is delivered of her baby. “We have a sister who assists to deliver our babies. She was trained by her late mother and now she took over from her. We just take the lady in and pray for her ‘til she delivers”.
How the Church of Jerusalem in Abagana deals with complications during childbirth is far from being spiritual. They simply give the mother coconut water to drink. When this fails, they send the mother to the hospital. Most times those mothers do not survive because they get to the hospital too late. Some actually die on the road to the hospital. At Christ Apostolic Church, Kuchiyako, Kuje, Abuja, an old lady works as a birth attendant for the brethren. Most mothers in Kuchiyako community trust her more than the regular maternity attendant.
Despite all the dangers of traditional maternity homes, some women give reasons why they still prefer such places. Victoria Emmanuel, 22, is one of the women for whom Joseph performed delivery at Kpakiama, Bomadi. The young lady got married at 19 and has lost three children at the hands of TBAs. She had only been able to deliver her first live birth and fourth baby when she met Joseph. Since then, her children have lived; her newest baby was just five days old when TELL Magazine visited her.
Emmanuel has the option of giving birth at the primary healthcare centre (PHC) in Kpakiama, but it lacks adequate infrastructure. The PHC facility in the village is quite a distance away and not easily accessible. The only road leading to the facility cannot be accessed by car. More than that, the women also claim that the PHC centre closes early, so that women who are in labour at night have no one to attend to them, even when they manage to surmount the challenge of bad roads to get to the facility. “My husband is always scared that I might die if I give birth in the primary healthcare centre in our village; he said women are abandoned in pain to die, so he vowed never to have his babies in any hospital,” Emmanuel explains.
For Blessing Avwotu, a 30 year-old mother who had all her seven children delivered in traditional birth homes in Atamua, Sapele, Delta State, her challenge is poverty. She is the breadwinner of her family and claims that she gets little or no support from her family and claims that she gets little or no support from her husband. The lady shares a room with her seven children. She feeds them from the cocoyam she cultivates and sells in the market. Going to the hospital for delivery is a fantasy to her because she cannot afford the bills. She would rather go to a family friend who is also a TBA and whom she can pay the bills in installments.
Beyond poverty, there are other women for whom cultural influences are at the centre of the preference for TBAs. One of these is Mariam Ibrahim, a 30 year-old mother of three from Pagin, Kuje, Abuja, who delivered her five children at home. The Gbagyi woman said it is against her culture for another man to see her private parts. Consequently, her husband arranges an elderly female birth attendant to deliver her babies at home.
Chenemi Idris, a 24-year-old housewife and a mother of one who lives in Shanagu Gwagwalada, Abuja, was forced to patronise TBAs because of absence of a properly equipped PHC in her community. She delivered her first son with help from an elderly woman introduced to her by her mother-in-law. “[This woman] is very good at birth delivery. My mother in-law said she delivered most of her babies and she wants me to always deliver my babies with her too,” she explains. For the past 15 years, Shanagu Community has had to convert its primary school into a makeshift clinic.
The stories of these women are not unusual. On the contrary, they represent the plight of a segment of women in Nigeria, which significantly contributes to the high maternal and infant mortality rate in the country.
Looking at the situation, Rilwan Mohammed, Executive Secretary of the Federal Capital Territory Primary Health Care Development Board, is of the opinion that the PHC system is not working in Nigeria. He says that PHCs are regarded as unimportant in Nigeria, and attention is only fixed on general hospitals. “In FCT, we have 250 primary health care centres and only 12 general hospitals, and [the hospitals] are working very fine while the primary health care centres are not working at all. I am the Executive Secretary, they are not in order in terms of equipment, in terms of facilities, in terms of essential drugs, in terms of electricity. They are closed by 4 pm, they are not working 24 hours’ service like most of the PHC centres in this country,” Mohammed says, while sounding rather frustrated.
The solution, he says, lies in the passage of the National Health Bill (which has just been passed by the National Assembly), whereby money will come from the federal government to strengthen the PHC centres. Under the new law, 50 per cent of the fund will go the to the National Primary Health Care, while the other 50 per cent will go to the National Health Insurance Scheme.
Realizing that most people in the villages prefer the TBAs, even in places where there are moderate health facilities, federal and state governments have taken steps to train the TBAs so they can improve on their handling of patients. But the results differ from one area to the other. For instance, Rukevwe Ugwumba, Special Adviser to the Delta State Governor on health monitoring, says that the efforts of the state government to train the TBAs have so far not been successful. She says that some women have continued to patronize the TBAs in spite of the fact that the state government provides free maternal health service. “Some people believe in [TBAs] no matter what they do. They will come to our antenatal class, yet they will go and deliver at the TBAs just because their great-grandmother and their families delivered there.”
Ebere Anene, Reproductive Health Coordinator at the Anambra State Ministry of Health, says that TBAs in the state practice in secret. “Anambra State government has donated 2,000 safe motherhood kits, that is what we call Mama kits, to about 14 health facilities in the state,” she explained. However, she lamented that there are not enough kits for all mothers. To curtail the risks faced by mothers who deliver at TBAs, the Anambra state government is also sensitizing TBAs to know when they are not supposed to take deliveries, and the dangers they and their clients are exposed to.
According to the World Health Organization, 608 deaths occur per 100,000 deliveries in Nigeria. These represent women who die during childbirth or within 42 days after childbirth. Nigeria ranks second only to India in the list of nations with the worst child mortality. Maternal and infant mortality rates are higher in places where women have many children within a short period of time. Sometimes it could be as a result of bad hygienic conditions, infections, HIV/AIDS, lack of access to medical care, bleeding after birth and lack of skilled birth attendants.
Indeed, whatever the reasons for mothers choosing to patronize TBAs, governments at all levels often insist that such centers are mostly run by quacks and should not take deliveries of babies. Does that render them anathema to good health delivery in Nigeria? Not really.
TBAs are believed to be serving an interim role in the provision of maternal health care in Nigeria in the absence of a better and affordable alternative for the people. For decades this has been the case, but recently there has been an ongoing debate as to whether they should continue to be a stopgap arrangement or a permanent alternative.
Around the world, different countries have adopted different legal approaches to the issue of TBAs. For instance, in Lebanon, Sudan and Turkey, TBAs are deemed illegal, while in the Philippines they are permitted to practice only in areas where there is no qualified midwife. In Nigeria, Rwanda, Zambia and the Democratic Republic of the Congo, they have no legal status but may practice in their respective communities.
On the other hand, in Chad, Colombia and Costa Rica, the practice of TBAs is regulated by the health authorities, so a register is kept. This practice, which is now increasingly being adopted by developing countries, appears to have also been adopted by some states in Nigeria. For instance, in Lagos, Ogun, Ondo and some other states, TBAs are trained and certified by the state health authorities, who also regulate their activities and link them to the nearest general hospitals to their communities for referral purposes, in the event that they encounter a difficult situation.
It is hoped that with such practises, the number of women who lose their lives at the hands of untrained TBAs will be drastically reduced.
*The fieldwork for this report was done with financial assistance from Partners for Democratic Change and the Institute for War & Peace Reporting. It is part of the Access Nigeria/Sierra Leone program funded by United States Department’s Bureau of International Narcotics and Law Enforcement.
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