Why pregnant women are shunning hospitals for their centresOur encounters with HIV-positive moms
In 2015, 342 of them helped birth 14,536 babies. In 2014, 809 of them attended to 23,229 deliveries, according to data from the Partnership for Transforming Health System 11 (PATHS2). In this report, HANNAH OJO writes on how trained Traditional Birth Attendants are reducing maternal and child mortality in Lagos State.
To arrive at Number 19, Lamidi Jemni Street in Egan-Igando, a community in the remote part of Lagos, one would need to meander through a labyrinth of swampy roads steeped in gallops. When it rains, access to the community is best described as a motorist’s nightmare and a bike rider’s burden.
The unpainted structure is a modest bungalow divided into three compartments: the first part is residential; the second a church while the third is a small space built with a wooden cabin. The cabin serves as a reception leading to another paved structure housing a labour room and a maternity ward containing three new maternity beds.
In another part of the compound with walls covered in algae, a construction is underway. When completed, the building would be a new clinic furnished with more toilets and a larger consultancy room. Welcome to the premises of God is Wise, a faith-based community birth attendant clinic.
Fifty-three-year-old Omowunmi Mary Olaoyenikan, a registered member of the Lagos State Traditional Medicine Board, manages the facility. Since she got trained by a church mission in the year 2000 to practise as a traditional birth attendant, she has taken delivery of more than 1000 babies.
“This work is a calling. You can’t just wake up and rush into it. Some pregnancies don’t show signs of complications until the time for delivery. It is a charity work. Many times, I have to cater for them with my resources,” she said, sitting across the reporter in the cabin which serves as reception.
A 14-inch box television sits atop a wooden shelf and walls in the cabin are plastered with posters of babies and pregnant women. In a corner of the wall hangs a calendar with the picture of the late Joseph Ayo Babalola, the famed founder of the Christ Apostolic Church.
Encounters with HIV-positive mothers
Many pregnant women often patronise the centre for “delivery miracles” without subjecting themselves to strident medical screening, Olaoyenikan said. Some pregnant women who have had caesarean sections in their first and second pregnancies also throng the centre hoping for a miracle that could make them birth babies without going under the knife. (Medically, anyone who has undergone a CS twice is usually booked for a third one automatically).
Olaoyenikan says she refers those women to the general hospital where they can receive comprehensive care.
“We let them know there are limits to what we can do”, she said, standing up to count the registration cards of patients who have been referred to the general hospital for caesarean sections.
With a registration card obtained for N500, the women are given a form which they take to the community health centre to conduct an antenatal screening which consists of several tests that pregnant women undergo for assessment of their overall health.
The result of the tests would also determine where they would deliver their babies: at the community birth attendants’ or at the general hospital in Igando.
“I take the time to check them up even after they’ve been referred to the general hospital. Some who are HIV-positive would run back here hoping for a miracle, but I encourage them to go back to their medication. In the end, they give birth to strong, healthy babies who are HIV-free thereafter.
“During pregnancy, some still insist that I follow them to queue for their retroviral drugs, while maintaining, for reasons best known to them, that their husbands should not be aware of their status. Women in this part of the world need encouragement to birth healthy babies,” she submitted, heaving a sigh.
Recently, figures from the Lagos State AIDS Control Agency show that 1,702 pregnant women tested positive to HIV in the last one year. The state’s Commissioner for Health, Dr Jide Idris, who reeled out the statistics, added that 1,143 babies who had been exposed to HIV were also placed on prophylaxis.
In order to enhance prevention and behavioural change, the state government, through the Traditional Medicine Board, has also engaged in rigorous training for traditional birth attendants, insisting on medical screenings for their intending patients.
A source at the Traditional Medicine Board, who pleaded anonymity, revealed that plans are underway to train TBAs in the state to manage HIV- positive mothers through pregnancy to delivery. The board, whose mission is “to evolve into an established traditional medicine practice that is standardised, documented and protected,” also sends the TBAs to observe a six-week internship in a general hospital close to them, in order for them to gain practical experience.
However, the insistence by the TBAs on tests for pregnant women often meets with resistance. Some women cite religion and low economic power as reasons for avoidance. Some of them end up with quack birth attendants, often leading to complications.
“They are usually vexed when we ask them to go for tests, but they don’t know that we are saving their lives. Some are even aware of their HIV-positive status, but they will come from far distances believing I would not insist on test results,” Olaoyenikan chipped in.
Unacknowledged heroines
A traditional birth attendant attending to a patient
The World Health Organisation defines a traditional birth attendant as a person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or by working with other TBAs.
In Lagos, each local government has one state-owned secondary health facility. However, these hospitals are not enough to cater to the teeming population of pregnant women. Neither do they have enough facilities or skilled staff to attend to them. In many cases, pregnant women are often turned away for lack of space.
Funmilola Biodun had her three children delivered at a TBA clinic. She told The Nation that the stress involved in accessing medical care in general hospitals was the motivating factor.
“Those women attend to us well. I have referred my other friends to them as well. The three children I delivered here are healthy and in great shape. Their services are convenient and pocket-friendly,” she said.
Instances like this underscore the efforts of TBAs in the informal health sector. Their presence bridges the gap, especially in communities where the closest health centre is many miles away.
Training TBAs is part of the efforts geared towards prioritising health care at the grassroots, especially in underserved communities. For those who are registered with the Traditional Medicine’s Board, the recognition by government helps in effective transfer of women in labour to health centres when complications arise.
This ease of transfer came in handy for Olaoyenikan recently when a pregnant woman with a history of high blood pressure was rushed to her place during delivery. “She initially registered at my clinic but after reading her test result. I sent her back to the general hospital. She was placed on bed rest but she ran from the ward and came to give birth at home because of her husband, who had two other wives, said he didn’t have money to pay. They rushed her to my place when she was convulsing and bleeding. It was the doctors at the General Hospital Igando who saved her,” she recalled.
Why pregnant women shun hospitals for traditional birth attendants
Although the Lagos State Government claims to operate a free maternal and child health care programme, findings revealed that various state owned hospitals charge pregnant women for antenatal registration, drugs investigations and delivery.
While normal delivery is pegged at N35,000 or more in state owned hospitals, caesarian section could go as high as N90,000 or more. However, with traditional birth attendants, delivery is much cheaper, ranging from N5000 to N10, 000. They also have the option of paying in instalments.
“We are closer to these women and they open up to us on intimate issues affecting them. A TBA would go and visit her patients in their homes, but a nurse cannot do that. Accessibility and psycho social care is another factor which makes our services appealing to ordinary people,” Veronica Tewe, another faith-based traditional birth attendant in Ikorodu told The Nation.
Perhaps the biggest downside is that there are many unregistered traditional birth attendants who have not been trained by health experts. This has led to a situation where women trying to avoid tests in order to minimise costs end up with quacks, leading to obstructed labour, excessive bleeding and eventual death for some.
Asked how pregnant women can differentiate registered TBAs from unregistered ones, an official from the Traditional Medicines Board who pleaded anonymity, said: “We instruct registered TBAs in the state to hang their certificates and licences on the walls of their clinics.” She added that crackdowns on unregistered TBAs are usually carried out through periodic monitoring or any time there is information leak from members of the public.
Also, since some herbal medicine practitioners boast of the ability to use herbs that will expand the pelvis so that pregnant women don’t need to do CS, the promise appeals to most would be mothers. But the practice is forbidden for registered TBAs in the state.
In Kio-kio, an Ijaw community close to Ikorodo famed for its traditional bone setters, The Nation met an aged woman who simply identified herself as Madam Maria. Her signboard announces her as “Dr Maria Fabor, a traditional gynaecologist specialising on barrenness, late menstruation and women infertility.” In a chat with the reporter, she also boasted of the ability to reset the womb and deliver babies without CS. These skills, she said, were acquired through an apprenticeship with her father.
In many cases, deliveries with TBAs have been tainted with use of unsterilised tools, unskilled personnel, poor environmental conditions and little or no knowledge of prevention of mother-to-child transmission. With all that the state is committed to doing, the best purveyors of safe birth, it appears, ultimately would be mothers themselves.
“Pregnant women need to be counselled to love themselves and take their health seriously. They blame us for forcing them to do tests, saying we don’t rely on prayers anymore. But that is a misconception. Some will tell you that in their culture, they don’t withdraw. They won’t consider the fact that you are trying to help them. The government should record jingles to educate them to be registered,” Olaoyenikan said as a final counsel.
The top causes of maternal mortality in Nigeria, according to a memo on the Lagos State Ministry of Health website includes hemorrhage (23 per cent), infection (11 per cent), obstructed pregnancies (11 per cent), among others. Also, the prevalence of traditional birth attendants at the community level who refused to follow laid down rules.
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