|Year : 2019 | Volume
| Issue : 2 | Page : 55-62
Integration of traditional birth attendants (TBAs) into the health sector for improving maternal health in Nigeria: a systematic review
Sulayman Hajaratu U1, Adaji Sunday E2
1 Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
|Date of Web Publication||04-Nov-2019|
Dr. Sulayman Hajaratu U
Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Shika Zaria. Kaduna State
Source of Support: None, Conflict of Interest: None
This work tries to look at how the integration of traditional birth attendants (TBAs) into the health sector in Nigeria can be a strategy for reducing maternal deaths. Skilled birth attendance in Nigeria is below 40% and most deliveries are with unskilled personnel like the TBAs. In the light of current evidence that training of TBAs can have some positive effect on neonatal outcome and with inconclusive evidence on their role in maternal health, this “birthing workforce” can be harnessed by the Nigerian government by re-defining their roles as health promoters with the overall aim of improving skilled attendance at deliveries and the reduction of maternal morbidity and mortality.
Keywords: traditional birth attendants, maternal mortality, Nigeria
|How to cite this article:|
SulaymanH, AdajiS. Integration of traditional birth attendants (TBAs) into the health sector for improving maternal health in Nigeria: a systematic review. Sub-Saharan Afr J Med 2019;6:55-62
|How to cite this URL:|
SulaymanH, AdajiS. Integration of traditional birth attendants (TBAs) into the health sector for improving maternal health in Nigeria: a systematic review. Sub-Saharan Afr J Med [serial online] 2019 [cited 2023 Mar 27];6:55-62. Available from: https://www.ssajm.org/text.asp?2019/6/2/55/270245
| Introduction|| |
The World Health Organization (WHO), International Confederation of Midwives (ICM), and the International Federation of Gynaecology & Obstetrics (FIGO) defined a skilled attendant as “an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” . There is ample evidence to show that when pregnancies and childbirths are supervised by skilled birth attendants (SBAs), the risk to the mother and her newborn is minimized . The WHO recommended the utilization of SBAs as a key strategy to improve maternal and newborn’s health. However, access to and utilization of SBAs remain low especially in low- and middle-income countries (see [Table 1]). A combination of factors like poverty, accessibility, acceptability, and culture has led to low utilization of SBAs in these settings.
|Table 1 Percentage of births assisted by skilled birth attendants (SBAs) in selected low and middle income countries|
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Enhanced availability and accessibility to SBAs was one of the core strategies of the Safe Motherhood Initiative (SMI)  of the WHO . The proportion of births attended to by a skilled health personnel was one of the indicators of Goal 5 of the Millennium Development Goals (MDGs) which focused on improving maternal health. SBA utilization continues to be at the center of global strategies and approaches to improving maternal and newborn health ,. Although there was an increase in SBAs in low- and middle-income countries between 1990 and 2015 from 57% to 70%, the rapidity of decline in maternal mortality ratios was slow and many countries did not meet the MDG goals . However, there was a global decrease in maternal mortality of 44% .
Despite huge investments to promote the availability and utilization of SBAs globally, there remains gaps in the proportion of births attended to by SBAs (see [Table 1]). Some estimates have shown that despite the slight increase in the number of SBAs from the 1990 levels worldwide, more than 45 million births still occur without skilled personnel ,. Where and when skilled personnel were not available or utilized there could be a resort to alternatives like traditional birth attendants (TBAs) and relations.
According to the WHO, a TBA is defined “as a person who assists the mother at childbirth and who initially acquired her skills delivering babies by herself or by working with other birth attendants” . However, maternal and neonatal mortality is still high especially in the developing regions of the world where only 66% of the births are attended to by a skilled attendant as compared to 99% in the developed regions . Communities have been known to have caregivers during child-bearing called TBAs or community midwives especially in areas where trained health personnel are lacking .
Debates around the roles a TBA could play where and when there is no SBA are not new. There have been arguments to promote the roles and practices of TBAs to improve maternal health and counter-arguments against giving them any roles. Proponents cite TBA attributes like availability, trustworthiness, proximity, knowledge of local customs, and culture and how these can be and have been leveraged upon to support the much-needed maternal health care delivery. However, opponents point out the risks associated with TBAs as maternal health providers who despite being trained could be too tenacious and unbending to align their practices with the training received .
As these debates rage on, many low- and middle-income countries have continued to record high levels of maternal deaths. Furthermore, many mothers continue to make the choice for TBAs especially when and where SBAs are not available .
This article seeks to revisit this debate as the global health community seems to be at yet another cross-road in strategizing to improve maternal and newborn’s health in low- and middle-income countries. At the heart of the new approaches being considered is universality of access to health care. The role of close to community healthcare providers like TBAs as vital links to hard to reach communities would come into sharp focus under the Universal Health Coverage paradigm.
This review also revisits the debate on the roles and practices of TBAs and their integration into the formal health sector in the Nigerian context, one of the countries with little progress in reducing maternal and newborn deaths. With a population of about 160 million, about half of which are women, maternal health remains a huge public health concern in Nigeria. Depending on the sources, maternal mortality ratio in Nigeria ranges from 350 to 545 per 100,000 live births ,.
Nigeria is the most populous black nation in the world . The national total fertility rate is 5.7 births per woman (7.0 in the north west). A quarter of women begin child bearing as teenagers (23%), contraceptive prevalence is low (17.30%) with less than 30% of women using any method. Maternal mortality ratio was 545 per 100,000 live births in 2008 (this figure is twice as high in the north-western region of Nigeria) and in 2012 it has reduced to 350 per 100,000 live births , (see [Table 2]).
|Table 2 Summary of millennium development goal 5 (improving maternal health) and their indicators in Nigeria in 2012|
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A recent baseline survey on the health-related Sustainable Development Goals (SDGs) in 188 countries showed that SBA in Nigeria was 43% . Nationally, 66.3% of women attend at least one antenatal care (ANC) by a skilled provider and 57.8% attend at least four ANC visits by any provider but in the north west only a third do. Skilled attendance at delivery in the north-western part of Nigeria is only 10% with about 90% of deliveries being at home .
TBAs take 70–75% of deliveries in Nigeria and these figures are higher in the rural areas . In the northern parts of Nigeria, women either deliver alone, with TBAs, or under the supervision of family members . Usually TBAs do not offer any form of ANC, they are called when women go into labour and they assist in conducting delivery, cutting of the umbilical cord, and burial of the placenta . The average number of deliveries by TBAs in Nigeria is 72 per year .
| Rationale for the literature review|| |
More than half of the 130 million deliveries worldwide are attended to by TBAs .
Nigeria has paucity of SBAs. The 2008 National Demographic & Health Survey in Nigeria showed that 58% of pregnant women received ANC from a skilled provider (doctor, nurse/midwife, or auxiliary nurse/midwife) during their last pregnancy. Nurse/midwives providing 32%, doctors 23%, 3% from a TBA, and 36% had no ANC despite all the efforts to increase skilled birth attendance in the last decade .
Notwithstanding these challenges, the Nigerian government can still optimize the use of its existing “birth workforce” to increase skilled attendance at birth as has been shown in some developing countries like Tanzania where trained TBAs have been used to increase skilled birth attendance .
TBAs have been known to play several roles in health delivery which have contributed positively to maternal and child survival.
Using recent literature (2001–2016), this study seeks to revisit the tasks and roles TBAs have played towards the prevention of maternal and newborn deaths. Based on the findings, opportunities and pathways for integration of TBAs into the formal health sector in Nigeria to perform low-risk roles and promote universal health coverage will then be identified.
| Research question|| |
What is the impact of integrating TBAs into the health sector on skilled attendance at birth and maternal morbidity and mortality in Nigeria?
| Objectives|| |
- To investigate the opportunities and pathways for integrating TBAs into facility-based maternity care in Nigeria.
- To assess how TBAs can support efforts to improve access to skilled care.
- To review the possible effects of TBAs as health promoters in reducing maternal morbidity and mortality.
| Methodology|| |
A total of 60 journal articles were shortlisted and of these 36 relevant journals were then selected. Other relevant articles and reports were included. The review included peer-reviewed journal articles including systematic reviews as well as relevant reports from the WHO, UNFPA, and the Nigerian Ministry of Health (Figure 1). Full-length articles were summarized with regards to role of TBAs, training of TBAs, integration of TBA into formal health sectors, and consequences of such integration.
| Results|| |
Key findings from the review of this literature were centred around:
- attributes of TBAs;
- low-risk roles assigned to TBAs;
- training of TBAs to perform new roles and integration into formal health sector.
The current position of TBAs
The WHO in 1999 stated that above 60% of deliveries in sub-Saharan Africa still took place at home and at present in the developing regions of the world, skilled attendance at birth was less than 50% and these services would still not be available in the near future . This was illustrated by a study in Tanzania which showed that though most TBAs were illiterate and ill equipped to recognize the danger signs of pregnancy, they would continue to exist especially where there was poor commitment of governments to provide affordable and accessible healthcare. They could be trained on early recognition and referral of obstetric emergencies with proper supportive supervision ,.
Attributes of TBAs
TBAs are more accessible: Lack of economic and geographic access to health facilities in rural India was the reason why more than 80% of the deliveries were conducted by TBAs  while in Indonesia, TBAs were preferred because they belonged to the communities, were matured, patient, older, and more accessible especially at night than the village midwives who were seen to be young and inexperienced .
TBAs are accepted by the community: TBAs are held with great honour and respect within their communities and were usually elderly women or neighbours with proven birthing skills who assisted women during deliveries and played a significant role in the immediate care of the newborn as seen in Nigeria, Malawi, and Nepal ,,. In Kenya, TBAs believe that they had received a spiritual gift which enabled them to practice traditional midwifery .
Among the non-orthodox health providers in Ghana, the TBAs were preferred because they were more culturally sensitive, had empathy, and spent a lot of time with women and would involve the women’s families in decision making regarding further care ; while in Ethiopia TBAs were said to uphold some sensitive societal values like burying the placenta near the home and they were flexible and cheap .
In Loa People’s Democratic Republic, where skilled birth attendance was 15%, home deliveries were with TBAs due to low cost, convenience, and women were allowed to deliver in the squatting position unlike in the health facilities. They also felt more comfortable in their homes because of the support from husbands and other family members during the birthing process .
Low-risk roles for TBAs
TBAs, especially when trained, could be used to carry out activities within their communities which has positive impact on maternal and neonatal health. An example is the administration of 600 mcg of Misoprostol by trained TBAs to pregnant women immediately after delivery in the rural communities in Ethiopia, Nigeria, and Pakistan for the prevention of post-partum haemorrhage (PPH) which is a major cause of maternal deaths ,,.
In Zimbabwe, TBAs were used to follow up HIV positive women in their communities within one week of deliveries and they linked these women and their children to health services for further care .
One study from Ghana showed that TBAs could be trained to report cases of PPH within their communities by using the mobile phones .
In all the above cases, the patients were subsequently linked to the health facilities in cases of complications and for follow-up care.
Increasing skilled birth attendance by the use of TBAs
The possibility of increasing skilled birth attendance by the incorporation of TBAs into the health system was investigated in a systematic review . This has been put into practice in some countries like Samoa where TBAs were part of the formal health sector as healthcare advocates and this led to an increase in skilled birth attendance from 67% between 1974 and 1975 to 81% in 2012. The department of health in collaboration with WHO trained TBAs and by 1998 births by TBAs dropped to 20%. All TBAs in Samoa are required to be registered by the Ministry of Health and they have an annual review of their training by midwives . In Liberia, however, traditional midwives (TBAs) were engaged in running maternity waiting homes and this led to an increase in skilled birth attendance .
Training TBAs to perform new roles and integration into formal health sectors: Strategies for the reduction of maternal and perinatal mortality can be implemented by the incorporation of TBAs into the health sector by training. In Guatemala, a population-based prospective interventional study was done on the impact of training 522 TBAs using the WHO Emergency Neonatal Care package on perinatal outcomes. It was a five-day course involving didactic and practical lessons on hygienic delivery practices, care of the newborn, thermo-regulation, resuscitation, Kangaroo mother care as well as recognition and treatment of complications. Perinatal mortality reduced from 39.5/1000 to 26.4/1000 as well as the stillbirth rate; there was no change in neonatal mortality rates. It was suggested that training of TBAs assisted babies to breath in the immediate neonatal period and this had the potential of being a high-impact intervention in communities in the medium term . A similar training on emergency maternal and neonatal care was done in Sudan for community health workers which included TBAs .
TBAs in India were trained in neonatal resuscitation after delivery and this led to a 44% decrease in death due to neonatal pneumonia among these babies . Trained TBAs were also more likely to adopt hygienic delivery practices, avoid harmful neonatal practices, encourage early breast feeding and wrapping of the newborn as well as early referral in emergencies ,,. In Pakistan, there was a statistically significant reduction in both perinatal and neonatal death after TBA training ,.
A systematic review of 15 interventions involving TBAs and village midwives in the reduction of maternal mortality and morbidity was done and substantial reductions in maternal mortality, an improvement in some morbidity outcomes, referral rates, and knowledge retention were observed. Though the TBAs were involved in a multi-sectorial programme, larger studies were said to be needed to define their individual roles . Decentralization of ambulatory reproductive and intrapartum services led to increase in ANC attendance and skilled attendance at birth in rural parts of Rwanda, Africa, when TBAs were used as health promoters .
| Discussion|| |
The above studies show that TBAs are culturally acceptable to women and their families. They have empathy, are affordable, accessible, culturally sensitive, and accept non-financial, stalled payments which is very convenient for the majority of women in low resource settings like Nigeria. Attempts by some governments to ban TBAs have been met with a lot of opposition by the general public in some countries like Malawi .
In Nigeria, there are many ongoing efforts to reduce maternal deaths, one of which is the Abiye Project which was embarked upon by the Ondo state government sought to address the issues of maternal mortality using a model that sought to eliminate the four major delays that cause maternal death during pregnancy, which include delays in seeking, reaching, and receiving health care as well as referrals. It involved the training and retraining of health workers (Health rangers), provision of skilled personnel for government health centres and hospitals, and the provision of essential drugs and services for emergencies. The result was an overwhelming reduction in maternal deaths which was commended national and international bodies .
Despite their limitations, TBAs will continue to be the first point of call for many women during pregnancy and childbirth except committed governments redefined their roles with a view to increasing skilled attendance at birth with a consequent reduction in maternal and neonatal mortality.
Though meta-analysis showed promising perinatal outcomes when TBAs are trained, their role in maternal mortality reduction was inconclusive, there is therefore a possibility that there may be actual improvement in maternal health .
The WHO suggested practical roles for TBAs in their communities which include being health promoters in maternal and newborn health, encouraging male involvement especially in reproductive health issues, serving as birth companions, supporting households in birth preparedness and complication readiness, and encouraging community participation in developing and maintaining the continuum of care. This can be adopted and adapted by the Nigerian government by using the integration of TBA model shown in [Figure 2].
|Figure 2 Context-appropriate application of traditional birth attendant integration strategies. Source: Byrne and Morgan (2011).|
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This model of integration of TBAs into the health sector showed two pathways on whether TBAs are accepted or illegal. Since TBAs are illegal in Nigeria their roles could be redefined to involve referral of pregnant women to facilities and participating in community-based healthcare activities like preventing harmful neonatal and maternal practices .
Other roles that TBAs could play include vital registration and in the implementation of Maternal Death Surveillance and Response (MDSR) currently being adopted by many countries. However, the attitude of health workers towards the TBAs must improve. They should be treated with respect and dignity. Incentive for early referral and communication in the form of stipends to replace their previous earnings may encourage sustainability and commitment.
| Implications for policy and implementation|| |
There are human resource gaps in the health sector in Nigeria hence the need for a medium-term intervention in the form of integrating the TBAs into the health sector.
Though the present Nigerian health system does not recognize the TBAs, their role in health care delivery cannot be overlooked hence the need for a policy that will ensure that all practicing TBAs in the country be registered by the Ministry of Health through the Primary Health Care (PHC) centres in their communities. They could also be mandated to report all maternal and neonatal deaths that occurred within their communities in the last 24 hours to the PHCs through the community health extension workers. Toll-free mobile phones could be made available for this as well as incentives. Since all burial grounds in Nigerian communities are under the jurisdiction of the Local Government Area Councils, there could be a policy ensuring that all dead bodies, especially maternal and newborn deaths, must have certificates before burial. This will also help in getting accurate figures of maternal and neonatal deaths in Nigeria.
There may be opposition from other health care workers as some view TBAs as a threat, but with proper sensitization and streamlining of the above policy, the challenge of integrating TBAs into the health sector can be minimized.
| Conclusion|| |
Both the Nigerian government and healthcare workers cannot continue to assume that TBAs do not have a role to play in the health of pregnant women and their babies. Since they are present in more than 60% of the deliveries, it is only logical to streamline their roles such that they have a positive impact on the lives of these women and their children. Yes, TBAs can be integrated into the health sector in Nigeria and it is my sincere belief that this will increase skilled birth attendance and subsequently reduce maternal deaths.
| Limitations|| |
Analysis was based on secondary data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]