TBAs are considered to be an important part of the informal community health care system. Moreover, they have been in existence before the advent of modern medical practices, making them deep rooted among community members. They are an asset in communities in terms of their accessibilities and low cost alternative. Their existence have aided in the decline of maternal mortality because large number of the populace see the TBAs as their only alternative in birth delivery. Efforts are been made by the Government to enhance their skills professionally on maternal and child health through training. Though, TBAs are seen not to meet up with measurable standards due to their level of professionalism, there still exist increase in their patronage by community members. A crucial oversight informing their high patronage is the spirituality and religious beliefs of the pregnant women and their significant others in lieu of a successful pregnancy outcome.

•    Traditional birth attendant
•    Pregnant women
•    Patronage
•    Spirituality
•    Nigeria

Adegoke O, Jegede A (2016) Continued Patronage of Traditional Birth Attendants (TBAs) by Pregnant Women in a Traditional African Community. Ann Public Health Res 3(3): 1045.

TBA: Traditional Birth Attendant; WHO: World Health Organization; MDGs: Millennium Development Goals; SDGs: Sustainable Development Goals; HIV/AIDS: Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome; UNICEF: United Nations Children’s Emergency

From time immemorial Traditional Birth Attendants (TBAs) have been of great asset to communities in terms of their accessibilities and low cost alternative. Traditional Birth Attendants (TBAs) play important role in settings where most births take place in the home. They attend to majority of deliveries in the rural areas of developing countries. More so, their clients trust them and share their secrets with them [1]. They are considered to be an important part of the informal community health care system, because they serve as the lifeline for many women most especially in developing nations [2]. Moreover, they have been in existence before the advent of modern medical practices, making them deep rooted among community members. According to World Health Organization (WHO) [3], a TBA is a “person who assists the mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other Traditional Birth Attendants”. However, the definition of a TBA given by WHO goes beyond a woman trained in the art of birth delivery within the Traditional African Community. There exist TBAs who are faith based and herbal based of whom their art of practice is precedent on their belief. Thus, their functions vary across cultures having an undertone of supernatural beliefs with reference to birth deliveries which does not apply to the rural community dwellers alone, but generally in any African Community. There is little doubt about their cultural competence because in all cases their beliefs and practices are influenced by local customs and sometimes by religion [4]. They are seen to fill the vacuum of the health care systems and complimenting in areas contemporary interventions might never access in years ahead. They remain perhaps the only available choice especially in remote areas. They are vital members of their communities and provide a channel of understanding to traditions and views regarding pregnancy and childbirth. Understanding the belief system of the TBAs as well as that of expectant women and community members who patronize the TBAs will be an impetus in enhancing strategies that will reduce maternal mortality.

Traditional Birth Attendants Overview

The World Health Organization through Safe Motherhood Program of 1987 found TBAs to have a significant role in reducing maternal and newborn mortality. It was ascertained that trained TBAs in sub-Sahara Africa can have positive impact on reducing maternal and newborn mortality if the Safe Motherhood Programme is well implemented with systematic follow up after training. In bid to reduce maternal mortality, 147 Heads of Government and 189 nations in total signed the Millennium Declaration, in which the proportion of births assisted by TBAs became an important indicator to measure the progress of improving maternal health (Millennium Development Goal {MDG} 5) [5]. The inconclusive achievement of the MDGs necessitated the emergence of the Sustainable Development Goals (SDGs) which was incorporated at the United Nations Sustainable Development Summit on 25 September 2015. World leaders adopted the 2030 Agenda for Sustainable Development, which includes a set of 17 SDGs to end poverty, fight inequality and injustice, and tackle climate change by 2030 [6]. Each goal has specific targets to be achieved over the next 15 years. The third sustainable development goal is good health and well being. This encompasses reducing child mortality, improving maternal health and tackling Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome (HIV/AIDS), tuberculosis, malaria and other diseases. In line with achieving the measured indicators for SDG 3 such as improving maternal health, is the relevance of the TBAs. In many countries, training TBAs have been an important component of strategies to improve maternal and neo-natal outcomes. However, findings have shown that the impact of training TBAs in reducing maternal mortality is low [1,7,8]. Despite the commitments of African countries to improve maternal health, maternal mortality remains high at 1,000 deaths per 100,000 live births against 9 / 100 000 in developed countries. Nigeria accounts for loses of 2,300 of under five children and 145 women of child bearing age daily; making Nigeria the 2nd largest contributor to the maternal and under-five mortality rate globally according to United Nation Children’s Emergency Fund (UNICEF). Nigeria, said to be the most populated African nation with over 182 million people as at 2015 [9], have majority of the populace resident in the rural communities. These areas are characterized with poor infrastructures and amenities such as roads, electricity, water and ill equipped health facilities with numbers of skilled health providers severely limited or non-existent. It should be noted that TBAs are characterized as unprofessional personnel with unsterilized tools in poor environmental conditions. By and large, their relevance to improving maternal and child health is being contested. Over the years, there has been increasing debate over their usefulness. Although, contrary on this view are ProTBAs who have opined the need to strategize in partnering with the TBAs to achieve significant reductions in maternal mortality [10]. The TBAs contribution in reducing maternal mortality and improving the survival rates of newborns cannot be underrated especially in the hard to reach areas such as the rural communities. They are the closest and easily accessible birth delivery persons in the resource-poor settlements. Government are partnering with them so as to improve maternal and child health as well as general improvement of their services.

Continual patronage of the TBAs

Basically reasons for the continued patronage of TBAs and which would be seen documented repeatedly in the mass media have been mentioned earlier. These are: accessibility, less expensive, cultural acceptability, familiarity, familial decision on health seeking and hostility of skilled health personnel [8].

However, the spirituality of the expectant woman is a cogent factor in the continual patronage of the TBAs which is sparsely documented. This spirituality extends to her spouse and close relatives such as her parents and in-laws. Moloney [11] asserts that “cross-culturally and throughout history, pregnancy and childbirth have been perceived as spiritual events because of the miraculous processes involved”. More so, because of superstitious beliefs, an individual will engage in behaviours which will safe guard the pregnancy. Spirituality is an inherent component of being human, and is subjective, intangible, and multidimensional. It has been defined in numerous ways, including belief in a power operating in the universe that is greater than oneself; a sense of interconnectedness with all living creatures; an awareness of the purpose and meaning of life and development of personal values. According to medical ethicist spirituality and religion is said to form the basis of purpose and meaning for many people. For most people, their spirituality is found through religion, while still an individual can be religious without being spiritual.

Pregnancy period seem to be a time of heightened spiritual awareness for most women. Some are bound to see signs in their daily lives which instills in them information about their pregnancy. For some they experience vivid dreams about their babies or prophetic dreams about their pregnancies. Birth in itself is sacred, a spiritual transforming experience to welcome a child into the world. For instance, the numerous ethnic groups in Nigeria attach lot of importance to child-bearing. The mother and unborn child are vulnerable at this time, hence care must be taken to preserve the sacredness of their lives. It is believed that there are evil spirits which are capable of tampering or interfering with the pregnancy. Lot of measures is put in place to ensure safety and survival of the pregnancy. With such superstitious belief irrespective of the individuals’ socio-demographic status (education, income, ethnicity, age, religion etc.), modern health care facility is secondary to such person. Primary safety measure to such individual is visiting the TBAs which could be faith or herbal based. They are seen as scientist because even without a laboratory they carry out research on the spiritual and medicinal power. According to Parrinder [12], especially among the Herbal Based TBAs, they use the laws of the universe, not only of nature but also spiritual forces… believing there are hidden powers that can be tapped. Thus consultations with the oracle are embarked on, rituals are carried out and herbal medications are prepared for the expectant mother.

In the Faith Based Birth Delivery centers, the expectant woman is subjected to prayer and a times fasting. Women have used prayer and other spiritual practices for their own and others’ health concerns for thousands of years [13]. Prayer is an act of putting oneself in the presence of or conversing with a higher power. It has been used as means of healing across all cultures throughout the ages. For instance, there is intercessory prayer also known as distance prayer or distance healing which is the act of asking a higher power to intervene on behalf of another either known or unknown to the person praying. Singing of praise worship songs is another activity conducted in these centers. This is said to wade off evil spirits which might forestall a successful pregnancy outcome. Pregnancy period is seen as a time to draw closer to God and influencing successful birth outcomes. Attending to women’s spiritual experiences during pregnancy is an important way to enhance care. Furthermore, it is an ideal context to improve one’s spirituality.

TBAs cannot be substituted for skilled providers, but they can contribute to the survival of mothers and newborns by facilitating access to needed information, clinical services and support. In other words, TBAs, like other community health workers serve as a good communiqué in providing information to those who patronize them. This is inclusive of the families and community members in a cultural appropriate way that will help them to recognize danger signs during pregnancy and know where to seek for help (referral). They are known to serve as an alternative health care provider most especially in resourcepoor countries where large number of birth takes place in the rural areas and urban slums. In lieu of this, various suggestions have been postulated aside from training TBAs. They should be empowered technological with mobile phones and mobile vans for ease of communication and movement to enhance effective referral of women in labour to health centers. Moreover, efforts need to be made via research on the knowledge and practice of the TBAs on what they can do and cannot do. On this premise policy makers and planners can strategize on enhancing their effectiveness. Meeting needs of the populace on a minimal level of obstetric care might be difficult to achieve. Thus, the TBAs are important resource in birth delivery that needs to be harnessed factoring in the socio-cultural context of the time and space in which they exist.

I acknowledge Prof. A.S Jegede who supervised my Doctoral Thesis from where I got the insight to write this mini-review based on my empirical findings.

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