Introduction

There are an estimated 4 million neonatal deaths and 500,000 maternal deaths worldwide each year ₁ . The vast majority of these deaths occur in developing countries, where 43% of births are attended to by traditional birth attendants (TBAs), the proportion generally being higher in rural areas with most of these deliveries taking place at home ₂₃ .

In most developing countries, the TBAs are frequently older women, often illiterate, who have learned their trade through apprenticeship or experience ₄ . Some assists with a small number of deliveries per year; others do with frequent deliveries ₄ .

Many programmes have been initiated by various organizations/agencies including the World Health Organization (WHO) for training of TBAs between 1970s and 1990s ₁ . The rationale for such programmes has been the assumption that TBAs are present at most home deliveries and can be trained to avoid harmful delivery and postnatal practices and TBAs can be trained to recognize complications in the mother and the newborn and make appropriate referrals ₅₆ . It is often assumed that with trained TBAs, there will be a reduction both in maternal and neonatal morbidity and mortality _{1 78} .

Reports on TBAs globally focused on reducing maternal and perinatal mortality as it relates to Millennium Development Goals 4 and 5. Studies from Pakistan and Bangladesh revealed that with training of TBAs, both Infant and maternal mortality rates declines especially those due to infections _{15 689} . Other reports from the same area however, disagrees ₃₇ . A major factor contributing to perinatal mortality arises from poor cord care manifesting as omphalitis and/or neonatal tetanus usually associated with a high mortality ₁₀₁₁₁₂ . Improvement in cord care practices will improve the outcome of pregnancies ₁₀₁₁₁₂ .

We try to document the delivery/newborn care practices of TBAs in Konduga Local Government Area of Borno State with a view to identifying harmful practices and improving on them, this we believe will reduce both maternal and neonatal mortality.

Methods

The study was conducted in Konduga Local Government area of Borno state which is about 36km from Maiduguri the Borno state capital. Konduga town has a General hospital manned by a Doctor and Nurses and a health centre in each of the other 4 districts manned by community health extension workers.

Data were collected based on a proforma questionnaire by final year medical students during an eight week posting in the area. Data collected include distribution of traditional birth attendants (TBAs) across the districts, age and practicing age in years, their training status and who trained them, number of deliveries conducted/year, cord care practices and problems encountered if any and what they think of such problems.

Data collection by the medical students, were supervised by academic and consultant staff in the departments of Paediatrics and Community Medicine, University of Maiduguri including the authors.

Data was analyzed using Statistical Package for Social Science version 13.

Results

There were a total of 48 traditional birth attendants (TBAs) spread across the 5 study districts with 17 (35.4%) in Konduga, 10 (20.8%) each in Kawuri and Auno, 6 (12.5%) in Dalwa and 5 (10.4%) in Malari. The age distribution of the TBAs is shown in Table I. Thirty three (68.8%) of the TBAs have been in practice for more than 10 years while 15 (32.3%) started practicing 9 years ago.

Table I - Age and number of traditional birth attendants seen in Konduga Local Government Area of Borno State North Eastern Nigeria.

Only 12 (25%) had some form of training, while 36 (75%) did not have any form of training. Among those that had training 8 (66.7%) were trained by some health personnel, while 4 (33.3%) were trained by some NGOs. Of those trained only 1 is a paramedic. Ten (20.8%) were retrained, 9 were by health personnel and one by an NGO. Of the twelve that were trained, they all had delivery kits, only 2 (5.5%) of those not trained have delivery kits. All the 12 trained TBAs sterilize their delivery kits before any delivery. Only 2 (4.2%) of the TBAs do take deliveries in their homes, the rest 46 (95.8%) take deliveries in the mothers place. Cord was severed using a new razor blade by 44 (91.7%) of the TBAs, 3 (6.3%) used bamboo or back of corn stick, while one (2.1%) used a pair of scissors.

Regarding the number of deliveries conducted in a month, 20 (41.7%) of the TBAs had between 1-3 deliveries, 3 (6.3%) between 4-6 deliveries, 6 (12.5%) between 7-10 deliveries with only 1 TBA having delivered more than 11 babies in a month. Eighteen TBA s (37.5%) said they had not conducted any delivery in the past one month.

Table II shows the various items used in securing the cord while Table III shows the various materials the mothers were advised to use for cord care. Twenty five (52.1%) of the TBAs sterilize their instruments after every use, 21 (43.8%) do not sterilize while 2 (4.2%) sterilize their instruments before and after use. The various difficulties encountered during deliveries are outlined in Table IV.

Table II - Various materials used in securing the cord by traditional birth attendants in Konduga Local Government Area of Borno state North Eastern Nigeria.

Table III -Various materials applied to the cord by the traditional birth attendants in Konduga Local Government Area of Borno state, North Eastern Nigeria.

Table IV - Difficulties encountered by the traditional birth attendants during delivery in Konduga Local Government Area of Borno State North Eastern Nigeria.

When asked if they know of a child who have died as a result of stiffness during the cord care period, 23 (47.9%) said yes while 25 (52.1%) said no. Twenty five (52.1%) said it is not too common, 3 (6.3%) said it is common, only 1 (2.1%) said it is very common, while 19 (39.6%) said they have not seen or are not aware of the illness. Eleven (22.9%) of the TBAs saw about 1-2 cases of children dying of stiffness in the last one month, 2 (4.2%) saw 3 and above of such cases, while 35 (72.9%) said they have not seen any of such cases in the last one month. The response of the TBAs as to what causes stiffness is outlined in Table V.

Table V - Traditional birth attendant’s response to causes of stiffness in the Babies they deliver in Konduga Local Government Area of Borno State North Eastern Nigeria.

When asked what danger they think can result from not taking proper care of the cord, 18 (37.5%) said sickness /death, 14 (29.2%) said abdominal distention or perforation, 6 (12.5%) said stiffness, 5 (10.4%) said poor cord healing while 5 (10.4%) said they don’t know.

Discussion

There are a number of traditional births attendants in the 5 districts of Konduga Local Government Area where the study was undertaken and they by far outnumbered the health personnel who are mostly unskilled and many times may not be available when their services are needed especially at night. The TBAs, are however always around and available within the communities and readily available to the expectant mother. This agrees with reports from other studies ₈ .

Most of the TBAs in this study are older women who have been in practice for years. Only a few of them have been trained and provided with delivery kits. This does not agree with reports from other studies in the developing world where TBAs have been trained with an improvement in pregnancy outcome ₁₅₆₉ . All the trained TBAs sterilize their delivery kits after using them, leading to an improvement in infection rate as a complication of such deliveries.

The majority of TBAs in this study use new (not sterile) razor blade to severe the cord, a few use scissors (unsterile) while some use bamboo stick, these are bad practices and needs to be discouraged as they may lead to cord infection with its accompanying mortality ₁₀₁₁₁₂ .

The cord is tied with thread in most, with a few using string or just soaking in dettol. Cord care practices are poor with most of the TBAs applying hot fermentation with application of cheese/Vaseline, rag and or lantern, charcoal, mahogany oil and or sand. A few that were trained however apply methylated spirit or gentian violet to the umbilical stump. This is in agreement with reports from other studies ₁₀₁₂ .

Difficulties encountered by the TBAs in the course of delivery includes retained placenta, difficulty with breech deliveries, prolonged bleeding and lack of facilities. A large percentage of the TBAs also encountered with babies becoming stiff in the postpartum period and many of them do not know the cause or what to do. Such has been documented by other researchers ₆ . The TBAs needs to be trained as this will empower them to identify problems and refer them appropriately ₄₆ .

In conclusion, there are few facilities and skilled attendants in Konduga Local Government Area to manage normal deliveries and diagnose, manage or refer obstetric and neonatal complications. There is therefore the need for training and retraining of TBAs on safe delivery and good cord care practices. The development of an effective referral system for referral of complicated deliveries and newborn problems needs serious consideration. This will go a long way in lowering the high maternal and neonatal mortality with subsequent lowering of perinatal mortality rates.