*Ignorance, Poverty Bane Of Child Birth Complications
Fortune smiled on 19 year-old Iyabo Abayomi immediately after her traditional wedding. She became pregnant, and her husband, Bamidele, handed her over to his eldest sister, whom he believed would properly guide her through the peril of pregnancy.
The Lagos-based Bamideles hail from Yoruba land in Nigeria, where pregnancy is viewed as a time of great peril for a woman. Many sayings and actions attest to this, but the most widespread is the greeting after child birth: e ku ewu omo (congratulations on delivery from the peril of childbirth). It is therefore common practice for young pregnant women to be under the tutelage of older ones believed to be experienced in pregnancy matters for guidance during this period of peril.
Iyabo’s non-literate sister-in-law immediately enrolled her in a near by traditional maternity home, admonishing her to abide by all the instructions that would be given there. “My sister in-law told me she had had all her children at the maternity home, run by a traditional birth attendant (TBA), stressing that it was the way to go,” Iyabo told Independent.
Although she had earlier registered at a private hospital, she followed her sister-in-law’s advice and religiously visited the TBA home, where she dutifully bathed with and drank agbo, a herbal concoction. At 28 weeks, she was given a substance called aseje, which she ate, and a powdery mixture made from some crushed dried leaves, which she added to pap.
And at 30 weeks, she was given a black soap for bathing. All of this was for safe pregnancy and easy delivery.
Iyabo also regularly visited County Hospital, Ogba, the private hospital where she had registered for antenatal care.“I would have loved to deliver in the hospital, but I could not, due to family pressure, which saddled me with the burden of being under the supervision of my sister in-law, and she insisted that my delivery must be in the TBA home.
“Out of ignorance and pressure from family members who would say ‘this is the way to do it’, and you would be afraid that if you defied them and something happened to the baby or to you…So as soon as I noticed signs of labour, I summoned courage and went to the TBA home,” Iyabo further told Independent.
At the TBA’s,an attendant inserted a finger into her and said that the baby was due. “That was around 6p.m. He gave me two injections, and I thought l would die. The man is neither a doctor nor a nurse, and he administered injections to me. Then, labour started strongly.”
The TBA prepared all sorts of concoctions, which she was made to drink, and a soap with which she bathed, but Iyabo says she didn’t even understand what she was going through.“However, to God be the glory, I had the baby around 3.30 am, but unfortunately, l sustained a serious tear. The next morning my husband took me to County Hospital because the TBA could not repair the tear.”
At County Hospital, the doctor could not hide his anger, and wondered how Iyabo had survived the trauma and blood loss. He explained that the baby ought to have been delivered by Caesarean Section (CS) as he was too big to pass through the birth canal easily, hence the tear. The doctor stitched her up, while the baby received attention.
Iyabo survived to tell the story, which represents the ordeal of thousands of pregnant Nigerian women who visit TBA homes where there are no gynaecologists or nurses, and no proper antenatal or post-natal care.
Unlike, Iyabo, however, many others do not survive the ordeal; they die in the process of giving birth at TBA homes. At other times, when things get out of hand, TBAs encourage family members to rush dying women to orthodox health facilities, where they may be brought in dead, or die shortly after arrival. This annoys many orthodox maternal health providers, who decry the cunning of TBAs in pushing to them deaths that should not occur in the first place.
Eighteen year-old Hannatu did not receive proper antenatal care because she did not register with any hospital. She visited a TBA home until she was due for delivery, but the TBA did not know that she had a small pelvis and would not be able to deliver her baby normally. On the day that labour started, although the TBA discovered that she had weak contractions, he did not know what to do to help Hannatu deliver, and failed to refer her to a hospital. Hannatu laboured for two days and eventually died with the baby in her womb.
Yoruba people seem to be right about pregnancy and childbirth being a time of peril. A woman dies while giving birth in Nigeria every 15 minutes of the day.
According to the National Demographic and Health Survey (NDHS) 2013, the maternal mortality ratio is 576 deaths out of every 100,000 live births, the second highest maternal mortality ratio in the world. 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, the NDHS 2013 survey said.
With about seven million annual births, the number of women who die is about 58,000 each year.
The World Health Organisation(WHO) blames the deaths on simple mistakes, wrong diagnosis, carelessness, incompetence, and lack of access to prompt and affordable healthcare. Many other African nations, record fewer maternal deaths, which irks many health care providers in Nigeria. The argument is that with the huge amount of resources at Nigeria’s disposal, having the second worst number of maternal deaths in the world is a shame. In some advanced nations, maternal deaths are as low as three per 100,000.
Why Women Prefer TBAs
Investigations revealed that most pregnant Nigerian women, particularly from the Southern parts of the country, prefer using traditional medical facilities because they see it as part of their culture.
Theresa Pius, who had her first baby at Yewa Traditional Clinic and Maternity Home, Agege in Lagos, five years ago, said she has been using the TBA home ever since.“It was a friend who introduced me to the home when I was pregnant with my first child. I had developed a problem during the fifth month, and she introduced me to Yewa Traditional Maternity Home where I later delivered my baby,” she explained.
Another patient, Oyin Agida said that it was the problem of infertility that made her mother introduce her to a TBA.“I actually started coming here because I was looking for the fruit of the womb. Before then, I had visited some other TBAs to no avail.”
On her part, Muyibat Adisa started visiting Yewa in 2013 because she had been unable to conceive for four years, after which her mother in-law introduced her to the home. After a while, she became pregnant and gave birth to a baby girl who is now three years old now.”
“When my mother was having babies, she also used TBAs. I am Yoruba and I know that we have the leaves and herbs; in fact everything, and I believe that they would work perfectly. This is what my mother told me, and I have learnt from it,” said another TBA client, Adesina Adenike.
Shortage of Medical Personnel
For many people, a visit to public hospitals in Lagos and other parts of the country on a weekday is an eye-opener. The situation at any of the primary, secondary or tertiary health centres is usually depressing, and many people ask: where are the nurses, doctors, and other health workers? This is because there are always too many patients,and not enough health care personnel around to cater to their needs. During the 2014 Ebola virus disease outbreak, for instance, health worker shortage was a big threat to the containment effort.
On the average, a doctor, who should not see more than 30 patients is compelled to attend to between 100 and 150 daily. Sometimes, one doctor is on call for two to four days at a stretch. And not only is there a shortage in numbers, there is shortage in specialisation.
WHO defines health workers as “all people engaged in actions with the primary intent of enhancing health,” including those paid as “health service providers” and “health management and support workers.”
Going by WHO standards, Nigeria is not on track to meet the very low benchmark of 2.5 doctors per 1,000 people.
WHO also recommends a ratio of one nurse to 700 people. But, according to the Open Journal of Nursing 2014, Nigeria has fewer than 150,000 registered nurses for an estimated 160 million population, giving an average nurse-population ratio of 1:1,066 people.
For pharmacists, the Registrar of the Pharmacists Council of Nigeria (PCN), Mohammed Elijah said, “Although WHO recommends one pharmacist per 2,000, in Nigeria we have approximately one pharmacist per 12,000 population.”
The health worker shortage therefore underlines the need for TBAs capacity building, and Lagos State Governor, Mr Akinwunmi Ambode, said this is a challenge that requires new strategic thinking.
Intervention to Make TBAs Safe
Recognising the role of TBAs as the preferred service providers for child delivery in rural communities even though they are usually self-taught or informally trained, the Lagos State Government initiated the General Hospitals Immersion Programme. Under the programme, TBAs undergo training to build their capacity for improved antenatal care and delivery.
Speaking, while presenting certificates to some TBA graduates last year, Governor Ambode said: “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 health care 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, the governor explained.
The state decided to train TBAs to provide the following services: protecting the health of mother and baby; care of women during pregnancy and child birth; and referring women and newborn to higher care when conditions arise beyond their scope of practice and capabilities.
“We are committed to taking traditional medicine practice to a higher level through innovative research and development. We will continue to strengthen our efforts in the areas of regulation, training, coordination, monitoring, and supervision of practice of traditional medicine towards effective integration with orthodox medicine,”the Governor said.
“We know a lot of our people go to TBA homes for cultural reasons. Why do they go there? This is because there is a gap in service provision; it is that gap that we are trying to fill. Our facilities are not enough, and we are renovating more. The attitude of some of our staff is very bad; TBAs are compounding the problem, said Lagos State Commissioner for Health, Dr Jide Idris.
“If our people have places to go, they wouldn’t need to visit TBAs. But, you cannot stop TBAs when you have not provided the people where they will go. So let’s deal with the problems rather than the symptoms,” he added.
Orthodox Practitioners’ Attitude
On preference of TBAs by rural dwellers, the Minister of Health, Prof. Isaac Adewole, once said that traditional healers were competitors of orthodox medicine practitioners, and that the only way to really create a change in their view of orthodox medicine is to offer better services, show more care, and more compassion. “Let us be honest, traditional healers communicate better with our people,” he said.
“The average Nigerian who patronises them does not see them as arrogant, but people complain about the negative attitude of our nurses. So, we (orthodox medicine practitioners) need to change that perception.”
He added that orthodox medicine providers also need to make health care services affordable. “Some years back, baby delivery in my Church was N300.
At that time, in the University College Hospital, Ibadan, in Oyo State, ante-natal care was N18, 000. So, people would line up in the Church. We need to make health care services affordable; we need to show compassion; we need to show care and really recognise that we have competitors. If we don’t, patients wouldn’t come to us even though we are doing something greater and better.”
Mrs. Adeyemo Muinat, TBA nurse at Yewa Traditional Clinic and Maternity Home, Agege, concurs. She said: “One of the things that scare women from delivering in public health facilities is lack of money for treatment, drugs and blood.”