Birth-related complications are associated with increased mortality and disability rates. Direct causes of deaths during delivery (maternal deaths) are eclampsia, obstetric hemorrhage, obstructed birth canal, sepsis, abruptio, and ruptured uterus. Avoiding these medical conditions during childbirth requires qualified care. Still, women continue to patronize these unskilled birth attendants because of poverty, ignorance, and cultural acceptance.
Interactions with pregnant women revealed that they went to TBAs (traditional maternity companions) because they were closer to them, they were allowed to pay their bills in installments, and they sing and dance because they loved them. Pregnant women want easy access to care. Stakeholders must realize this and strategize to save lives. Interactions with PCAs reveal that they are uneducated and unable to provide the necessary care to prevent maternal mortality and morbidity. The majority of TBAs did not have any formal training and have no idea about the treatment or management of birth-related complications. This is similar to the findings of Ofili and Okojie up to 2005.
TBA has been a longstanding challenge for improving maternal health in Nigeria and African and Asian countries. In a 2014 editorial, Okonofua and Ogu stated that interventions based on the provision of social safety nets in terms of cost reduction, transportation provision and conditional cash transfers for women wishing to give birth in hospital would likely be effective in increasing the proportion of women giving birth by skilled obstetricians in the female population. It protects TBAs due to lack of transportation. Poverty is the reason TBAs give birth in traditional ways. This is because women cannot pay for services in government or private facilities that offer quality care.
During the index discussions, women reiterated that they use TBAs as they are cheaper for them. Poverty is real and cannot be ignored. Economic empowerment is part of the solution to reducing maternal mortality. Some have called for TBAs to be integrated into quality care at birth, but despite these calls, most practitioners are uneducated. These are largely women who want to take care of pregnant women but cannot afford orthodox tuition or attend training schools. The loose nature of healthcare in developing countries such as Nigeria has made TBA exist as an unskilled healthcare provider. Here, the service is the care of pregnant women and those who give birth during childbirth.
It is clear that there is a need for more qualified staff during the birth. An estimate of 2 in 1,000 people currently in Africa is far from confirmed. Thus, the unmet need for skilled birth attendants is met by TBAs. However, TBAs are poorly equipped and cannot prevent morbidity and mortality during delivery. Some likewise called for TBAs to be banned. Will the government banning TBAs be a solution to the problem of TBAs? A 2012 study in the western part of Nigeria found that more than 77% of TBA users opposed the ban on TBA services.
A recent study from Malawi found that a ban placed under the auspices of the TBA significantly aggravates the barriers that pregnant women face in attempting to access health services during childbirth. The “care” of TBA in the face of ruptured uterus, obstetric bleeding, malpression, eclampsia and obstructed delivery will not prevent or treat birth complications that result in morbidity or mortality. Accordingly, a TBA without the knowledge and skills to use and administer aseptic techniques, uterotonics, antibiotics, anticonvulsants, blood transfusion will basically cause preventable maternal and perinatal deaths. It reiterates that only long-term action, backed by political commitment and adequate investment, will lead to the transformative changes needed to achieve sustainable results in the development of the health workforce.
There is a truth, there can be no health without workforce. A clear lesson learned so far is the need to move away from piecemeal approaches and short-term solutions; Retraining TBAs to be aware of the danger signs of pregnancy and childbirth will not improve outcomes if they continue to provide the care they cannot provide. A TBA cannot turn into a skilled birth attendant. The basic foundation gained during education in medical and nursing school is lacking. Implementing an effective intrapartum care strategy is an overwhelming priority in the pursuit of maternal mortality prevention. Therefore, concerted efforts are essential to support and strengthen existing health care systems to provide skilled emergency obstetric care.
A healthcare intrapartum care strategy is the best scenario for reducing high maternal mortality rates. Delivery in a healthcare facility where a skilled obstetrician can provide a clean environment and delivery technique to prevent postpartum infections and optimize delivery outcomes. The partograph is essential for birth surveillance to detect early complications and prevent prolonged and obstructed labor. Active management of the third stage of labor with oxytocics is mandatory to prevent postpartum hemorrhage. The ability to use magnesium sulfate in the management of eclampsia, antibiotics to prevent puerperal sepsis, the application of operative interventions such as cesarean delivery and hysterectomy save lives. Here, skilled assistance to a woman during labor and delivery, including supportive attendant wherever possible, detects complications early.
Early detection of these maternal complications and early referral of all pregnant women with maternal complications prevent all causes of maternal deaths. Likewise, early detection of neonatal complications and rapid referral of all complicated newborns prevent neonatal morbidity and mortality. Simple procedures such as resuscitation of the newborn with at least one Ambu bag, adequate neonatal temperature, hygienic cord care, early breastfeeding with recommendations that encourage early and only breastfeeding ensure the survival of the newborn. Pre-arranged organized transportation to dispatch facilities is essential to prevent all causes of death. These intrapartum interventions are crucial for reducing mortality and morbidity during delivery.
They want TBAs to be officially recognized by the government and to work on a permanent basis. This could be a solution to the plight of women giving birth with an unskilled companion. TBAs can be employed by the government and paid to ensure that all pregnant women are referred to healthcare facilities to give birth with skilled staff. It could be a viable strategy, a situation where the government has commissioned TBAs as health promotion officers – they can be trained for a month to learn how to effectively deliver the red flags of pregnancy and childbirth and referrals.
Education about the danger signs of pregnancy and childbirth is to make them see that trying to provide quality care is not practical. Their employment as a health promotion officer will assist pregnant women in attending a health facility with suitably qualified staff. Bryne and Morgan have demonstrated in their systematic review that improving the interpersonal and communication skills of official health workers to improve their interactions with PCAs is an integration mechanism and increases PCA referrals and skilled birth participation.
Therefore, training healthcare professionals to collaborate effectively with TBAs and women as practiced in Peru and by Mullany and Colleagues increased skilled birth participation from 37% to 95% and from 5% to 48.7%, respectively. . Likewise, integrating PCAs into the formal health sector without first causing community participation can ultimately be detrimental to continuity of care, as seen in Malawi. Therefore, the Primary Health Care Development Agency, an arm of the government tasked with providing primary health care, must urgently do more and destroy the way forward.
Too many women died during childbirth because they could not afford qualified maternity care. As TBAs are the first destination for many pregnant women, the health governing board must take responsibility and ensure appropriate care is provided by qualified staff in relevant healthcare facilities. Emergency ambulances and pregnant woman’s transport / TBA couple should be deployed to quickly bring them to appropriate healthcare facilities.
In addition, efforts should be made to ensure and maintain the training of qualified obstetricians such as midwives and doctors. Medical Schools and Universities such as Ondo State University of Medical Sciences should be encouraged, supported and funded to produce medical staff. Only long-term action, backed by political commitment and adequate investment, will lead to the workforce needed to improve maternal health and prevent morbidity and mortality during childbirth.
Poverty, ignorance and cultural acceptance continue to trigger pregnant women to use traditional obstetricians. Traditional obstetricians are not well equipped to prevent maternal deaths or manage obstetric complications. Traditional birth attendants are believed to be employed by the government and are paid to ensure that all pregnant women are referred to healthcare facilities to give birth with skilled staff.
Medical Schools and Universities should be financed to produce the required skilled health workforce / manpower. The economic empowerment of women, health workers have improved well-being, increased government commitment to functioning healthcare facilities, are some of the interventions needed to prevent maternal mortality. It should be turned into long-term action supported only by political commitment and adequate investment.
Author: Ozlem Guvenc Agaoglu