Orthodox care vs TBAs: A lingering challenge

At 15, Hajara was already married and began having children a year later. Now 32, she has had five children all of whom were delivered by a traditional birth attendant (TBA) resident in her Ibwa  village in Gwagwalada Area Council of the Federal Capital Territory (FCT). Like her, so many other women in the community […]

At 15, Hajara was already married and began having children a year later. Now 32, she has had five children all of whom were delivered by a traditional birth attendant (TBA) resident in her Ibwa  village in Gwagwalada Area Council of the Federal Capital Territory (FCT).
Like her, so many other women in the community and beyond, as well as in other States in northern Nigeria do not deliver their children in hospitals.
This situation which is becoming worrisome features prominently in a recent report released by the  United States Agency for International Development (USAID). The report noted that ninety five percent of Sokoto State’s expectant mothers give birth at home with the aid of TBAs.
Dr. Abubakar Maishanu, the USAID deputy chief of party, in a previous report, stated that only 4.7percent of women in the State give birth in a health facility. A situation, he observed, which has worsened the incidence of maternal deaths in the state, adding that the likelihood of receiving assistance from skilled providers during delivery was low.
“Only 17 percent of mothers received ante-natal care from a skilled provider,” he said.
Although these statistics are of Sokoto, it is hardly different from other parts of northern Nigeria.
There are various reasons for these statistics including religious and cultural values, attitudes/care, availability of health facilities with economic challenges and family expectations looming in the horizon, amongst others.
Culture and religion
Zaria’s Hauwa’u Al-Amin, a mother of four, who got  married  just as she became a teenager, was delivered of all her children by  a  highly revered near seventy year-old TBA. Al-Amin explains that her upbringing has taught her that it is a taboo for a male to touch a woman who is not his wife or sister, and since delivery involves a lot of body contact, she would prefer to employ the services of  traditional birth attendants.
As with many parts of Nigeria, women are sent to their mothers or mothers-in-law for their deliveries, especially when it is their first. In rural communities where this usually occurs, mothers ensure that their daughters get the best care from TBAs.
The women also add that TBAs give them a variety of delivery positions as the Sokoto report stated. “In hospitals women lie on their backs to give birth. Opening our legs is not ideal when we can squat in the traditional homes and not expose our privates so much.”
A group of three elderly women  in their late 60s to early 70s, said they have practiced as TBAs for the last 30 years ,and explained the delivery process through an interpreter, in Ibwa. “When labour comes we rub the stomach in circular motions.
“When we see that the baby is ready to come out, we get a piece of cloth and put it beneath the woman’s anus. The woman squats and we continue the circular motions and add a gentle massage, until the baby comes out,” they said.
The belief is that if the women don’t give birth in a squatting position, ‘the baby will not come out successfully.’  
Although a Christian, Blessing Chechet who was born and raised in the community and is now having her own children, told our reporters : “I also don’t give birth lying down. It’s a lot easier in the  squatting position and less embarrassing too.”
It’s better now because we have a primary healthcare centre in the community, said Musa. In the past if any woman delivered in a hospital, her peers and even her in-laws (especially the women) would call her weak. To prove their strength, women outdid themselves by ensuring only a TBA attended to them.
Attitude vs Attitude
Extra care and attention from TBAs as against nurses in the hospitals is another reason women stick with them.
Attitude of TBAs compared to the attitude of nurses, is a significant factor in the choices available to an expectant mother when she goes for her delivery.

Recounting her experience, Larai Patrick said: “When I went to have my first baby, the pain was unbearable. The nurse kept slapping my thighs and raining abuses on me. Even after the labour pains ended, I was still writhing in pains from the slaps and her very unkind words.
“When I got pregnant again, a friend introduced me to the Hajiya who helped her, and that’s where I went to deliver  my other three children,” the Galwuyi resident of Bwari Area Council added.
Another woman, Jummai Hamza, said TBAs take care of the babies more than nurses. “All these young nurses don’t want to mess their hands and therefore don’t clean/bathe the babies well. The TBAs take their time to do this and also encourage you ,the new mother,” she said.
Adding that: “They bring you all sorts of specially prepared meals to help you heal and get your body back. They massage your body and make you sit in hot water to heal the wound.
While they are doing this, they are praying for you and the baby.
“Even when the child is growing, they are proud to show off that he is one of their products,” she said of Jigawa’s TBAs. She emphasised : “they maintain a relationship with you forever.
“With them, I don’t miss that my mother isn’t around me when I give birth,” she quipped.
Hospital vs TBA demands
“When you go to the hospital, they ask for so many things and even if you cannot afford them, you have to buy,” said Ajumma Idris.
According to her, “the painful thing is that those government nurses don’t always return what you didn’t use.”
The Nasarawa mother of two who had her second baby at  a TBA’s said: “I only had to buy Dettol and spirit. I used the clothes I wore when I had  the senior child, and I took palm  kernel oil and shea butter along with me. In the hospital I would have been ashamed of the smell and would have gone to buy baby oil or some other fancy item and new cloths.
“Many of us are forced to go out of our means in a quiet competition with other mothers who come to hospitals with nice things,” Idris added.
Crowning this, Idris said, is the fact that TBA deliveries are at no cost beyond a few yards of fabrics or GL jewelry to say ‘thank you’, unlike the bills which have to be paid in the hospitals.  
Proximity/availability of health centres vs TBAs
Another draw back for many mothers is that  “staff who work in the health centres usually close at 4pm,” Lawal Ibrahim said. In some places, they close earlier, he added.

Explaining further he said: “There are times when our wives go into labour after such hours. We take them on motorcycles or carts to the nearest hospital ,which is usually no less than a 45minute bike ride,  and at least one hour thirty minutes by bicycle,” the Ibwa II resident said.
In the 10 kilometre perimeter of the railway community, Issa in Kagarko Local Government Area of Kaduna State, there were no health facilities in site beyond a grossly under-equipped patent medicine store at the top of the road leading into the community.
Therefore, in case of an emergency or labour at night, “we are at the mercy of our husbands’ motorcycles or bicycles, and sometimes even donkeys” said, Maimuna Jafaru.
“It is a lot easier to access the TBAs because they are in the community with us. They have had this training all their lives, so even when you knock on their doors at midnight, it is with excitement that they welcome you. There is no waste of  time or ceremony, as they immediately get to work.
Hajiya Hadiza Adamu ,a TBA in the community said, “we know the pregnant women and when we see their stomachs and when they start dropping, we know those who will soon be knocking on our doors.”

She showed off her clay pots, dried herbs and other appliances with which she works, adding “the fresh materials we need, we can easily source for from the  nearby bushes or get from our neighbours.”  
Contending with complications
It was a relief to realise that both the women and TBAs know that they should go to hospitals when there are complications. But with zero antenatal sessions during pregnancy, how do the women know a potentially complicated pregnancy?
According to Adamu: “When we massage, we can tell if the  baby is well positioned or not, or if there is any other problem with the pregnancy.” She however admits that her diagnosis haven’t always been correct, but fortunately, rescue came and there have been no recorded mortalities so far.
In some cases where complications arise during delivery, the mother or baby or both have died.
As the medical field continues to battle the dearth of female personnel ,there doesn’t seem to be an end to the habit of  women in northern Nigeria visiting TBAs.    
Not all that glitters is gold
Although the women tell glowing tales of their TBA encounters, and others justify their visits to them, there are some others who tell a different story.
Madam Jane, a mother of three in Maraba, a suburb near the FCT, recalled her ordeal in the hands of the TBA and vowed never to visit any again.
“My first labour started very late in the night, and because my husband does not have a car, and considering the high charges in the private clinic in the neighbourhood, my husband took me to the TBA, I nearly lost my life following the complications that arose,  and instead of telling us the truth, the old birth attendant kept us in her house for three days and I was suffering seriously. I nearly died,” Jane said.

Another woman, Ada said she almost died patronizing a TBA thinking hospitals were expensive. “We had just moved into Abuja from Imo State and considering the high cost of things in Abuja, I went to a popular TBA near my house thinking I was cutting cost, not knowing that I was digging my own grave.”
“My husband is a policeman and we didn’t have enough money for me to travel to the village to enable my mother attend to me, so I registered with this woman near my house. I am lucky to be alive today.The hygienic situation in her home is not good ,and she was patching me up with any cloth she could  lay her hands on when I started bleeding,” Ada added.
What the experts say
Dr Theo Ochonu, a family medicine physician with the Federal Medical Centre, Keffi explains : “ There is no comparison between services rendered to an expectant mother by a professional medical personnel, and what the traditional  birth attendant does. Every day we see cases of women being brought in as a result of one complication or the other arising from child birth, and these  are cases the TBAs can’t handle.
TBAs are needed because it is very difficult to find trained medical personnel all over the place, but the problem is that most of them arrogate to themselves the powers or duties of a doctor. We can never eliminate the TBAs from the child birth chain, because there are some women that will never deliver in the hospital no matter what incentives are put in place. But the bottom line is that the TBAs need to be trained and retrained from time to time, because of the important role they play in society.”

This report emerged third place winner  at the 2014 International Centre for Journalism (ICFJ) and Hala Nigeria Story Contest.