Knowledge and utilization of Traditional Birth Attendants by Women of Reproductive Age in Alanamu Community Ilorin, Northern Nigeria

Abdulwahab Lawal
University Of Ilorin teaching Hospital.

Wuraola Salawu
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

Oluwanifemi Makanjuola
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

Ambali Ambali
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

Oreoluwa Alabi
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

Ahmed Kareem
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

Chinjindu Nnaemeka
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

1Maryam Akande
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

1Tanimola Akande
Department of Epidemiology and Community Health, College Of Health Sciences, University Of Ilorin.

DOI: https://doi.org/10.55320/mjz.50.1.345

Keywords:knowledge, utilization, TBA, Traditional birth attendant, Nigeria

Background: The lack of access to skilled healthcare services during childbirth remains a major factor for high maternal mortality in developing countries as traditional birth attendants (TBAs) continue to serve as the predominant providers of maternal health care in rural communities. This study explores the knowledge and utilization of TBAs by women of reproductive age in a rural community of Ilorin, Kwara state in Nigeria.

Methods: This study is a descriptive cross-sectional study which was conducted using a well-structured interviewer-based questionnaire, administered to 212 women of reproductive age-group to collect data on their knowledge and utilization of the services of TBAs. Analysis was done using Statistical Product and Service Solutions (SPSS) software version 20.

Results: One hundred and fifty three respondents (72.2%) had background knowledge of TBAs, 91 (40.8%) had visited a TBA at least once to carry out their deliveries, of which 73 (80.2%) of them had successful deliveries, while 18 (19.8%) had complications during their deliveries, and 7 (7.7%) were referred to health care facilities for expert management. The study showed statistical significance between the level of education of respondents and their patronage of TBAs (p-value= 0.041), and showed no statistical significance with their level of income.

Conclusion: This study showed adequate knowledge and utilization of the services of TBAs by members of the community. The practice of TBAs has continued to thrive in rural communities. Integrating their services with the standard healthcare system as well as continuous sensitization of rural communities on their roles and limitations would go a long way in reducing maternal morbidity and mortality associated with the use of poorly trained TBAs.

A traditional birth attendant (TBA), may be defined a person who assists a pregnant woman during childbirth and had acquired her skills informally through the delivery of babies herself or through apprenticeship to other TBAs.^[1] A skilled TBA is one who has received a standard training course through the modern health care system, and has been educated in the skills and knowledge needed to be proficient in the management of uncomplicated pregnancies and childbirth with the ability to promptly identify and refer complications.^[1-2]

The roles of TBAs vary depending upon the local community.^[3] The primary function ascribed to a TBA is assisting pregnant women at the time of labour; this usually includes delivery of the baby, cutting and care of the cord, as well as disposal of the placenta. It may also involve post-delivery care such as maternal massage, child bathing and circumcision, domestic chores, and counselling during the postnatal period.^[1,2,3] Many TBAs are also consulted for counselling on family planning and infertility.^[3] Furthermore, there are some TBAs who also perform the functions of herbalists and spiritualists within the community.^[1-3] A trained TBA on the other hand is expected to augment her traditional functions by performing risk assessment in the prenatal period, as well as referral to health care facilities for expert management in the event of complications or emergencies.^[3,4,5]

There is no doubt that TBAs play a significant role in maternal and neonatal health within rural communities, however it is noted that they lack the special skills and knowledge to handle peculiar emergency situations and obstetrics complications^[4-5] . Pregnancies and deliveries taken under the supervision of skilled birth attendants are associated with a reduced risk to mother and child^[6] . In developing countries such as Nigeria, many women lack access to skilled health care delivery during childbirth, which has contributed to rising maternal and child mortality^[1-6] , The World Health Organization currently estimates the maternal mortality ratio to be more than 1000 per 100,000 live births in many African countries^[1] , whereby only about 46% of women living in rural areas receive antenatal care services from skilled birth attendants.^[1-2] In Nigeria, only about 38% of deliveries are carried out by skilled birth attendants, 74% in Ghana, 71% in Malawi, 66% in Sierra Leone, 44% in Kenya, and 32% in Bangladesh.^[6,7,8,9] A study from Eastern Nigeria showed that of the 49% of the 93% of rural women who had registered for prenatal care, had their delivery at home through TBAs^[10] , similarly, a study of 377 women in Ogbomosho; South-Western Nigeria revealed that 65% women had their deliveries carried out by TBAs.^[11] Various factors have been found to be associated with the patronage of TBAs such as illiteracy, low socio-economic status and high-risk socio-cultural beliefs.^[10,12,13] Studies have suggested that financial factors influence the choice to patronize TBAs, as it reflects the ability or inability to afford the fees of professional health care services, as majority of people opt for services of the TBA because they find it relatively cheaper.^[6,14,15] The services of TBAs are seen to be more easily accessible and user friendly by local communities^[6] , and TBAs are perceived to be more mature, patient and accessible than midwives and other skill birth attendants.^[6]

The availability of a skilled birth attendant at every child birth is an essential strategy to reduce maternal and neonatal mortality and improve pregnancy outcomes in low and middle income countries.^[16,17,18] One of the interventions adopted in promoting safe pregnancy and delivery is the incorporation of TBAs as well as local midwives into the health care system to assist in the provision of standardized maternal healthcare within rural communities.^[4,5,19] However, despite the high level of advocacy and intervention, rural communities have been found to still continually utilize the services of untrained TBAs.^[6] This has given rise to the need to explore the knowledge and the utilization of the services of TBAs by women in rural communities and implement effective measures in reducing the patronage of unskilled birth attendants.

This study was conducted in Alanamu community, a rural part of Ilorin west Local Government in Kwara state, Northern Nigeria. Alamamu community has a range of social services such as primary health care and maternity centers, primary education, markets, and road networks, which are provided by the local government. The population size of Alanamu community is estimated to be 2000 with our target population being women of reproductive age (15-49 years), with an estimated population of 380 individuals.^[20] A total of 212 questionnaires were administered to cover for a 10% non-response rate.

A descriptive cross sectional study was conducted using a well-structured interviewer-based questionnaire administered to 212 women of reproductive age-group collecting data on their socio-demographic variables such as age, occupation and marital status as well as their knowledge and utilization of the services of traditional birth attendants.

A consecutive sampling technique was adopted in administering the questionnaire, and analysis was done using Statistical Product and Service Solutions (SPSS) software version 20

Inclusion Criteria:
• Women of reproductive age (15-49 years)

Exclusion Criteria:
• Female traditional Birth Attendants within the community
• Women who were visitors within the community

Socio-Demographic Variables:

One hundred and forty three women (67.5%) were between the age group of 15-30 years, 45 (21.2%) were 31-40 years, while 24 (11.3%) were the ages 41-49 years. One hundred and sixty three (77.0%) of the respondents were traders, 136 (64.2%) earned an average monthly income of less than 18,000 naira ($30), 73 (34.4%) earned between 18,000 - 50,000 naira, while about 1.4 % (3) earned above 50, 000 naira ($80). Thirty (14.2%) of the respondents had no form of formal education, 41 (19.3%) respondents had completed primary education, 66 (31.1%) respondents had completed secondary school education, while 75 (35.4%) had completed tertiary education.

Knowledge about Traditional Birth Attendants:

One hundred and fifty three (72%) of the respondents were aware of the term “traditional birth attendants”, of which 62 (40.5%) ascribed the use of traditional birth attendants to be a safe practice, with no associated danger attached to their patronage. Eighty one (53%) of the respondents believed it to be an unsafe practice, while 10 (6.5%) of the respondents had no idea about its complications.
About 64.6% (137) of the respondents ascribed the services of traditional birth attendants to be more affordable compared to standard health care services.

Attitude towards the use of Traditional Birth Attendants:

About 67.5% (143) of the respondents affirmed to the importance of TBAs in the community, while 69 (32.5 %) of the respondents were of the opinion that TBAs were of no significance to the community. One hundred and fifty four (72.6.7%) of the respondents would prefer the services of skilled health care providers, while 58 (27.4%) of the respondents preferred the services of local traditional birth attendants to that of a trained health care worker. Eighty one (38.2%) of the respondents would recommend the use of TBAs to other people, 116 (54.7%) of the respondents discouraged the practice, while 15 (7.1%) were indifferent to the practice.

Practice towards Traditional Birth Attendants:

Ninety one (40.8%) of the respondents have had their deliveries carried out by a TBA at least once, of which 50 (56.0%) were satisfied with the service rendered to them, 37 (39.7%) were not satisfied and 4 (4.3%) were indifferent. Seventy three (80.2%) of those who had patronized a TBA had successful deliveries, while 18 (19.8%) of the respondents had complications during their delivery of which 7 (7.7%) were referred to a health care facility for expect management. Fifty two (47.3%) of these respondents were willing to continue patronizing the services a traditional birth attendant.

The practice of TBAs is believed to have originated centuries ago, and has continued to thrive, whereby traditional birth attendants still serve as the predominant providers of maternal health care in rural communities.^[1-6] This study assessed the knowledge and utilization of the services of traditional birth attendants by 212 women of reproductive age in a rural community in Kwara state, Northern Nigeria. One hundred and forty three (67.5%) of the respondents were between the ages of 15-30 years. Majority of the respondents were educated, with 142 (66.9%) having at least a primary level of education. Ninety one (43%) of the women in the community had their deliveries carried out by TBAs at least once. One hundred and thirty one (61.8%) of our respondents did ascribe the services of traditional birth attendants to be affordable, however from the analysis of the level of income of the respondents in relation to their utilization of traditional birth attendants, a Pearson chi-square value (p-value of 0.873) was obtained, showing no significant statistical association between these variables, this goes to show that low socio economic status alone is not considered as a sole contributing factor influencing the patronage of TBAs in this community, as suggested by similar studies^{[10,11,12,13]} other factors such as educational background and socio-cultural beliefs also play significant role. Analyzing the statistical relationship between the level of education of the respondents with their knowledge and utilization of TBAs, a Pearson chi-square value (p-value) of 0.041 was obtained showing statistical significance between these two variables, as about two third (182) of our respondents had at least a primary level of education, unlike other studies conducted in other regions of the country in which majority of the women were found to be uneducated with associated higher level of patronage of TBAs^[9,10,11] . This goes to show that illiteracy and lack of health education is a significant contributing factor to the patronization of untrained TBAs by members of rural communities, as the more educated and enlightened the community is, the less likely their patronage of unskilled birth attendants would be. Hence it is vital that rural communities are continuously sensitized on the roles and limitations of TBAs in the community. Identifying these limitations and knowing when to seek expert medical care is crucial in preventing maternal and neonatal morbidity and mortality.

Eighty one respondents (56.2%) were aware of the possible dangers involved in patronizing untrained TBAs, which included bleeding complications during child birth, transfer of infections, and death of mother and child. Seventy three (80.2%) of the 91 respondents who had patronized a TBA before had successful deliveries, while 18 (19.8%) developed complications during their delivery and only 7 (7.7%) were referred to health care facility for expert management. This goes to show the limitations of unskilled birth attendants in providing the needed essential care for promoting safe pregnancy and delivery in rural communities.

One hundred and forty three (67.5%) of the respondents affirmed that the traditional birth attendants do have important roles to play in the community, however, 154 (72.6%) of our respondents would rather have their health care services delivered by a well-trained healthcare provider who would be able to effectively attend to any form of complications that may arise, while 58 (27.4%) of the respondents are willing to continue patronizing TBAs if they are well trained. This tends to buttress the fact that members of the community do actually find the roles of the traditional birth attendant pertinent and vital in the community, however, a larger proportion of rural dwellers are beginning to put more trust in standardized health care services rather than seeking the services of poorly trained traditional birth attendants. Integrating the services of TBAs into the health care system by providing them with essential training and skills would also go further in promoting safe motherhood in rural communities and prevent maternal morbidity and mortality.

TBAs have continued to play impstrortant role in rural communities, integrating their services with standard healthcare system, as well as continuous health education and sensitization of the community on their roles and limitations would go a long way in reducing the high maternal and neonatal morbidity and mortality associated with the use of untrained TBAs.

The authors declare no conflicts of interest.

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Medical Journal of Zambia, Vol 50, 1

The Medical Journal of Zambia, ISSN 0047-651X, is published by the Zambia Medical Association.
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