Expectant women in Internally Displaced Persons (IDPs) camps in the Federal Capital Territory (FCT) have been depending mostly on traditional birth attendants to be delivered of their babies during the pandemic. AFRIUPDATE investigates how unskilled TBAs have come to the rescue of women in the camps and looks at what has been done in other states to reduce maternal mortality rates.
Helping a woman to birth a child was the last thing on the mind of 28-year-old Godiya John, mother of four.
When her pregnant neighbour, Tabitha Sunday, 23, a mother of three, cried out for help in the middle of the night, she assumed that she would only be required to take her to the hospital or to call the traditional birth attendants (TBA) at the Kuchigoro camp for Internally displaced persons (IDPs) in Abuja
However, this was not to be because Tabitha was fully dilated and there was no alternative for Godiya but to help Tabitha deliver her baby at home.
“I was scared because I had never assisted in a delivery before,” Godiya said.
Seeing the agony in Tabitha’s face, Godiya set aside her fears and swung into action. “Tabitha directed me to her cache of delivery items—gloves, anointing oil, bleach, a bottle of disinfectant, a polythene bag, sanitary pads, several clips and wrappers. From my experience having delivered all my four children at home, I felt it would be best to massage her stomach as she pushed for the baby to come out. The baby’s head was already popping out. Since she did not have bed pads, I laid out some wrappers for her to deliver on.
“After the baby was born, I cut the umbilical cord with a razor, held it with a clip, cleaned the baby with a clean sanitary pad and the oil which l had poured all over it like l had seen other TBAs do. Then I put the baby in diapers and some clothes before turning to the mother whom l helped bathe with warm water.”
Enoch Yohanna is not a TBA and had never helped a woman deliver before he came to Kuchigoro camp six years ago. Yohanna, who escaped the frequent Boko Haram attacks at his home in Gwoza, Borno State, has so far delivered 52 babies in the camp. He has no medical qualifications and has not received any basic training on delivering babies.
Yohanna said, “A few weeks into my arrival at the camp, I was called upon to assist a neighbour, Laraba Yusufu, who went into labour at about 10 PM. Some members of the camp and I took her to the Federal Medical Centre Jabi, where we were asked to pay N20,000, which we could not afford. We pleaded with the hospital to allow us to pay after delivery, but they refused.”
Yohanna said they were also rejected at the National Hospital and the Asokoro General Hospital because they did not have the money. After the run-around at the hospitals, they were directed to the Old Kuchigoro Primary Health Care Centre. But by then, Laraba’s labour was too far advanced. Yohanna helped deliver the baby who was born under the Area One bridge while on their way to the centre.
Yohanna did not know what to do after the baby was born— how to deal with the afterbirth or clamping the umbilical code. However, he was able to get the new mother and her baby to the health centre where the nurses helped. “We were asked to pay N6000 before the nurses agreed to detach the placenta. Unfortunately, the baby fell seriously ill and almost died. He was saved after the Nigerian navy came to offer free medical services to the camp residents. The baby was treated by the navy doctors for free,” he says.
Soon after the incident, he was made the camp secretary. During the period he realised that members of the Kuchigoro host community were taking advantage of the IDPs, selling them medication and food at exorbitant rates as they were new to Abuja and did not know their way around. He eventually resolved the issues with the host community and began applying the little medical skills he had acquired from watching his parents who were both medical professionals.
After Laraba’s successful delivery, Yohanna successfully delivered three more babies. Since then, the pregnant women have come to trust him and have been calling on him to help deliver their babies.
“I already knew most of the things that need to be done. My mother taught me the basics. Both of my parents were medical practitioners. My mother was a pediatric nurse and my father was the head of the Orthopedic Department at the General Hospital Goshe in Gwoza Local Government Area of Borno State.
“Both of my parents were missionaries who assisted our community in Gwoza when they were alive. My mother was always the first point of call by the women who were in labour and she often allowed me to assist. We also had a pharmacy at home and my parents taught us how to give injections, first aid and the basics, like how to set a cannula and a line for a drip.”
Why take the risk
A January 16, 2020 article by the International Committee of the Red Cross (ICRC), ‘Traditional birth attendants in north-east Nigeria affirms the integral role that traditional birth attendants, even accidental ones like Yohanna, play in helping to reduce the maternal mortality rate in Nigeria and particularly in the northeastern region ravaged by insurgency forcing thousands of people into camps.
“Without them, we would be doomed!,” the report quotes Samuel Okech who is responsible for the ICRC health programs in Maiduguri when referring to the role that the traditional birth attendants play in helping mothers deliver safely.
Nigeria is considered a dangerous place to become a mother. It has one of the highest maternal and neonatal mortality rates in the world with over 40,000 maternal deaths occurring yearly. This is according to a report by the Federal Ministry of Health titled, ‘Accelerated reduction of maternal and newborn mortality in Nigeria, a roadmap for action 2019-2021.’
The lifetime risk of dying in pregnancy and childbirth in Nigeria is estimated to be 1 in every 22 women, which is the highest in Africa. As of 2013, Nigeria was recording 576 maternal deaths per 100,000 live births and neonatal mortality of 37 deaths per 1000 live births. On average, 303,000 women die every year from pregnancy-related causes. The country’s maternal mortality burden of 58,000 lives and a perinatal mortality rate of 77 per 1000 births is second only to Pakistan. Maternal and neonatal mortality rates are higher among women in the Northern States as compared to women in other parts of the country. For example, the maternal mortality rate in the North-Eastern region is three times higher than the national average.
The major causes of maternal and neonatal deaths are lack of knowledge by the women on the importance of attending antenatal care services, lack of skills, equipment, drugs and tools in health facilities, the poor state of facilities and slow and unreliable life-saving care as well as the cost of accessing these services. TBAs fill in the gap and therefore play a huge role in helping reduce maternal and infant mortality.
“Health professionals do not recognise TBAs, but the communities rely on them heavily. They trust them. This is why we have to train them,” says Peace Njideka Nwokorie, Health Assistant for the ICRC which has been training TBAs best practices for delivering babies. The TBAs are also trained on how to deal with family conflicts and domestic violence.
One of such TBAs is 57-year-old IDP and mother of nine, Naomi Isiaku. She has been delivering babies for the past 20 years. On her last count, she had delivered 37 babies including 27 at the Kuchigoro camp where she has been living for the past six years. Naomi’s mother was also a TBA and she grew up watching and assisting her in helping her deliver the women of their village in Gwoza.
She said, “All the 37 babies were delivered safely except one which was a stillbirth. I was called to deliver the baby and I realised that it had died in its mother’s womb. Those I delivered at home in Gwoza, at the IDP camp in Cameroon and here in Kuchigoro, were safely delivered.”
Tabitha Sunday had planned to deliver her third baby in a hospital. Her two previous births had been at the hospital.
She said, “I went for three antenatal sessions, but I could not afford the N2500 required for a scan. As my time for delivery neared, I knew that my dream of having my baby at the hospital would be impossible because I had no money and the skilled health personnel that were assigned to the camp were no longer available due to the pandemic.”
Twenty-six-year-old Sarah Yusuf had no plans of giving birth in a hospital. The mother of three only attended one antenatal session. And this session was only because she got someone who offered to pay the N2000 required to open a file for her at the hospital. She could not afford a second session or the N2500 for a scan.
Preparing for a home birth, Sarah went to the camp dispensary and collected some gloves, clips for the cord for when the baby arrived. She also bought a bed pad and when her labour started in the middle of the night, she sent for one of the traditional birth attendants in the camp.
“The birth attendant here is well experienced, she assists us freely. But if you have money, you can give her N1500 and if you don’t, you can give her soap or a wrapper as a way of appreciation,” she says.
Naomi said that she does not ask for payment because she was also delivered of her children by TBAs who never asked for money.
“I do this to help my people and God takes care of me. When people come to the camp to donate, we get something to eat. When farming season arrives, I go and farm to feed my family,” she said.
Enoch Yohanna explains why so many of the women in the camp have opted to deliver their babies at home: “Abuja is not a place for the poor. Delivery in the hospital costs N25,000 and a delivery kit N15,000. You will also be asked to bring blood or pay N10,000. Our people can barely feed themselves. We depend on handouts from individuals, faith bodies and NGOs. But such assistance is no longer available due to the hardships caused by the pandemic.”
He said many of the TBAs are aware of the risks that come with delivering babies in the camp since they do not have the equipment or the skills to assist women having a difficult birth. He said they have been fortunate since none of the 79 babies that he and Naomi have delivered over the last 6 years have resulted in death. “We only have one case of stillbirth. The only other case of infant mortality we have had was not at birth but as a result of malnutrition after birth,” he said.
Why the huge success?
Both Yohanna and Naomi attribute their success to different reasons— faith in Naomi’s case and in Yohanna’s case, his ability to calm and reassure the mother’s fears at delivery as well as the rudimentary skills that he has been able to acquire from watching his mother when he was growing up and from the experience he has managed to gain over time.
Naomi and Yohanna try not to deliver women who have problem deliveries —those presenting breech birth positions or other similar complications. But all this is done in a haphazard manner since they are not able to determine those at risk of having a problem delivery as they do not have any equipment such as an ultrasound.
In such instances, they usually question the women to find out if the baby is presenting in a breech birth. If the woman says she feels her baby kicking around the ribs, lower down below the belly button or if they identify a hard round lump under the ribs of the expectant mother which does not move very much, they advise the woman to prepare to go and deliver the baby in hospital.
Sometimes these complications present themselves when it is too late—when the woman is already in labour. “In these instances we have to take the risk and deliver the woman,” Yohanna says.
In a place like the Kuchigoro camp where the displaced inhabitants depend on goodwill that is rare now as a result of the pandemic, TBA’s are a godsend to the pregnant who cannot afford to go and deliver in hospitals.
Yohanna’s motivation to help is his way of paying back for the support that the villagers gave to him and his family when his father was murdered by Boko Haram. The villagers defied the directives of the Boko Haram not to bury his father. “They used hoes and their bare hands to bury my father whose body had been left out in the open for three days. We fled from the village thereafter,” he recalls.|
A study published in August 2014 in the Journal of public health and epidemiology titled, ‘Traditional Birth Attendants and Women’s Health Practices: a Case Study of Patani in Southern Nigeria,’ By Geoffrey Nwakwuo, Ferdinand Oshonwoh and Christopher Ekiyor, outlines the importance of traditional birth attendants in Nigeria.
The study stated that despite the existence of modern health facilities in Nigeria, over 58% of deliveries still take place at home and only 37% take place in hospitals.
It added that a study of 377 women who delivered before arrival at the hospital in Ogbomosho, South-Western Nigeria revealed that, 65% of the mothers had been delivered by a TBA, while 73.7% had sought help from them for retained placenta with bleeding. In Chanchaga LGA of Niger State in North-Central Nigeria, 84% of households interviewed utilized the services of a TBA or village health worker.
External help for Kuchigoro
Unlike other TBAs in the camp, Tabitha has not received any training. Naomi said she and a few TBAs underwent some basic training and were given a delivery kit comprising of gloves and medicines to stop excessive bleeding. “They asked me to charge the women for the medicines and for my services. They gave me the medicines to be given to a woman after delivery to avoid blood loss and it was supposed to cost N3000. I thought it was too much and asked the women to give me N1500 for the medicine. And even at that, still a lot of them cannot afford it.”
Director, Public Health Center of the Federal Capital Territory (FCT), Public Health Center Board (PHCB), Dr. Ruqayya Wamakko explained that, “We follow the rules of task shifting and sharing policy. It says you can train health workers on life saving skills so that they can be skilled birth attendants under the supervision of midwives to take deliveries and on the danger signs of pregnancy, labour, postnatal periods, family planning and immunization, among others. But with TBAs, we know that they are in the communities. In the FCT we go by the national and international rules and regulations of WHO. So most times we don’t consider TBAs, we don’t work with TBAs unless on issues of HIV, where we tell them that if they see a patient with signs they should be referred to the facilities.”
Regarding their healthcare needs, Yohanna said the TBAs do not have enough delivery kits. According to him, the last donations made to the camp were in 2019 when the Australian government provided them with 200 delivery kits which he handed over to the Kuchigoro health centre to be used by the women from the camp. He said most of the kits were destroyed during a flood and those that remained were beyond salvage and had to be destroyed.
A basic delivery kit should, at a minimum, include a clean razor blade for cutting the infant’s umbilical cord, soap for washing hands before delivery, a pair of gloves, cord ties, a plastic sheet to ensure delivery on a clean surface, two pieces of cloth, one to dry the baby and the other one to wrap the baby and a pictorial instruction that unskilled TBAs like Naomi and Yohanna can use.
The Mothers’ Delivery Kit which retails at N1,700 in Nigeria has now started including medicine like misoprostol – a drug that stops postpartum haemorrhage – and mucus extractors used to prevent newborns from asphyxiating. Postpartum bleeding is a major cause of maternal deaths.
Dr. Wamakko explained that the FCT provides delivery kits under the pharmaceutical department in conjunction with the safe motherhood which they call Mama Kit. These are supplied directly to PHCs in the six area councils and not just communities for expectant mothers attending antenatal at the PHCs or going for delivery, but special attention is paid more to facilities with more patients.
She added that, “But we ran short of it in this period of COVID-19, our last deliveries were around January/February 2020 and since then there has been a shortage and we have not even produced at all.
“The Mama Kit is a bag where we put things necessary for delivery. It includes sanitary pads, bed pads, razor blades for cutting the cord of the baby, hand gloves, clips for the baby’s navel, 4% chlorhexidine used for neonatal infection, soap that the midwife can use to wash after taking delivery, methylated spirit as disinfectant. Sometimes Oxytocin is included, but we sometimes replace it with Misoprostol which is easier to store in PHCs without electricity for storage. The drug is used to make the uterus contrast to stop bleeding after delivery.”
Yohanna also expressed concern that the majority of the children born in the camp were not registered as the parents are expected to pay N100-N500 for a birth certificate.
Faced with forking out N500 which is equivalent to feeding a family for a day, most of the parents were unwilling to spend the money for a certificate. Out of the 79 children he and Naomi helped deliver, only about 10 to 20 are registered.
“When we ask for help from the FCT government they tell us that we are not IDPs, that we should return to Borno State. But is the State safe? Bomb blasts still occur in the camps over there. So why would you force someone to go and die?”
Responding to this, the acting Public Relations Officer (PRO) of the FCT Emergency Management Agency (FEMA) Faustina Ngaha said the IDP camps in the FCT are not considered legal settlements. “The settlements are not considered as IDP camps because there is a United Nations rule that guides the establishment of such camps. Camps are supposed to be located near the area of incident like we have in Maiduguri and that is why FEMA has time and again advised many of them to go back home, close to where the incident happened, where we have established IDP camps with allocations and where they will be well taken care of. Some of them have agreed to go but some have not.”
On IDPs access to health services, Ngaha said FEMA had arrangements with two hospitals in Abuja where they can receive treatment for free. “All they need is to come to FEMA offices and collect a card which they present at the hospital and FEMA pays the hospital. They have been doing this for years but due to the pandemic, one of the hospitals, Asokoro General Hospital was turned into an isolation centre. They can no longer access it but they are still able to access the Wuse General Hospital.” she said.
She said that since 2017 when the program commenced, about 170 IDPs have been able to access and receive treatment at these hospitals. Thirty three of these are IDPs from Kuchigoro. She said many of the pregnant women prefer to go to traditional birth attendants instead of going to hospital to deliver their babies. “They feel it is easier and convenient for them,” she says.
This is disputed by the women leader of the Kuchigoro camp, Ladi Mathias who says the women are dissuaded from delivering at the hospital because they are asked to pay. She said even those with cards issued by FEMA are expected to pay for health services.
“We no longer go to FEMA for the card because the hospitals do not accept it. They treat us like beggars or like we are not human beings when we go with it. They don’t take us seriously when we present it, you will be ignored by everyone including the doctors. They will keep you waiting for hours.
“My son almost died in July when I took him to Asokoro General Hospital.We took him to the hospital around 9AM on that day, by 4PM he was still lying inside the taxi that we brought him in because they would not agree to take him at the emergency unit. The driver became angry and threatened to leave.
“When I presented the card to the doctors and everyone at the hospital, they refused to attend to us and told us they had no bed. By 4PM, I called a friend for help and she sent me N20,000. I took him to Wuse General Hospital and they accepted to treat him when they realised that I had come with money and not the card. The last time we went for the card was in February 2020 and the patient that we took to the hospital with the card died after being unattended to for a whole day,”she says
Way out
Some states in Nigeria are taking steps to address the problem of ensuring mothers deliver safely. The Abiye (Safe Motherhood) campaign launched by Ondo State is a good example of local solutions to reduce infant and maternal mortality. According to the 2008 Nigeria Demographic and Health Survey, Ondo state had the worst maternal outcomes in Nigeria’s South West region.The state’s maternal mortality rate 745 per 100,000 lives birth which was far above the national average of 545 per 100,000 live births.
To reverse this situation, the State initiated the Abiye (Safe Motherhood) programme. By 2016, Ondo State had managed to reduce the maternal mortality to by 84.9 per cent to 112 per 100,000 live births. And it was the only state in Nigeria that was able to meet the Millenium Development Goals indicators of reducing maternal death in the country, surpassing that goal with a 75% reduction. involves community engagement, health system strengthening and the removal of user fees.
About 92.0% of women had received antenatal care in the 2018 survey. Majority of births 80.7% took place in health facilities by the NDHS report of 2018.
The Abiye programme caters for pregnant women and young children aged upto five years. To address the problem of women delaying in seeking care, a health ranger — a specially trained community health extension worker — is assigned to 25 pregnant women who she visits and monitors regularly.
The pregnant woman is also provided with a mobile phone once she registers at a primary health care center so that she can keep in touch with the health ranger or the primary health care centre where she has registered. The number is toll-free thereby not requiring the women to spend money on calls related to their health and that of their babies.The phones are prepaid by the government and are linked to a caller-user group, and tracked by trained personnel who monitor the calls.
To deal with the problem of commuting to hospital to deliver, the health rangers and health facilities are equipped with transportation means that are appropriately suited to the area of operation such as motorcycles, tricycle ambulances to four-wheeled ambulances. Tricycle ambulances have become popular in other states where they are used to transport COVID-19 patients.
To ensure there is appropriate care for the women when they arrive at the hospital, the Ondo State government improved the health care facilities, provided equipment and medicines and retrained the existing health workers and particularly community health workers who were under-utilised. The state also established two Mother and Child Hospitals at Akure and Ondo. These hospitals specialise in maternal health and serve as referral centres. Pregnant women are provided with free consultations, laboratory tests, medication, admissions, and surgeries.
Alongside the Abiye initiative, Ondo State also established the Agbebiye (Safe Birth Attendant) Initiative in response to a 2012 Confidential Enquiries into Maternal Deaths in Ondo State (CEMDOS) report which linked over 90% maternal deaths to the negligence or delayed referrals by traditional birth attendants.
Under the Agbebiye programme in Ondo State, the TBAs are provided with incentives such as cash, training in acquisition or alternative vocational skills and even small micro-finance initiatives— to refer pregnant women to authorized public facilities and ensure the child is taken delivery of at the facilities. The TBAs receive a voucher on every delivery of a referred pregnant woman in the health facility.
Due to the success of these initiatives and to curb maternal health tourism from neighbouring states, the Ondo State government introduced a residence card Kaadi Igbe Ayo. Only those women with these cards are able to access the state’s free maternal health services.
The Abiye and in particular , the Agbebiye initiative would help meet many of the challenges facing women in the IDP camps. Re-training TBAs, incentifying them to refer pregnant women to hospital, providing the camps with tricycle ambulances can help reduce the risks that women in the camp are going through.
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This report was supported by the Africa Women Journalism Project (AWJP) in partnership with the International Centre for Journalists (ICFJ).
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