Traditional birth attendants are more trusted, affordable – 29-year old mother of three
Many suburban dwellers unaware of Nigeria’s National Health Insurance Scheme (NHIS) established 1999 – now National Health Insurance Authority (NHIA)
Nigeria’s maternal and child health indices are among the world’s worst – WHO
50 percent reduction in Egypt’s maternal mortality linked to number of births assisted by qualified professionals – WHO
By Kazeem Akolawole
In Nigeria’s capital, Abuja, many women and their families choose the services of a traditional birth attendant rather than the Primary Healthcare Centers because they trust the knowledge and experience that this traditional folks provide and are also much more affordable.
Sadia Huraira is a resident of Gwagwalada Area Council in Abuja, Nigeria. The 29-year old mother of three was delivered of her children at home with Traditional Birth Attendant (TBA), names withheld.
The TBA is the community’s most dependable and lives two houses away. Her delivery suite is a mat in a poorly lit room with a small window.
The octogenarian TBA who showed off her knowledge, told Africa Health Report, AHR, that “I can tell from the look of their ‘stomachs’ and the way they drop, whose husband will soon be inviting me.” There are clay pots filled with dried herbs, leaves and various concoctions lined up in TBA’s compound which she administers to the women.
It was an easier and cheaper option for Huraira to pay Mama for a little below N500 than to go to the community’s Primary Healthcare Centre (PHC) run by a male community health worker.
The cost of the PHC is five times Mama’s amount, where there is no toilet, no water and no medicine. Huraira’s, husband, a commercial motorcyclist, earns N17,000 monthly, and she supports him by growing vegetables and grains.
For another member of the community, Rose Ishaku, a young mother of two boys, the cost of the PHC would have meant she could not afford the ‘other’ basics, such as clothing and school fees. Her mother cut the umbilical cords of her sons with a razor blade. Her mother also provides food for the family in the absence of a father.
Rose takes the view that since her deliveries went smoothly, and her sons were healthy and continue to be, the routine immunisations at birth were unnecessary. Now three months into her third pregnancy, Mary has no intention of changing her patterns.
Also Lydia Adamu explains to AHR that when she went into labour, her first child seven months ago the PHC was not even open.
Her words: “I went into labour at about 3am and my husband took me to the health centre. But it was locked. We waited a short while for the security man who then came to open the centre, as I sat waiting on the pavement. Not too long after, he arrived and let me in. No sooner had I sat on the bed than my baby was born.”
The security man got on a motorcycle to collect the health worker, who arrived ten minutes later, only to cut the umbilical cord and clean up Lydia and her newborn.
The delivery cost Naomi N2,500. Although she was given a mosquito net and a piece of fabric which she was told to wrap her baby in, Naomi said she does not know what the N3, 000 payment was for as no form of medication was administered to her.
Sadia, Rose and Lydia are all unaware of Nigeria’s National Health Insurance Scheme (NHIS) set up in 1999, now transformed to National Health Insurance Authority (NHIA) as President Muhammadu Buhari signed the Act 2022 into law.
The Act is designed to cushion the burden of healthcare. They are not alone. Only a handful of people resident in the suburbs are aware of the scheme which ordinarily should be available in all PHCs based on the mandate establishing them.
Speaking on the issue, Director of Policy and Advocacy, Nigeria Health Watch, Dr. Ifeanyi Nsofor, said the major mandate of the NHIA was to provide health for all Nigerians, regardless of location, through different pre-payment mechanisms, otherwise known as health insurance. Unfortunately, so far it has only covered one percent of Nigerians.
For Rose, she considers it to be “a long journey” to achieving healthcare if when she went into a labour at 3am nobody was available to attend to her. “It was my first time and I was scared. I was worried my baby would catch a cold in that harmattan,” she said.
PHCs should ordinarily be equipped to support mothers giving birth and others for their health needs. But for the likes of Sadia and the rest of her community, this seems to be a tall order.
Inadequate Medicare
High maternal mortality ratio in sub-Saharan Africa (SSA) has been linked to inadequate medical care for pregnant women due to limited health facility delivery utilization.
According to the study that used the most recent secondary dataset from Nigeria’s Demographic and Health Survey (NDHS) conducted in 2018. The results showed that the prevalence of health facility deliveries was 41% in Nigeria.
The lowest adolescent birth rates are registered in Lagos (22) and Anambra (16). The highest rates are in Bauchi (166) and Jigawa (156).
Women who had their first birth below age 20 [aOR = 0.82; 95%(CI = 0.74–0.90)] were less likely to give birth at health facilities compared to those who had their first birth at age 20 and above.
The findings suggested the need to design interventions that will encourage women of reproductive age in Nigeria who are younger than 20 years to give birth in health facilities to avoid the risks of maternal complications associated with home delivery.
Such interventions should include male involvement in antenatal care visits and the education of both partners and young women on the importance of health facility delivery.
The Sustainable Development Goal (SDG) 3 aims to ensure healthy lives and promote well-being for all ages.
However, high maternal mortality ratio (MMR), especially in low-and middle-income countries (LMICs), has remained worrisome. In line with this, SDG 3, calls for the global MMR reduction to less than 70 per 100,000 live births by the year 2030.
Although many countries have reduced their MMRs, causing a general global decline, efforts to reduce MMRs of countries in sub-Saharan Africa (SSA) have largely stagnated.
According to World Health Organization(WHO), Nigeria’s maternal and child health indices are among the worst in the world.
In 2015, WHO estimated that 19% of global maternal deaths occurred in Nigeria with an estimated MMR of 814 per 100,000 live births, and this placed a lifetime risk of maternal death at 1 in 22 in contrast to 1 in 4900 in developed countries.
Nonetheless, the 2018 Nigeria Demographic Health Survey (NDHS) estimated MMR of 512 per 100,000 live births. Despite this reduction, Nigeria still remains one of the countries with the highest MMR globally.
Neonatal Mortality in Sub-Saharan Africa
Neonatal mortality is another serious public health threat in Sub-Saharan Africa (SSA). In 2019, SSA had an estimate of 27 per 1000 live births, while Nigeria reported 36 per 1000 live births out of the estimate.
Similar to Maternal Mortality Ratio(MMR), efforts to reduce neonatal mortality in SSA, especially in Nigeria, have been relatively slow. Between 2010 and 2019, only a 13% reduction in neonatal mortality ratio was achieved in Nigeria.
The high prevalence of maternal and neonatal deaths in SSA and Nigeria have been linked to inadequate medical care for pregnant women, resulting in low health facility delivery.
Experts affirm that health facility delivery is an important aspect of maternal care because of the presence of skilled birth professionals, as well as an enabling environment where resources necessary for effective management of obstetric complications are available.
Adolescent Birth Rate
According to 2021 Multiple Indicator Cluster Survey (MICS), released by United Nations Children’s Fund (UNICEF) in partnership with the Federal Government and other partners, showed that adolescent birth rate is 75 births per 1,000 women aged 15 to19 years and this is a relative decrease of 38% from 5 years ago.
MICS also revealed that the lowest adolescent birth rates are registered in Lagos (22) and Anambra (16) and the highest rates are in Bauchi (166) and Jigawa (156).
Impact of Qualified Professional Birth Assistants
A WHO report showed a 50 percent reduction in Egypt’s maternal mortality when the number of births assisted by qualified professionals doubled.
This implies that maternal and neonatal mortality in Nigeria can be reduced by ensuring that women have better maternal healthcare services, especially health facility delivery.
Although home delivery may be relatively cheaper for these women, evidence suggests that home-delivery can pose a serious health risk to both the mother and infant.
Advocacy and Awareness to Mothers and Caregivers
Other than financial constraints, other identified factors for poor utilization of maternal health services in SSA include maternal age, maternal and partner literacy level, poor knowledge about obstetric danger signs, cultural beliefs, poor referral practices, scarcity of trained health workers, and poor coordination among staff. These barriers have been found in Nigeria.
Studies in the past have suggested age at first delivery as a determinant of health facility delivery in Nigeria.
For instance, a study conducted among women in a semi-urban settlement in Zaria, Northern Nigeria, found that 77% of women who had first pregnancies before age 18 delivered at home compared to their older women counterparts with 56% home deliveries. This implies that younger women in Nigeria tend to deliver at home compared to older women.
Similarly, the 2013 NDHS conducted estimated that 23% of Nigerian women aged 15 to 19 had begun childbearing, of which 17 percent out of this had their first child, and 5% were pregnant with their first child.
The 2018 NDHS also showed that the median age at first birth among women age 25 to 49 was 20.4 years. This means that half of the women aged 25 to 49 gave birth for the first time before age 21.
Experts therefore recommend that, there is a need to examine how age at first birth is associated with health facility delivery in Nigeria.
