Background to the study
Every year, approximately 600,000 women die of pregnancy-related causes (WHO, 2010). Ninety-eight percent of these deaths occur in developing countries, and for every woman who dies, at least 20 others suffer injuries and, often, permanent disability (WHO, 2010). Maternal mortality rate in Nigeria is estimated to be approximately 630 deaths/100,000 live birth in 2010, and the main causes identified include: hemorrhage, infection, obstructed labour and hypertension (WHO, 2012). Nigeria accounts for 40% of the global burden of vesico vaginal fistula, which translates to an estimated 800,000 women suffering from conditions arising from prolonged labour and complicated deliveries. One of the major factors responsible for the identified causes of rising maternal and infant morbidity and mortality is lack of skilled birth attendance at birth (WHO, 2008). In developing Countries, specifically in Sub Saharan Countries many women do not have access to skilled birth attendance during child birth. According to the Nigeria demographic and health survey (2009), between 2003 and 2008, only 46% of women living in rural areas received antenatal care from skilled provider (i.e doctor, nurse/midwife, auxiliary nurse/midwife), 28% of births were assisted by a skilled provider and 25% of deliveries took place in health facility (NDHS, 2009). An eastern Nigeria study also showed that although 93% of the rural women registered for pre-natal care, 49% delivered at home under the care of the Traditional Birth Attendants (TBAs) (Imogie, 2012).
In Nigeria, the choice to deliver outside hospital settings could be motivated by varying factors such as economic, social, physical, cultural or institutional (Ahmed, Odunukwe, & Akinwale, 2009). Outside the hospital setting, women can be assisted by an attendant who may be unqualified. These attendants could be a TBA, village midwife, members of the family or neighbour (Ahmed et al, 2009). A TBAs as defined by the World Health Organization (WHO) is a person who assists members during childbirth and acquired her skills by delivering babies herself or through apprenticeship to other TBAs (WHO, 2008). Throughout history, TBAs have been the main human resources for women during childbirth. Their role varies across cultures and times, but even today, they attend to the majority of deliveries in rural areas of developing countries.
Secondary analysis of the 2003 to 2008 Demographic Health Survey (2009) found that TBAs (Trained and untrained) assisted 24% of 200,633 live births (ranging from less than 1% to 66%) in 44 developing countries representing five regions of the world. TBAs attend to a number of deliveries especially where modern health services are unavailable or inadequate (Hussien & Mpembeni, 2009). In Nigeria it is estimated that between 60% and 80% of all deliveries occur outside modern health facilities with significant proportion of these attended to by TBAs (WHO, 2008). Typically, TBAs attract clients by reputation and word-of-mouth and usually they receive remuneration for the services rendered.
Rural dwellers prefer to use the services of TBAs as compared to their urban counterparts. Reasons for the preference include TBAs availability, accessibility, cheap services and rural dwellers faith in the efficacy of their services (Bello et al, 2009). Despite the high patronage of TBAs, their practices during childbirth have been found to adversely affect the health of the mother and the fetus (Hussein & Mpembeni, 2009). There is need for improvement through a more holistic training programme including monitoring and supervision. Health education, training and other strategies aimed at changing the attitude of TBAs towards utilization of sterile procedures, immunization services and prompt referrals of complicated obstetric clients to where modern healthcare facilities exist are recommended (Rowen, Prata & Passaw, 2009). The objective of the training of TBAs is to ensure that they have gained competencies in information, certain skills and procedures necessary for the safety of the mother and the baby and most importantly recognizing high risk pregnancies and complications during labour and referring them promptly to the modern health facilities (Sibley Sipe, Brown & MCnatt, 2010).
A well-functioning referral system is an important element of successful safe motherhood programme. However, in most developing countries many health systems fail to optimize women’s access to emergency obstetric care due to poor referral system. The most affected women are those who are poor and marginalized especially in rural area (Murray and Stephen, 2010). The TBAs are expected to refer their clients to the health facilities and preferably to a government facility, although the various primary, secondary and tertiary health facilities and also the private hospitals serve as referral centre.
In a 6 years period (1997-2002) review of maternal mortality in University of Ilorin Teaching Hospital in the North zone of Nigeria, the maternal mortality was found to be 825 per 100,000 live birth (Abioye-Kuteyi, Fakunile and Akinfolayan, 2011). This relatively high MMR for teaching hospital in the north central zone of Nigeria was attributed to high number of unbooked patients and late referral of patients from referring centres among other external factors. In another study of maternal mortality in South Eastern Nigeria, Ekabua and Ekabua (2011) identified problems associated with referrals of clients by TBAs to be transportation and distance between referral points, opposition and embarrassment faced from medical personnel and rejection of referrals by clients themselves or their relatives. There have also been reports that some TBAs felt referral of clients was not important as they claimed they could manage complications in pregnancy including abnormal lie and malpresentation by simple manipulation and turning the baby or simply by making some incantations (Granja & Machango, 2011). This made referral to the health facilities too late and sometimes at the time the pregnant women health are unsalvageable.
With the high maternal mortality due to delay in or non-referral of clients appropriately, the knowledge of clients for and practice of referrals by TBAs need to be addressed by policy makers and planners. There is need to make positive effort through research based on a firm understanding of what TBAs can and cannot do (WHO, 2008; UNICEF, 2009). It is also important to know the strength and limitations in TBAs referral practices especially as they affect maternal mortality rate (MMR) which in Nigeria is given at 10.5/1000 live births, whereas, it is 3.0/1000 live births in Sudan and 0.1/1000 live births in England/Wales (UNICEF, 2010). This has prompted the researcher to carry out this study.
Statement of Problem
Maternal mortality is the most important indicator of maternal health and wellbeing in any country (WHO, 2008). From recent estimates, the number of deaths each year from maternal causes worldwide decreased from 536,000 in 2008 to 273,000 in 2011 (IHME, 2012). Even though maternal mortality is a worldwide phenomenon, the central issues associated with it are most profound in developing countries. Hence, of the estimated figure for maternal deaths worldwide, developing countries account for 99 percent with an estimated 265,000 maternal deaths occurring in sub-saharan African (WHO, 2010).
The reasons that are adduced for this is persistent tradition in deliveries in domiciliary settings in unsafe and unhygienic conditions by untrained or poorly trained traditional birth attendants (Izugbera & Ukwaji, 2009). Still most women prefer to patronize the traditional birth attendants because they were accessible, available and provide cheap services. Traditional birth attendants deliver the majority of women in Nigeria as in other developing countries. According to Sibley et al, (2010), 70 – 75% of all deliveries in Nigeria are undertaken by TBAs and this percentage is much higher in rural areas where public health intervention is at a poor state. More than 80% of maternal deaths in Nigeria occur due to TBAs patronage (Sibley et al, 2010). Ebuchi and Akintujoye (2012) reported from their study on perception and utilization of TBAs that 80% of maternal mortality was due to late presentation and late referrals of women by TBAs. Bello, Amse, Yahaya and Omohura (2010) equally reported that majority of the trained TBA’s studied failed to refer client promptly to next level of care. In Cross River State Udoma, Ekanem, John & Eshiet (2013) in their study on role of institutional factor in maternal mortality reports indicated that mothers who suffered mortality were more likely to be those who did not receive antenatal care, those who reported late in hospital when they developed complications or those who were attended to at delivery by unskilled health personnel and were brought to hospital in critical condition.
Since the use of unskilled personnel (including TBAs) is argued to be among the reasons for high maternal mortality and from the empirical evidence reported, there is bound to be an increase in the incidence of maternal mortality due to delays and late presentation of clients. The question is; do the TBAs have knowledge of clients for referrals; do they have the proper criteria for referrals? What type of clients’ condition do they actually refer? Are these determined by their demographic status? Seeking answers to these questions motivated the researcher to assess the knowledge of clients for and practice of referrals among TBAs in Southern Senatorial District of Cross River State.
Purpose of the Study
The purpose of this study is to assess the knowledge of clients’ condition and practices of referrals among Traditional Birth Attendants in Southern Senatorial District of Cross River State, Nigeria.
Specifically, the objectives of the study are to:
- ascertain TBAs level of knowledge of type of clients’ condition that need referral to the next level of care during pregnancy and labour.
- identify the criteria that determine the TBAs practice of referrals during pregnancy and labour.
- determine the type of clients during pregnancy and labour that were referred by TBAs.
- determine the association between socio-demographic data and TBAs practice of referral of clients.
- establish the associations between TBAs knowledge of clients’ condition and practice of referrals.
Based on the specific objectives formulated, the following research questions were asked.
- What knowledge do the TBAs in southern senatorial district of Cross River State have on types of clients’ condition that need referral to the next level of care during pregnancy and labour.
- What criteria determined TBAs practice of referrals during pregnancy and labour
- What are the types of clients’ condition during pregnancy and labour that were referred by TBAs
- What is the association between socio-demographic data and TBAs practice of clients for referrals
- There will be no significant association between educational attainment and knowledge of clients’ condition for referrals among TBAs in southern senatorial district of Cross River State.
- There will be no significant association between years of experience and practice of referrals of clients’ condition among TBAs in southern Senatorial District of Cross River State.
- There will be no significant difference between trained and untrained TBAs in their practice of referrals of clients’ condition to the next level of health care facility.
- There will be no significant association between TBAs knowledge of clients’ condition for referrals and their practices of referrals of clients.
Significance of the Study
The findings from the above study will provide information to health care providers who will see the need to organize regular training and retraining of TBAs with routine monthly and supportive supervision which will help in prompt referrals of high risk and complicated pregnancies and deliveries by TBAs.
Nurses and midwives will partner with the TBAs to encourage proper monitoring and supervision and continuous training of the TBAs. Nurses and midwives will also sensitize the government to provide materials in terms of human and finance for the training of the TBAs on identifications of complicated clients’ condition during pregnancy and labour and referrals to the modern health facilities.
Improvement in the ability of the TBAs to identify complicated clients’ condition during pregnancy and labour will lead to reduction in late referrals and reduction in maternal mortality and morbidity due to pregnancy and labour complication thereby enhancing the anticipated outcome of the achievement of Sustainable Development Goal (SDGs) of improvement of maternal health and reduction in maternal mortality. Lastly, the information obtained from this study may be of help to other researchers interested in working in this field as it will serve as a reference material for further research.
Scope of the study
The study is delimited to Traditional Birth Attendants who are resident in Southern Senatorial District of Cross River State irrespective of their level of education, years of practicing experience and training. It is also delimited to their knowledge of danger signs during pregnancy and labour to be referred, TBAs criteria for practices of referrals during pregnancy and labour, type of clients’ condition during pregnancy and labour that were referred; preference for health care system for client referrals and association between TBAs knowledge of clients’ condition for and practices of referrals.
Operational Definitional of Terms
Traditional Birth Attendants
A traditional birth attendant (TBA) also known as traditional midwife is a person who assists mothers during pregnancy and child birth and acquired their skills by delivering babies herself or through apprenticeship to others. They could be trained or untrained.
Trained Traditional Birth Attendants
These are the TBAs who have received official skill acquisition on delivering babies organized by government or non-governmental organizations in Nigeria to upgrade their skills on procedures necessary for the safety of the mother and baby and most importantly recognizing high risk pregnancy and complications during labour and referring promptly to the modern health facilities.
Untrained Traditional Birth Attendants
This is the traditional birth attendant who has not received any official skill acquisition on delivering babies organized by government or non-governmental organizations. These untrained TBAs only received their training by working with other TBAs, or relatives.
Traditional Birth Attendants Knowledge of Clients for Referrals
In this study knowledge of clients for referrals is the ability of the TBA to recognize the type of clients that need referrals during pregnancy and labour. The danger signs are previous post partum haemorrhage, severe headache, swollen feet, anaemia, abnormal presentation, convulsion, bleeding in late pregnancy, prolonged labour, maternal distress and fetal distress. And complications of not referring are asphyxia, still birth, ruptured uterus, post partum haemorrhage, sepsis, intrauterine death and maternal death; also, the benefits of prompt referrals. Knowledge could be high, moderate and low.
High Knowledgeable TBAs
Are those who would score above 30 points on answering questions on knowledge of danger signs during pregnancy, delivery and post-delivery to be referred.
Moderately knowledgeable TBAs
Are those who would score 20 – 29 points on answering questions on knowledge of danger signs during pregnancy, delivery and post-delivery to be referred.
Low knowledgeable TBAs
Are those who will score up to 10 – 19 points on answering questions on knowledge of danger signs during pregnancy, delivery and post-delivery to be referred.
Criteria used for referrals:
Refers to the basis in which TBAs decide on referrals of clients; these include, stage at which referrals should be made either appropriately or delayed, places chosen to refer clients to either another TBA or to primary, secondary or tertiary health facility, and also which clients to be referred to different levels of care, if client is accompanied to the next level of care when referred and by who.
In this study appropriate referral, refers to TBA sending complicated clients’ condition to the next health facility within 1 hour after identifying a complicated clients’ condition.
Delayed state of referral to the health facility
In this study will refer to TBA sending clients to modern health facility after 1hour following detection of complicated clients’ condition.
Practice of referrals
In this study, practice of referrals means whether the TBAs have referred clients in pregnancy and labour, types of referrals in terms of always, often, seldom and never. Practice could be highly adequate, moderately adequate and inadequate.
Highly Adequate Practice
Are those who will score mean of > 3 points on answering questions on practice of referrals during pregnancy and labour in terms of always often, seldom and never.
Moderately Adequate Practice
Are those who will score <3 but > 2 points on answering questions on practice of referrals during pregnancy and labour in terms of always, often, seldom and never.
Are those who will score mean of <2 on answering questions on practice of referrals during pregnancy and labour in terms of always, often, seldom and never.
Socio-demographic characteristics to be used in this study are traditional birth attendant’s educational attainment (primary, secondary and tertiary education), years of experience and training.