Knowledge and practice of antenatal care among traditional birth attendants in Southern Cross River State, Nigeria

INTRODUCTION

Skilled attendants at birth are proven interventions to improve maternal and newborn health outcomes and have been one of the consistently highlighted as an area for greater attention by global health organizations. This has been done through various efforts aptly emphasized in the Millennium Development Goals 3 and the sustainable development goals (SDGs).^[1,2] Increasing women’s access to focused antenatal care and health facility birthing with skilled birth attendants are effective strategies to achieve (SDGs 3.1).^[2] In many developing countries where there is often a shortage of trained biomedical personnel, maternal care is usually provided by Traditional birth attendants (TBAs).^[3] The World Health Organization (WHO) defines TBA as “a person who assists a mother during childbirth and initially acquired her skills by delivering babies herself or through an apprenticeship to other TBAs” and skilled birth attendant.^[4] One key intervention to improve maternal health is to ensure that all women have access to skilled care during labor and delivery. Unfortunately, <40% of Nigerian women give birth with a skilled attendant. This suggests that over 60% of Nigerian women are at excess risk of maternal death, as they do not have access to or utilize available lifesaving services.^[5] Throughout history, TBAs have been the main human resource for women during pregnancy; their roles vary across cultures and times, but even today, they attend to the majority of pregnant women in the rural areas of developing Countries.^[6] Egharevba et al.^[7] opined that TBAs are accessible, culturally acceptable, and are known to influence women’s decisions about using their care settings. There is little doubt that they have a significant role when it comes to cultural competence and psychosocial support during pregnancy, all of which are important benefits for the woman and also the newborn baby.^[8] The WHO^[9] observes that TBAs can potentially improve maternal and newborn health at the community level and while the role of TBAs in caring for pregnant women and conducting deliveries is acknowledged, they are generally not trained. The WHO further reports that TBAs and community midwives have a key role to play in midwifery practice. They are often the only available source of basic prenatal care and family planning services in isolated communities and are generally the main source of help in pregnancy and childbirth. They are highly respected members of the community and have proven asserts in addressing poor maternal outcomes.^[7] Studies in developing countries such as Bangladesh, Turkey, South Asia, and Nigeria revealed that TBAs are generally older, non-literate women who have learned the care of pregnant women, delivery, and postpartum care through apprenticeship.^[10]

The TBAs consider themselves to be the private practitioners who respond to requests for services. TBAs receive some compensation for their services, mostly in kind and some accept whatever monetary amount is given to them by the families.^[11,12] The TBAs also have a variety of names depending on where they are operating; rural or urban areas all over the world, and often render services in their homes or churches as the case may be; these practices have gained momentum by the day, as their services could be accessed widely. Frequently, their services include helping with household chores, massage of the woman’s body, antenatal care, deliveries, care of the neonates, and family planning services.^[13] However, TBAs have no formal training on how to attend to pregnant women, including how to recognize and respond appropriately to complications of pregnancy, for this reason, the way many attend to delivery has been observed to be traumatic, resulting in disability, leading to poor health outcomes and even death.^[9,14] Although the majority of TBAs are illiterates who learn their skills through experience, they are also described as members of the community; who share cultural and health beliefs with the women they serve and have strong ties with the community.^[15] These cultural ties give them an age over the use of government facilities, even with skilled birth attendants.^[16,17] Certain characteristics among TBAs have been reported to draw pregnant women to seek their care. These include, among others a strong personality, stable emotional state, understanding of the culture, and patience that enables the birthing woman to move through the event with courage, power, and ease.^[4,18-20]

There is a growing awareness in many African Countries that TBAs have a major role to play in the prevention of HIV and maternal death through first improved antenatal practices and their use of the language spoken and understood by the women based on cultural practices.^[21-23] This is also because of their accessibility to communities and the relationship they share with women in local communities, especially if the women are unable to access biomedical skilled services irrespective of their harmful cultural practices that result in poor health outcomes.^[24,25]

Many studies have advocated for the training of the TBAs to improve their skills and knowledge to help utilize sterile equipment during care and actively involve them as assistants in disseminating information to the community since they are already known and utilized in the community. This action will help them do referrals appropriately.^[26] These critical steps to improving the care of pregnant women at the community level are important because each pregnant woman is expected to be attended to by trained personnel “skilled attendants” who have been trained and licensed to manage normal deliveries, diagnose, manage, or refer complications as well as give the necessary supervision and care during pregnancy, labor, and the postpartum period.^[27] It is surprising to see that even though the TBAs are reported to lack the knowledge of focused antenatal care,^[5,9,19,23] the women in the community still prefer patronizing them because most women based on cultural beliefs attribute pregnancy-related complications to be caused by witchcraft, think the TBAs always stay with women and help them deal with the physical and psychological challenge while they perceive the health facility to be a hash setting for women during pregnancy due to the attitude of the health-care providers. Ogunyomi and Ndikom^[28] reported that many TBAs have expressed some of the dilemmas and challenges, they face during caring for pregnant women considered to be at risk for referral to health facilities. Some of the challenges include Transportation, poor road infrastructure, cost of care, and the abusive attitude of the healthcare providers at the reference point.^{[10,12,14,29-31]}

Maternal outcomes have continued to be a major public health challenge in developing countries; irrespective of the government, and other agencies’ efforts to improve the knowledge and practices of TBAs. Despite these numerous efforts made through training programs and procurement of equipment necessary for care during pregnancy, maternal outcomes continue to be a major public health challenge in developing Countries. This challenge implies that antenatal care services will lose their value as many pregnant women will be presenting with poor health conditions during pregnancy, such as anemia, preeclampsia, and eclampsia, which can result in maternal and fetal death. In Cross River State, antenatal care is free for all pregnant women. It is worthy of note that even though these care services offered free; pregnant women still go to the TBAs for care. It is based on this premise that the researchers undertook this study on knowledge and practice of antenatal care among the TBAs. The Anderson behavioral model modified by Ogbo et al.^[15] was adopted to guide the study as shown in [Figure 1].

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Figure 1:

The conceptual Model for the use of unskilled birth attendants in Nigeria. Adopted from Ogbo et al.^[15]

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The purpose of the study thus was to determine the knowledge and practice of antenatal care among TBAs in the Southern Cross River State with the following specific objectives to: Assess knowledge of antenatal care among the TBAs, determine the attitude of TBAs toward antenatal care, establish the influence of sociodemographic variables on the knowledge of antenatal care among the TBAs, ascertain the influence of socio-demographic variables on knowledge and the practice of antenatal care among the TBAs.

The findings from this study that we hope will give a better understanding of how maternal and fetal outcomes can be improved in the community, especially among those utilizing the TBAS, and contribute significantly to the growing body of scientific knowledge on best practices for antenatal care. Feedback will be given to the women in these communities to help them make an informed choice of whom and where to receive antenatal care services. The study will also be made available to the general public through publication.

MATERIAL AND METHODS

The study was conducted in the Southern Senatorial Districts of Cross River State made up of seven Local Government Areas, Calabar South, Calabar Municipality, Akpabuyo, Bakassi, Biase, Odukpani and Akamkpa Local Government Areas. The population of this study consisted of 371 TBAs who care for women during pregnancy, labor, and the third stage of labor periods. The sample size for the study consisted of 191 TBAs which reflected 52% of the entire population size. The size was determined using Yaro Yamane’s formula (Minimum Sample size formula) for estimating a simple finite proportion. The sample was obtained as follows:

Where, n = Sample size

N = Population

e = Level of error = 0.05

RESULTS

The results details are presented at the end of the document please in a text box.

DISCUSSION

This study on the knowledge, attitude, and practice of antenatal care among TBAs in Southern Cross River State, Nigeria, found that sociodemographic variables example age, educational status, and gender did not in any way influence the knowledge of antenatal, labor, and postpartum care as reported by Ugboaja et al., Inyang and Anucha, Egharevba et al.^[5-7] that women who patronized the TBAs were likely to have less than secondary education, reside in rural areas, have poor family wealth index, and were unemployed. Religious denomination rather was observed to have a strong influence on the choice of utilizing TBAs as the result revealed that Catholics were found to be more knowledgeable on pregnancy issues based on their earlier affiliations with the colonial masters to utilize health-care facilities and services in their settlement or communities. It was also clearly shown that the learning pattern of the TBAs involves both observation and imitation, in contrast to the instructive style of education of professional midwives. These findings are in disagreement with Babalola and Fatusi^[22] who opined that a woman’s age may act as a proxy for the woman’s accumulated knowledge of healthcare services, moreover, a woman acquires her experience and skills with age.

The findings from this study are supported by other studies^[4,10,15,20] and clearly show that TBAs acquire their knowledge of skills through traditional and informal methods, which include, their own experience as mothers, from assisting other women, family members (mother and other relatives), observation of healthcare personnel and traditional healers. These findings, however, are in disharmony with the studies by Liambila and Kuria,^[13] Mathole et al.,^[29] who noted that some TBAs claim to have supernatural powers to protect pregnant women against witchcraft, these groups comprise women who are known as prophetess who are associated with the church and use their prophetic powers to influence women to patronize them.

The majority of the TBAs opined that they know what to do during the antenatal care periods, thus claiming to have good knowledge as shown in [Table 3]. This is partially in agreement with the view of the WHO^[3] report that TBAs continue to play an important role, in providing antenatal care, assisting during labor and delivery, and initial postpartum care. However, these findings also revealed that 18 (19.5%) of the respondents do not understand the need for health education on nutrition, and the danger signs of pregnancy to prepare the women for any eventuality, 76 (44.4%) have no knowledge of the number of antenatal visit the pregnant women needs. This indicates clearly the risk the women face when they seek care services from such TBAs. 36 (21.1%) do not know the importance of tetanus toxoid to pregnant women and when to get it while 12 (7.0%) have no ideal about folic acid tablet; a routine drug given during pregnancy to prevent anemia. These findings may look insignificant but have a huge impact on women. These observations are supported by the WHO,^[3] Ganle,^[25] Nigeria Demographic and Health Survey^[26] assertions that blamed the TBAs for their lack of knowledge and skills necessary for a safe delivery and in detecting danger signs or responding effectively to complications of pregnancy, yet most rural women still deliver with the assistance of the TBAs in unhygienic environments.

The result of this study showed that the TBAs receive their clients warmly, offer prayers and incantations to their clients to allay the fears and anxiety associated with pregnancy, give clients an opportunity to choose between paying bills in cash or kind as well as listen to fetal heart and administer hematinic to pregnant women most during each antenatal visits. This agrees with Imogie,^[8] MacArthur,^[11] and Ogbo et al.^[15] who assert that abusive attitudes and culturally unacceptable invasive procedures carried out by skilled birth attendants are responsible for the low utilization of health facilities. The use of routine drugs and palpation of the abdomen are indications that TBAs have good antenatal, labor, and postpartum care practices This affirms what MacArthur^[11] further stressed that the TBAs also wash their hands and wear gloves to prevent infection and feed the pregnant women with chicken broth and tea which they believe facilitate labor and provide energy for the women. This, however, is not in agreement with Zaraba et al.^[24] who asserted that infection is a major cause of maternal deaths in developing countries since most of the TBAs still operate in unhygienic circumstances which often increase the risk of infection for pregnant women. The findings of this study also revealed that pregnant women who patronize the TBAs are some concoctions to drink, enemas of different kinds with incantations made to fasten the labor and delivery. These actions have been reported to be detrimental to women and their unborn babies. This result is supported by Ogunyomi and Ndikom’s^[28] study on perceived factors influencing the utilization of the TBAs’ Services.

A significant relationship between TBA’s knowledge of antenatal care, attitudes, and practice was revealed as buttressed by Oshonwoh et al.,^[30] Mathole et al.,^[29] and Ogbo et al.^[15] but disagrees with Falle et al.,^[9] Silbey et al.^[31] who assert that in some countries, formal training programs have been devised for training the TBAs to provide safe birth practices, avoid harmful practices, and improve their techniques, with particular reference to asepsis, and detection of abnormalities that indicates the need for referral, they further, opined that the educational training and skills of TBAs are not sufficient enough to fulfill all the requirements for management of normal pregnancy and for identification and management of complications.

CONCLUSION

Although the TBAs in this study were observed to have some good knowledge, positive attitude, and some level of good practices of antenatal care, an in-depth assessment of their knowledge is still required using other research designs to support information from a questionnaire. It is recommended that more studies be conducted to validate the TBAs’ true knowledge to help prevent complications often associated with care rendered to pregnant women by the TBAs.