ABSTRACT
Despite all efforts to reduce maternal
mortality rate during the Millennium Development Goals (MDGs) initiative,
maternal mortality remains unacceptably high. In Nigeria, the maternal
mortality rate is 800-1,000 per 100,000 live births, making Nigeria accounts
for about 10% of the global estimate for maternal mortality. One of the reasons
MDGs initiative failed to achieve the set target was because it focused mainly
on clinical measures and other important drivers of maternal health care were
ignored. For instance, some of the vital roles of traditional birth attendants
(TBAs) were ignored.Although, TBAs practices are not in consistence with best
practices but they are safety nets in areas where maternal health care services
are short served. They were isolated
from the strategies in implementing the MDGs.In Africa, Over 58% of deliveries
are delivered outside hospitals in the rural areas which traditional birth
attendants have higher patronage and according to WHO, global goal is that over
70% of deliveries should be assisted by skilled birth attendants so as to
manage complication cases. Lifetime risk of women to die as a direct result of
complication during pregnancy and delivery is estimated to be at 1:16mothers
compared to 1 in 8,700 in North America or Europe.Therefore, the main objective
of the study was to determine factors that ensure emergency obstetric referrals
and referral intentions among traditional birth attendants in Lagelu local
government, Oyo State, Nigeria
The study was a cross-section design in which
a focus group and validated questionnaire was used to collect information from
52 consenting female traditional birth attendants in lagelu local government.
Ethical clearance was obtained from Babcock University Health Research Ethics
Committee (BUHREC) to conduct the study. Data collected was analysed using
frequency distribution, summaries and descriptive statistics was done.
The result in this study showed that the mean
age of the participants was 49 years with majority (75%) attaining primary
education only. All the participants (100%) are women. Majority (95%) are also
married with 90% of them being Christians. Years of experience of all
participantsare from 2-25years. High patronage by pregnant women was recorded
with each of traditional birth attendants attending to deliveries in a range of
1-25 births annually. Attitude of most of the respondents was unfavorable with
mean score of 7.6 on a rating scale of 27points.Subjective norms were above
average with 62.52% with mean score of 13.13 on a rating scale of 21 points.
Referral intentions were positive for majority(95%) There was a significant
relationship between attitude and perceived behavior with p-value less than
0.05. (P < 0.05)
The study concluded that traditional birth attendants
have a strong influence on the utilization of emergency obstetric care by
pregnant women and a good strategy in reducing the alarming high maternal
mortality would be to use the qualities of traditional birth attendants to
improve bilateral respect between pregnant women and the hospital staff. The
traditional birth attendants should be involved in planning, implementation and
monitoring of any intervention training directed to them to enhance their
skills in referrals. Partnership between the tbas and the biomedical staffs should
also be strengthening.
CHAPTER
ONE
INTRODUCTION
1.1 Background to the Study
Pregnancy
complication is unpredictable even when it occurs and a major cause of maternal
mortality in developing countries where majority of the pregnant women are
assisted by Traditional birth attendants during deliveries. (TBAs)(Julia Hussein, 2012) Three quarters of
maternal death occurring in developing countries are caused by direct obstetric
cases such as postpartum hemorrhage, postpartum sepsis, Eclampsia, obstructed
labor and complications of unsafe abortion.(WHO, 2004)
A global goal is to ensure that before 2015, 80% of deliveries should be
assisted by skilled birth attendants but over 50% of deliveries are assisted by
TBAs in developing countries.(Statistics, 2015) Although, the positive impacts of TBAs
can’t be neglected but their attitudes, belief and perceived behavior towards
obstetric care is needed to be determined since they can’t handle complications
in pregnant women and this contribute mostly to maternal mortality. Pregnancy
complications cause 75% of maternal death in developing countries which are
categorized as direct causes while indirect causes have 25%.(Imogie, 2013) TBAs can’t predict
nor handle complications in pregnant women but they can facilitate a smooth
referral to skilled birth attendants where emergency obstetric care can be
performed. TBAs have been identified to be the backbone of maternal health care
for pregnant women in Africa.(Foundation, 2010) A global goal in improving maternal
health is that 80% of deliveries should be assisted by skilled birth attendants.
However, over 50% pregnant women patronize TBAs in a developing country which
thus, increases over the years.
According
to United Nations, A traditional birth attendant (TBA) is a pregnancy and child
care provider. They assist pregnant women during deliveries and acquired skills
by delivering babies herself or through apprenticeship to other TBAs. They
attend to majority of deliveries in the rural areas of middle and low-income
countries. They are highly respected in Africa communities. They provide
essential social support to women during childbirth with little or no financial
reward. Their clients trust them more than the skilled birth attendants and
share secrets with them because community women perceive them as part of the
community and this fosters a very good relationship between the TBAs and the
community members.The TBAs have been the natural helpers at therural areas
where the official health care services are not accessible or short
served. They bridge the gaps in
supporting women with deliveries. Some received formal education but choose not
to register with official health system. One of the criteria for being accepted
as a TBA in some communities is having experience as a mother.As seen in
Mexico, TBAs attend to approximately 45% of deliveries.(Olufunke M. Ebuehi, 2012) The health system of
Ghana also allows TBAs to attend to routine deliveries while complications
cases are referred to skilled birth attendants due to the partnership that
exist between the official health care and TBAs and this has a significant
impacts in reducing maternal mortality in Ghana.
In
SierraLeone, it is estimated that TBAs conduct approximately 70% of deliveries
so any intervention set to reduce maternal mortality, it is very important to
involve the TBAs because they are key to maternal health globally. Although,
training of the TBAs is important to achieving the said goal because studies
conducted in Edo state, in Nigeria to assess the services provided by TBAs
revealed that management of complication, umbilical cord, infection prevention
method are poor.(Okojie, 2014)
Another research carried out in Tanzania on TBAs perceive utilization of
hospital, Findings reveal that they found it important to refer in complication
cases that they can’t handle but they are poorly linked with official health
system so the study concluded that there is need to enhance communication
between the TBAs and official health especially in terms of prompt referral.(Gladys Mahiti, 2014)
These
are the responses obtained from few women that are within the age of
childbearing who were interviewed on comparison of the TBAs and the skilled
birth attendants at the official health system.In terms of availability of
Official Health Centers VS TBAs, Staffs who work in the health centers usually
close at 4pm, Lawal Ibrahim said. In some places, they close earlier, he added.
It’s a lot easier to access the TBAs because they are in the community. In
terms of Attitude VS Attitude, Attitude of TBAs compared to the attitude of
nurses,this is a significant factor in the choices available to an expectant
mother when she goes for her delivery. Recounting her experiences Larai Patrick
said; when I went to have my first child, the pain was unbearable. The nurse
kept slapping my thighs and raining abuses on me. Even after the labour pains
ended, I was still writing in pains from the slaps and her very unkind words.
Culture
and Religion; Zaria Al-Amina, a mother of four delivered of all her children by
a highly revered near seventy year old TBA. She explains her upbringing has
taught her that it is a taboo for a male to touch a woman who is not his wife
or sister and since delivery involves a lot of body contact, she would prefer
to employ the services of TBAs. Contending with complications; it was a relief
to realize that both the women and the TBAs know that they should go to
hospitals when there are complications. But with Zero antenatal sessions during
pregnancy, how do the women know a potential complicated pregnancy? According
to Adamu’’ When we massage, we can tell if the baby is well positioned or not
or if there is any other problem with the pregnancy. She however admits that
her diagnoses haven’t always been correct but fortunately rescue came and there
have been no recorded mortalities so far.
Although,
they can’t replace the skilled health attendants but with the access and good
relationship they have in the communities, they can use their close ties in the
various communities to bridge the gap between the community members and the skilled
birth attendants so as to improve maternal care, such as an effective referral
system. Referral system is a connecting linkage between the TBAs and the
skilled birth attendants that enables smooth working relationship between them.
Referral system is very essential in improving maternal health outcomes. Its importance is recognized, but the
policy priorities for achieving it in Nigeria are not consistently or
coherently explored in the various state. Although, it works in Ondo State
where the StateGovernment in partnership with MDGs and other agencies came up
with Abiye’ initiative to reduce the alarming high maternal mortality rate in
the state.The Ondo state government, in partnership with ministry of health,
community development in the LGA authority addressed and eliminates maternal
mortality issues and there was drastic reduction in 2years. The three delays;
Delay in seeking health care services, Delay in reaching the health care due to
bad roads and Delay in receiving timely emergency care from the health
professionals was addressed. Referral was addressed by enhancing the community
health extension workers ways to ensure that pregnant women utilize the
provided health facilities by the state government.
1.2 Statement of the Problem
In Africa, 1 in 16 pregnant women is at risk
of complications during pregnancy delivery compared to 1 in 8,700 in North
America or Europe. (L Keri, 210) Despite
all efforts to reduce maternal mortality rate during the MDG initiative, maternal
mortality remains unacceptably high. In Nigeria, the maternal mortality rate is
800-1,000 per 100,000 live births (WHO 2014) making Nigeria accounts for about
10% of the global estimate for maternal mortality.(L Keri, 210) Maternal mortality
of Oyo state is 262/100,000 live birth with Lagelu LGA one of the LGAs
contributing to the burden.
According to WHO, global goal is that over 70%
of deliveries should be assisted by skilled birth attendants but in Nigeria,
Over 58% of deliveries are assisted by TBAs.(Oshonwoh Ferdinand E., 2014) Pregnancy
complications accounts for more than half of maternal mortality rate in Nigeria
where TBAs provide assistance in most deliveries. These TBAs are not trained to
detect nor handle complication. E.g. Transverse fetal position,bleeding and
obstructed labor. Only the trained health provider can handle such cases and
various studies conducted in western and Eastern part of Nigeria showed little
or no referral linkages between the TBAs and official health system.(Olufunke M. Ebuehi, 2012) This study will
unveil the determinant of responsive emergency obstetric referral among TBAs.
This will be of benefit to enhance and modify their attitudes and behavior
towards referral. A typical example is found in Ondo state, where the state
ministry of health in partnership with TBAs and some NGOs showed how training
of skilled birth attendant to modify their attitudes and behavior and in
combination with good co-operation with TBAs in reducing maternal mortality in
the state. They named this movement as “Abiye initiative”.In another study
carried out in Malawi, it was deduced that referral system had save more poor
pregnancy outcomes when referred to skilled birth attendants in hospital in the
case of complications like Hemorrhage.(M. K. Mattews, 2020) Most maternal death
can be prevented if pregnant women receive timely care during emergency cases.
1.3 Objective of the
Study
The
main objective of the study is todetermine factors responsive foremergency
obstetric referrals and referral intentions among traditional birth attendants
in Lagelu LGA, Nigeria. The specific objectives are:
1. determine
the beliefs and attitude towards responsive emergency obstetricreferrals among
the respondents;
2. determine
perceived behavioral control (Self-Efficacy) in terms of confidence of the
respondents in referring their clients when the need arise;
3. determine
the subjective norms among the respondents towards responsive emergency
referrals;
4. identify
the nature of referral linkage between traditional birth attendants and the
professional birth attendants;
5. make
recommendation for the need to integrate TBAs into emergency obstetric referral
system and
6. assess
the utilization of referral system by the respondents
1.4 Research Questions
This study has raised a number of research
questions that guided the direction of the study and these include;
1.
What is
the attitude of the respondents towards referral of complication cases to
official health care?
2.
What motivates the respondents to refer their
clients when complication arises?
3.
What is
the level of self-efficacy in terms of confidence to make decision among the
respondents?
4.
What is
the working relationship between the TBAs and official health care in terms of
skilled birth attendants and hospital staffs?
1.5 Hypotheses
Four research hypothesis were set in solving
the identified problem
H1 There will be a significant
relationship between attitudes of the respondents and their referral
intentions
H2 There will be a significant
relationship between subjective norms and the respondents’
referral intentions behavior.
H3 There will be a significant
relationship between perceived behavioral control (Self-Efficacy)
and their attitudes towards emergency obstetric
referrals.
1.6 Justification for the Study
Most research studies on benefits of referral
system in reduction of maternal mortality in developing countries doesn’t lay
emphasis on traditional birth attendants as key drivers of an effective
referral system where emergency obstetric care is available.(Diana Gil-Gonzalez, 2006) (Andrea B Pembe, 2013) A study in Malaysia
showed how increased availability and training of skilled birth attendants
combined with increased smooth communication with TBAs were significant
components of a successful intervention.(Pathmanathan, 2012) Also, there has been no conceptual
frame work in grounding these studies(Snehan Patel, 2016) It would therefore, be of benefit to
find the determinant of responsive emergency obstetric referral and outcomes
among TBAs using the theory of planned behavior to find out their attitudes and
belief towards referral thereby providing a baseline for behavioral
modification.Also, this research would recommend policy formulation that would
improve maternal health at all levels.
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