INFLUENCE OF TRADITIONAL BIRTH ATTENDANTS ON FACILITY-BASED DELIVERY AMONG PREGNANT WOMEN IN IKOT EKPENE, AKWA IBOM STATE.

CHAPTER ONE

ABSTRACT

Background: Traditional birth attendants (TBAs) continue to play a significant and deeply embedded role in the maternity care landscape of southern Nigeria, including Akwa Ibom State. In Ikot Ekpene and its environs characterised by a mix of rural, semi-urban, and culturally cohesive Annang-speaking communities TBAs are often the first and sometimes the only source of obstetric care for pregnant women. The extent to which TBA engagement facilitates or impedes facility-based delivery is a critical question for maternal health programming in the region.

Objective: This study investigates the influence of traditional birth attendants on facility-based delivery among pregnant women in Ikot Ekpene, Akwa Ibom State.

Methods: A descriptive cross-sectional survey was employed. Using multistage sampling, 360 women who had delivered within the preceding 12 months were recruited from communities in Ikot Ekpene Local Government Area. A structured questionnaire and in-depth interviews with TBAs and community health workers were used. Data were analysed using SPSS version 26.

Expected Findings: It is anticipated that TBA contact during pregnancy will be significantly associated with reduced likelihood of facility-based delivery, mediated by trust in TBAs, cultural preferences, financial barriers, and TBA counselling against hospital delivery.

Conclusion: Bridging strategies that engage TBAs as facilitators of facility referral, while ensuring clear delineation of their scope of practice, represent the most pragmatic approach to increasing facility-based delivery in Ikot Ekpene.

Keywords: Traditional birth attendants, facility-based delivery, pregnant women, Ikot Ekpene, Akwa Ibom State, maternal health, referral.

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

For decades, writers and policy makers have discussed T.B.A. involvement in the maternity care systems of low and middle-income countries with much debate. The traditional birth attendants (TBAs) have a contested position in the maternal health system, as defined by the WHO (2004) as "those who assist the mother at child birth and who, at least at first, learned their skills in child birth without the assistance of a skilled birth attendant. BMC, on the other hand, are considered to be trusted community resources and have a high degree of social and cultural capital, they offer emotional support, cultural congruence and geographic access to women who may otherwise not receive skilled assistance during childbirth (Akeju et al., 2020). The clinical constraints of TBAs, including their inability to handle obstetric emergencies, aseptic procedures and life-threatening medications, have then been linked to preventable maternal and neonatal mortality in places where they may be delivering babies at home instead of at a health facility (Kana et al., 2020).

The delivery to a skilled birth attendant at a healthcare facility is the cornerstone of maternal mortality reduction in Nigeria as outlined in the National Policy on Maternal, Newborn, Child and Adolescent Health (RMNCAH). The 2018 National Demographic and Health Survey (NDHS) also suggest that only 39% of all births in Nigeria happened in health facilities, indicating a wide disparity between geopolitical zones; the South-South region (Akwa Ibom included) records about 61% facility delivery, compared with as low as 12% in the North West zone (NPC & ICF, 2019). Although the extent of TBA involvement in the South-South is comparatively higher, the impact and presence of TBAs in communities like Ikot Ekpene are still firmly established and engagement of the TBAs with maternal health decisions to deliver in facilities has not been studied systematically in this community.

Ikot Ekpene Local Government Area of Akwa Ibom State is a business centre where majority of inhabitants speak Annang language, have well-developed communal practices and rich artisanal tradition and settled social class structure. The TBAs of the area are usually older women who have acquired their position through their experience in and awareness of the community and their ability to create a combination of working together as a team behind the scenes and as active leaders. In Ikot Ekpene, these women's preferences for TBA-assisted delivery or facility delivery are not simply a rational health choice, but a result of both trusting the TBA and feeling at ease with her cultural identity and financial capability, as well as previous experience with the formal health system (Ekele et al., 2021). The aim of this study is to explore and analyse TBAs' influence on the facility-based delivery decision in this context systematically.

The assistance offered to childbirthers is called TBAs and has a long history in sub-Saharan African countries, before the establishment of biomedical-based obstetric care. In Nigeria, it is estimated that 30–60% of all deliveries take place outside the health facilities, of which TBAs and other informal providers deliver the majority of these in rural and peri-urban areas (Kana et al., 2020). A survey conducted by the State Ministry of Health, Akwa Ibom State, in 2020, found that about 38% of women in the State's rural and peri-urban areas had their last delivery attended by TBA; particularly, greater the distance from public health facilities, the higher was the proportion of women having their delivery attended by a TBA (Akwa Ibom State Ministry of Health, 2020).

There is inconsistent evidence from around the world regarding the effectiveness of TBA assisted delivery and the outcomes of such deliveries. However, a detailed Cochrane Review by Sibley et al. (2012) showed that although there was a modest impact on health seeking behaviour such as facility referral, the training programmes were not found to have a significant effect on maternal mortality. Evidence that followed, which was reviewed by Akeju et al. (2020), indicated that it is not the TBA training itself, but the quality of the TBA linkage to the formal health system, specifically whether TBAs actively facilitate referrals for obstetric complications or whether TBAs replace formal health system care entirely.

Evidence from culturally and geographically neighbouring areas of Cross River, Rivers and Delta States backed the cultural and geographic association of TBA contact during pregnancy with preference for TBA assisted delivery, low level of facility delivery and higher likelihood of delivery complications managed outside of skilled health service in southern Nigeria (Akeju et al., 2020; Ekele et al., 2021). There was, however, no literature on some institutional-level data from Ikot Ekpene LGA in Akwa Ibom state and this is a critical piece of evidence that hinders the design of context-specific maternal health interventions in this community.

1.2 STATEMENT OF THE PROBLEM

The impact of traditional birth attendants (TBA) in the decision for women to deliver in facilities in Ikot Ekpene, part of Akwa Ibom state is a major constraint in order to achieve the universal use of the facility among women in the area. Many women despite the primary health centres, general hospital and community health posts in Ikot Ekpene LGA still opt for the services of a TBA for home delivery because of their cultural endorsement of TBAs, the attendant financial constraints for facility delivery, and the benefits of attending home deliveries.

The repercussions of this pattern are delayed recognition of obstetric emergencies, lack of a skilled resuscitation for asphyxiated neonates, unsafe cord cutting techniques and delayed referral of women who develop more serious complications during TBA assisted delivery to a higher level facility. Although this trend is important to public health it is not empirically studied specifically looking at the nature and size of TBA's influence on facility based delivery in Ikot Ekpene. The lack of local evidence is a challenge for the Ikot Ekpene LGA Health Authority, the Akwa Ibom State Ministry of Health, and implementing partners to develop activities that are relevant to the community dynamics and TBA influence pathways in this space.

1.3 OBJECTIVES OF THE STUDY

The general objective is to assess the influence of traditional birth attendants on facility-based delivery among pregnant women in Ikot Ekpene, Akwa Ibom State.

Specific objectives are to:

1. Determine the proportion of women in Ikot Ekpene who had contcact with a TBA during their most recent pregnancy.
2. Assess the role and scope of practice of TBAs in the delivery care of women in Ikot Ekpene.
3. Examine the influence of TBA contact and TBA advice on women's decision to deliver in a health facility or at home.
4. Identify the sociodemographic and cultural factors that mediate the relationship between TBA contact and facility-based delivery in Ikot Ekpene.
5. Assess women's perceptions of TBA care compared to formal facility-based maternity care in Ikot Ekpene.

1.4 RESEARCH QUESTIONS

1. What proportion of women in Ikot Ekpene had contact with a TBA during their most recent pregnancy?
2. What is the role and scope of practice of TBAs in the delivery care of women in Ikot Ekpene?
3. How does TBA contact and TBA advice influence women's decision to deliver in a health facility or at home?
4. What sociodemographic and cultural factors mediate the relationship between TBA contact and facility-based delivery in Ikot Ekpene?
5. What are women's perceptions of TBA care compared to formal facility-based maternity care?

1.5 RESEARCH HYPOTHESES

H01: There is no significant relationship between TBA contact during pregnancy and the choice of delivery location among women in Ikot Ekpene.

H02: There is no significant association between TBA advice on delivery location and women's likelihood of facility-based delivery in Ikot Ekpene.

H03: There is no significant relationship between household income level and the choice between TBA-assisted delivery and facility-based delivery among women in Ikot Ekpene.

1.6 SIGNIFICANCE OF THE STUDY

The findings of this study will be of relevance to a wide range of stakeholders involved in maternal health programming in Akwa Ibom State and across southern Nigeria. For the Ikot Ekpene LGA Health Authority, the study provides the first empirical evidence base on TBA influence and facility delivery patterns in the area, enabling the development of targeted community-level interventions that account for the specific social and cultural dynamics operating in Ikot Ekpene communities.

For the Akwa Ibom State Ministry of Health, the study contributes evidence to support the design or strengthening of TBA linkage programmes formal mechanisms through which TBAs are engaged as community health allies who facilitate facility referral rather than substitute for skilled care. For the Federal Ministry of Health and implementing partner organisations including UNFPA, UNICEF, and MSH, the study adds to the national evidence base on TBA-facility care dynamics in the South-South zone, supporting the design of regionally appropriate safe motherhood interventions.

For the academic community, this study expands the body of evidence on TBA influence mechanisms in southeastern and south-southern Nigeria, providing a comparative reference for studies in similar socio-cultural contexts. For midwifery and nursing education, the study highlights the importance of culturally competent engagement with community-level care providers as a core component of contemporary maternal health practice.

1.7 SCOPE OF THE STUDY

This study is confined to women of reproductive age (15–49 years) who have had at least one delivery in the preceding 12 months in communities within Ikot Ekpene Local Government Area, Akwa Ibom State. It focuses specifically on the influence of TBA contact and advice on facility-based delivery decisions. The study does not extend to antenatal care utilisation, postnatal care-seeking, or to women who have not delivered in the reference period. TBAs are included as secondary informants through in-depth interviews, but the primary unit of analysis is the pregnant/recently delivered woman. The study is geographically confined to Ikot Ekpene LGA and does not extend to other LGAs in Akwa Ibom State.

1.8 LIMITATIONS OF THE STUDY

The study is subject to several potential limitations. Recall bias may affect women's accuracy in reporting the details of their most recent delivery experience, particularly for events occurring up to 12 months prior to the interview. Social desirability bias may lead some women to overreport facility delivery or underreport TBA contact in contexts where facility delivery is positively valued by health workers conducting the survey. The cross-sectional design prevents causal inference about the direction of the relationship between TBA contact and delivery location choice. Additionally, TBA in-depth interview responses may be influenced by the TBAs' awareness of health policy discouraging TBA-assisted delivery, leading to self-presentation that understates their actual scope of practice. Triangulation of data sources and careful interview technique will be used to mitigate these limitations.

1.9 DEFINITION OF TERMS

Traditional Birth Attendant (TBA): A person who assists the mother during childbirth and who acquired her skills by delivering babies herself or by apprenticing with other TBAs, operating largely outside the formal health system (WHO, 2004).

Facility-Based Delivery: Childbirth that takes place within a formal health facility including primary health centres, general hospitals, or tertiary institutions attended by a health professional (NPC & ICF, 2019).

Skilled Birth Attendant (SBA): A midwife, doctor, or clinical officer who has been educated and trained to proficiency in the skills needed to manage normal pregnancies, childbirth, and the immediate postnatal period, and in the identification and management or referral of complications (WHO, 2004).

Home Delivery: Childbirth that occurs outside of a formal health facility, typically in the woman's home or the TBA's premises, attended by a TBA, family member, or the woman alone (Akeju et al., 2020).

TBA Influence: The effect of TBA contact, advice, counsel, or active management during pregnancy on a woman's decision regarding the location and attendant for her delivery (Kana et al., 2020).

Cultural Trust: The socially constructed confidence placed in traditional healthcare providers particularly TBAs based on shared cultural values, community familiarity, and perceived social legitimacy (Ekele et al., 2021).

Obstetric Emergency: A sudden, severe complication during pregnancy, labour, or the immediate postpartum period that poses a serious risk to the life of the mother or baby and requires immediate skilled medical intervention (WHO, 2023).

REFERENCES

Akeju, D. O., Vidler, M., Sotunsa, J. O., Osiberu, M. O., Orenuga, E., Akintunde, A., & Bhutta, Z. A. (2020). The role of traditional birth attendants in a cluster randomized trial to increase demand for antenatal and maternal care in Ogun State, Nigeria. Reproductive Health, 13(Suppl 1), 93. https://doi.org/10.1186/s12978-016-0211-6

Akwa Ibom State Ministry of Health. (2020). Akwa Ibom State health facility survey 2020. Akwa Ibom State Government.

Ekele, B. A., Shehu, C. E., & Adamu, A. N. (2021). Traditional birth attendants and maternal mortality in Nigeria: A retrospective analysis. African Journal of Reproductive Health, 25(1), 17–27. https://doi.org/10.29063/ajrh2021/v25i1.2

Kana, M. A., Doctor, H. V., Peleteiro, B., Barros, H., & Lunet, N. (2020). Maternal and child health interventions in Nigeria: A systematic review of published studies from 1990 to 2014. BMC Public Health, 15, 334. https://doi.org/10.1186/s12889-015-1688-3

National Population Commission & ICF. (2019). Nigeria demographic and health survey 2018. NPC and ICF.

Sibley, L. M., Sipe, T. A., Barry, D., Fontaine, P., McMahon, C. L., & Corbett, K. (2012). Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database of Systematic Reviews, 2012(8), CD005460. https://doi.org/10.1002/14651858.CD005460.pub3

World Health Organization. (2004). Making pregnancy safer: The critical role of the skilled attendant. WHO Press.

World Health Organization. (2023). Trends in maternal mortality: 2000 to 2020. WHO Press.