Pa ge 1 Pa ge 1 American Journal of Physical Education and Health Science (AJPEHS) A Quantitative Assessment of The Perception and The Roles of Traditional Birth Attendants on Maternal Health Care among Women of Reproductive Age in Ifedore Local Government Area of Ondo State, Nigeria Ogunmakinwa Florence Iyabo1* Volume 1 Issue 2, Year 2023 ISSN: 2992-9679 (Online) DOI: https://doi.org/10.54536/ajpehs.v1i2.1823 https://journals.e-palli.com/home/index.php/ajpehs Article Information ABSTRACT Received: July 10, 2023 Accepted: August 12, 2023 Published: September 18, 2023 The fifth development goals (NDGs) aims at improving maternal health with the target of reducing maternal mortality ratio (MMR) by 75% between 1990 and 2015, but much has not been achieved in this area from then to the present time. It is in the light of the above that this study quantitatively assessed the perception and roles of traditional birth attendants (TBAs) on maternal health among women of reproductive age in Ifedore local government area in ondo state. The study relied on the health belief theoretical model to explain the social and psychological health behaviour of women of reproductive age with respect to patronage and knowledge of the TBAs. A descriptive cross –sectional study design was used for the investigation. The sample consists of three hundred and seventy-nine (379) respondents comprising 242 women of reproductive age, 100 traditional birth attendants, 20 medical and paramedical personnel randomly selected from local communities within Ifedore local government using a multistage sampling technique. Data were collected through structured questionnaire and the results were analysed using descriptive statistics. The findings revealed that majority of the respondents have good perception of the roles of the TBAs in that area and that child-bearing women patronized them because they are cheaper than government’s hospitals services and closer to them than government-owned health facilities. The study concluded that the TBAs play vital roles in maternity health care delivery among women of reproductive age in Ifedore local government area. It is,therefore, recommended that the government should as a matter of necessity foster partnership with a view of improving their skills to meet the global best practices. Also, health care services should be made affordable in public health institutions to encourage patronage by the rural and semi-urban dwellers. Keywords Birth Attendants, Health Care, Maternal Health, Reproductive Age, Respondents INTRODUCTION Traditional birth attendant (TBA) according to world Health Organization (WHO) is a person usually a woman who assists the mother at childbirth and who has initially acquired her skills delivering babies by herself or by working with other traditional birth attendants. Traditional birth attendants have been involving in national and international health programmes with a peak of interventions in the 1970s and 1980s. The enthusiasm declined in the 1990s with a debate on their cost- effectiveness and the missing impact of TBAs’ training to reduce maternal mortality. By 1997, senior policy makers decided to shift priorities on the provision of skilled birth attendant (SBA) and subsequent withdrawal of funding for TBAs’ training and exclusion of TBAs’ in policies and programmes worldwide. Emphasis has been on the training of TBAs’ since late 1950s and 1960s to a recommendation that TBAs’ work should be integrated into the health system via training, supervision and technical support to today’s position of promoting professionally skilled attendance at all births (9). The fifth millennium development goal (MDG) aims to improve maternal health, with the targets of reducing maternal mortality ratio (MMR) by 75% between 1990 and 2015 and achieving universal access to reproductive health by 2015. An essential strategy for reducing the high maternal mortality ratio is to ensure that all births are managed by skilled health professionals. In developing regions overall, the proportion of deliveries attended by skilled health personnel rose from 55% in 1990 to 65% in 2009, despite dramatic progress in many regions, coverage remains low in sub-Saharan Africa and Southern Asia, where the majority of maternal death occur(10). These two regions accounted for 85% of the global maternal deaths, with sub-saharan Africa alone accounting for 56%. It was further noted that in many of these countries with large numbers of maternal deaths, high quality maternity care is often unavailable and many deliveries are attended to by traditional birth attendants (TBAs), a relative or in some settings or no one, home births remain a strong preference and often is the only option in many areas, child bearing woman who does not give birth in a clinical setting relies upon TBA’s who may have received formal training or have gained experience by assisting neighbors, friends and family members to give birth (7,12). Many of these TBAs have helped with the birth of nearly entire generations in the villages, their social roles in the communities is recognized and respected and therefore, their attendance is highly valued. In 2007, Federal Ministry of Health formally approved and adopted the country’s reproductive health policy that stipulates that traditional birth attendants should only provide emotional support to women in labour but should not assist in delivery at home. This was in 1 Department of Public Health City University, Cambodia * Corresponding author’s e-mail: ogunmakinwaflorence@yahoo.com Pa ge 2 https://journals.e-palli.com/home/index.php/ajpehs Am. J. Phys. Educ. Health Sci. 1(2) 1-7, 2023 a bid to strengthening community based midwifery practice and helping the TBAs become advocates of safe motherhood and to enhance maternal health. However, this has faced several challenges one of them is being the poor relationship between TBAs and SBAs. To this end, TBAs still continue to practice home delivery and women continue seeking antenatal care (ANC), delivery and even postnatal care (PNC) from the TBAs. Between 2009 and 2015, Ondo state in response to an 80% proportion of TBAs related maternal deaths launched the “Agbebiye’’ programme to incorporate TBAs. The programme included free maternal and child health services in all public hospitals in ondo state establishing dedicated tertiary facilities for the care of pregnant women and children as well as collaborating with unskilled traditional and faith-based birth attendants to refer complicated labour case in their care to designated hospitals in exchange for cash incentives (20) Statement of the Problem The millennium development goal 5 set by United Nations is to improve maternal health by reducing the maternal mortality rate (MMR) by three-fourths by 2015. Nigeria was identified as one of the countries that needed to achieve MDG 5 due to the high maternal mortality rates occurring in the country. The 2018 Nigerian national demographic and health survey (NDHS) reported the maternal mortality rate was 512 deaths per 100,000 live births. It has been observed over times that the activities of TBAs have contributed in no small measure to ever increasing maternal mortality ratio index of the country due to their unsafe practices which are marked by hemorrhages, infections,pre eclampsia, prolonged labour, use of unsterilized equipment among others. In Ondo State Nigeria, the government in place between 2009 and 2016 regulated the activities of the TBAs in all the eighteen local government areas of the state following their unwholesome practices with attendants increase in maternal mortality rate among pregnant women but the exit of that government has brought back the unwholesome practices of the TBAs in the state which has assumed a worrisome dimension. It is in the light of the above that this seminar paper aims at studying the perception and the role of traditional birth attendants in maternal health care, particularly at Ifedore Local government area of the state with high number of traditional birth attendants. This study is guided by the following research questions. 1. What is the perception of the roles of traditional birth attendants in maternal health care among women of reproductive age in Ifedore local government area of ondo state? 2. What are the reasons for patronizing traditional birth attendants by women of reproductive age in Ifedore local government area of Ondo state? General Objective The general objective of this study is to study the perception and the roles of traditional birth attendants in maternal health care among women of reproductive age in Ifedore local government area of ondo state. Specific Objectives 1. To assess the perception of the roles of traditional birth attendants in maternal health care among women of reproductive age in Ifedore local government area of ondo state?. 2. To examine the reasons for patronizing traditional birth attendants by women of reproductive age in Ifedore local government area of Ondo state? Significance of the Study 1. The findings of the study will call for improvement in partnership among the government and the critical stakeholders in the health sector in order to improve maternal health among child bearing woman and. 2. The study will add to the body of knowledge regarding traditional birth attendants LITERATURE REVIEW Maternal Mortality in Nigeria The maternal mortality ratio for Nigeria remains quite high at 814 per 100,000 live births according o 2016 world health statistics. Across the country, pregnant women and children under five years are generally charged fees when accessing health care services, despite the federal government’s declaration of free health for pregnant women and children under five years of age in 2005. According to Nigeria demographic Health survey 2013, over 60% of pregnant women aged 15-49 deliver their babies at home without any antenatal care visits in rural areas, this value reaches 76.9%. The situation is critical in North east and north west regions of Nigeria where over 79% of pregnant women age 15-49 deliver their babies at home. Over 60% of pregnant women in Bayelsa, Plateau and Niger deliver at home rather than a health facility. The distance of pregnant women’s homes from a health facility and the cost of health care are some of the reason for not delivering at a health facility. The cost of health care and perceived low quality of care by the public have been argued to be the reason for the poor utilization of maternal and child health services in Nigeria. In addition health spending in Nigeria is low and this is responsible for the over-reliance on out of pocket payment for health care services. According to Federal ministry of health journal 2018. The Traditional Birth Attendants (TBAs) TBAs are defined by the WHO (1992) as a group of persons who assist mothers during childbirth and who initially acquired their skills by delivering babies themselves or through apprenticing with other TBAS. TBA’s have existed since time immemorial and fallen into the category of informal healthcare providers who work locally in the rural areas. Women in rural areas usually use their services more than they use formal healthcare Pa ge 3 https://journals.e-palli.com/home/index.php/ajpehs Am. J. Phys. Educ. Health Sci. 1(2) 1-7, 2023 providers (18.20). TBA’s still exist despite the formal health care system because rural areas are characterized by poor infrastructure including impassable roads and ill- equipped health facilities, among other things. TBAs fall under the informal health system which is defined by four categories, training, payment, registration and profession (21). The authors described TBAs as having received no formal training, although they may have gone through some level of formal training such as apprenticeships, seminars and workshop funded by NGOs. stated that TBAs receive payment directly from the clients they serve (3,6). The existence of TBAs in most villages is due to limited availability of professional health care providers in rural area, leaving TBAs to fill the gap. There is a wide between formal and informal health care providers due to literacy levels (18). The TBAs are here to stay. They are part of the community, socially, and culturally accepts and available whenever needed. This explains how important TBAs are in their communities. The TBAs enjoy an important status in the community, which likely explains why policy make should consult with the TBAs to improve the health of the mothers in the rural areas (14). The Roles of TBAs TBAs have existed for as long as women have given birth. The more they do has been tremendous and people in the rural areas value their services (13) Originally, TBAs had no form of training but they still perform midwifery duties. Training began in the 1970s by the WHO and other funding organizations (3). TBAs are a link between the rural people of African and health care delivery (5, 15). It was further stated that TBAs have unique talents. They use inherited knowledge of methods and practices that have evolved from the social, cultural and spiritual wealth of the communities they serve. Despite TBAs being linked to high maternal mortality, they may also play a significant role in mitigating maternal mortality because they are first and often the only health care provider who can easily accessed in rural area, therefore, there is a need to involve them. More than two thirds of TBA in their study had no designated delivery rooms (5). They also did not consider any pregnant women to be in danger, therefore, they saw no need to refer them to the hospital for further check – up. The author also stated that few of the TBAs examined women during their frequencies. Despite this mother still used the services of TBAs for many of their deliveries. Theoretical Framework The study is anchored on the Health belief theoretical model. According to Roserstock and Baker (1994), Health belief model is a social and psychological health behavior change developed to explain and predict health related behavior with respect to acceptance of intervention against disease or practice or otherwise. Therefore, the relevance of this theory to this study lies on the fact that on average pregnant women will voluntary opt for health facility for her deliver only if efficiency of health care service the facility offers and the perceived severity of her case. METHODOLOGY The research design adopted for this study was descriptive research design. This method allow for collection of data in quantitative manner. Study Population The study population comprise 232 women of reproductive age (15-49), 100 traditional birth attendants, 15 medical and 17 paramedical personnel residing in Ifedore Local government area of Ondo State, Sample Size To determine the sample size of this study, Leiz Fisher’s formular was adopted. Below is the calculation: n= Z2 (P [1-P])/d2 z= standardized normal (1.96) p = Prevalence of TBAs actions adopted from previous studies q= (1 - p) d= is the level of precision (0.05) z= 1.96 n= (1.962 x 0.6 (1 – 0.6))/0.052 n= (1.96 x x 1.96 x 0.6 ( 0.4))/0.052 n= 0.92194/0.0025 n = 369 The, 369 respondents were considered as the sample size. A multistage sampling technique was adopted for the selection of participant for the study. This type of sampling technique requires the researcher to choose his/her sample in stage until he/she gets the required sample (Asemali et al 2012). In using multistage sampling technique the ten (10) political wards in Ifedore local government area were first identified. They are Ero/ Ibuji/Mariiro, Igbaraoke I, IgbaraOke II, Ijare I, Ijare II, Ilara I, IlaraII, Ipogun/Ibule, Isarun/ Erigi, Ikota/ Irese ward. Stage 1 This stage involves using stratified sampling technique to stratify the ten ward to 6 urban wards and 4 rural wards. Stage 2 Here two (2) urban wards and 2 rural wards were selected through simple random sampling (balloting) Stage 3 Communities in the 4 selected wards were listed out and two communities each selected randomly. Thus 8 communities: 4 rural and 4 urban communities were selected in all. The 8 selected communities are: Aaye, Irese, Ayetoro, Uye, Igbeyin, Odofin, Asae and Iloro. Participants in the selected communities, were assessed using structured questionnaire. The questionnaire instrument has three sections: Section A – Socio- Pa ge 4 https://journals.e-palli.com/home/index.php/ajpehs Am. J. Phys. Educ. Health Sci. 1(2) 1-7, 2023 demography profile of the respondents. section B- consist questions raised to assess the perceptions of the respondents on the role of Traditional birth attendant. Section C- question raised on ways of improving activities of traditional birth attendant in the area. The question consist of both open and close ended question. The reliability of the study instrument was tested through a pre-test conducted in one of the selected wards (Ero/Ibuji) to ascertain the reliability of the research instrument. A total of 20 respondents were drawn from the said ward for this purpose. Data Presentation and Analysis The data collected were analyzed using descriptive statistics such as frequency table, percentage, mean, etc. The table below provides the socio-demographic profile of the respondent Section A: Socio--demographic profile of the respondents. Table 1 above present the analyses of age of respondent. From the table 206 (55.8%) respondents are between Table 1: Age of respondents. Age group(yrs) Frequency Percentage % 15–19 10 2.7% 20–39 206 55.8% 40–49 59 15.98% 50–59 74 20.05% 60–69 20 5.42% Total 369 100 Source: Field Survey 2022 the age bracket of 20-39yrs, 59 representing 15.98% are within the age range of 40-49yrs while 10(2.7%) fall within age 15-19yrs. This implies that the majority of the respondents are within the active reproductive age. Table 2 above presented the analysis of the marital status Table 2: Marital status Marital status Frequency Percentage % Single 12 3.3% Married 297 80.5% Divorced 25 6.8% Widowed 35 9.4% Total 369 100 Source: Field survey 2022 Table 3: Religion of respondent Religion Frequency Percentage % Christianity 300 81.3% Islam 30 8.13% Traditionalists 39 10.56% Total 369 100 Source: Field survey 2022 Table 4: Educational status of respondents Education status Frequency Percentage % Graduate (MBBS,BSC,B.TECH, NSC,HND) 50 13.55% OND,NCE Holders 100 27.10% Secondary schools leavers 150 40.65% Primary school certificate holders 40 10.8% No formal education 29 7.9% Total 369 100 Source: Field survey 2022 of the respondents. The table revealed 297 (80.5%) respondents are married while 12(3.3%) are singles and 25(6.8%) of them are divorcees, while 35(9.4% are widowed). This implies that the majority of the respondents are married women. The below table shows the analysis of Table 5: Respondents’ Views on Perception of Roles of Traditional Birth Attendants in Maternal Healthcare Among Women of Reproductive Age in Ifedore Local Government Area. Variable Yes% No% Are TBAs services important in Ifedore Local government area 360(97.5%) 9(2.4%) How many babies do you have 0 12(3.25%) 1 – 2 69(18.69%) the religion status of the respondents. From the table: the majority of the respondents are Christians 300 (81.3%) while 30(8.13%) are of Islamic faith and 39(10.56%) are traditional worshippers. It can be inferred from the table that Christians are in the majority. The above table presented the analysis of education attainment of the respondent from the table 100 representing 27.10% are graduates while 50 (13.55%) are secondary school levers, 150 (40.65%) are primary school leavers and 29(7.9%) are without formal education. This implies that respondents with secondary school certificate holders are in the majority. Research Question 1 What is the perception about the roles of traditional birth attendants in maternal healthcare among women of reproductive age in Ifedore local government area? Pa ge 5 https://journals.e-palli.com/home/index.php/ajpehs Am. J. Phys. Educ. Health Sci. 1(2) 1-7, 2023 3 – 5 268 (72.6%) 5 and above 20(5.42%) Do TBAs take normal delivery? 300(81.3%) 69(18.69%) Do they provide contractual services ? 300 (81.3%) 69(18.69%) Do TBAs provide family planning services? 280(75.8%) 89(24%) Do you believe complication can arise from the TBA care? 270 (73%) 99(26.8%) Do TBAs provide special maternal birth to ward off evil spirits? 300(81.3%) 69(18%) Do TBAs provide concoction for mothers to drink to make the baby strong? 320(86.7%) 49(13.2%) Source: Field survey 2022 Table 6: Reasons for using TBA’s Services among respondents Variable Yes% No% Do you believe TBAs service are cheaper? 300(81.3%) 69(18.7%) Do you believe TBAs services are culturally acceptable in your area? 297(80.5%) 72(19.5%) Are TBAs centers closer to your house than hospital services? 340(92.1%) 29(7.9%) Do you believe TBAs provide more compassionate care than orthodox health workers? 312(84.6%) 57(15.4%) Do you think TBAs services should be banned? 20(5.4%) 349(94.6%) Do you think TBAs service are effective but could be improved with some form of training? 340(92.1%) 29(7.9%) Are you satisfied with TBAs services? 320(86.7%) 49(13.3%) The above table presents the analysis of the perception of the respondent on the role of TBAs in Ifedore local government area. From the table 360 (97.5%) agreed that TBAs play important role in maternal health in Ifedore Local government while 9(2.4%) disagreed. 300 representing 81.3% agreed that TBAs take normal delivery only 69(18.69%) disagreed. Similarly, 300 (81.3%) agreed that they do conduct ante-natal care only 69(18.69%) disagreed. 280(75.8%) averred that TBAs provides family planning services while 89(24%) disagreed. however, 270(73%) agreed that simple form of complications could set in during their operations while only 26.8% disagreed. In the same vein, 300 (81.3%) agreed that TBAs usually provide their client with special maternal birth services to ward off evil spirit only 69(18%) disagreed. 320(86.7%) equally were of the view that TBA’s do provide concoctions for mothers to drink to make the baby strong only 15.2% disagreed. It can therefore be inferred from the above analysis that majority of respondents have good perception of the services of the TBAs. Research Question 2 What are the reasons for patronizing traditional birth attendants among women reproductive age in Ifedore local government area. The above table presents the analysis of the respondent’s reason for patronizing TBAs in their local government area. From the table 300 representing 81.3% of respondents agreed that TBAs services are cheaper only 69(18.7%) disagreed. Also, 297(80.5%) claimed TBAs services are culturally acceptable in their area only 72(19.2%) of them disagreed. On whether TBAs centers are closer to them than government hospitals, the majority 340(92.1%) answered in the affirmative while only 29(7.8%) did not agree. 312 (84.6%) respondents claimed TBAs service provide a more compassionate service than orthodox service only 57(15.4%) of them disagreed. On whether TBAs service should be banned, the majority of the respondents 349(94.6%) disagreed with the assertion only 20(5.4%) agreed with respect to whether TBAs services are effective but could be improved upon with some form of training 340(92.1%) agreed and 29(7.9)% disagreed. On whether the respondents are satisfied with the services of the TBAs, majority of them 320(86.7%) agreed that they are satisfied while only 49(13.3%) disagreed. From the above analysis it can be inferred that majority of the respondents have good reasons for patronizing the TBAs services. RESULTS AND DISCUSSION The purpose of this study is to assess the perception of the roles of TBAs on maternal health among women of reproductive age in Ifedore Local Government Area of Ondo State. Findings from the study revealed that the majority of the respondents are between the age range of 15-69 years. Also, the majority 360(93%) are married women.In respect to religion; Christians are in the majority (81.3%). The analysis of the educational status of the respondents revealed that respondents with secondary school certificates are in the majority. Their perception of the roles of TBAs in the area revealed that majority 297(80.5%) of the respondents are of the opinion that TBAs do take normal delivery only 18% Pa ge 6 https://journals.e-palli.com/home/index.php/ajpehs Am. J. Phys. Educ. Health Sci. 1(2) 1-7, 2023 disagreed. Similarly, 300 (81.3%) agreed that TBAs do conduct ante-natal care only 69(18%) disagreed. In the same vein, 300 representing (81.3%) do believe that TBAs usually provide their clients with special maternal birth to ward-off evil spirit only 69(18%) disagreed. 320(86.7%) of the respondents claimed that TBAs do give concoctions to their clients (mothers) to drink to make their babies strong only 49(13.2%) were not of the view. It can therefore be inferred from the above analysis that the majority of respondents have a good perception of the services of the TBA’s On the reasons why the respondents patronize the TBAs, analysis of the reasons revealed that, the majority of them 300 (81.3%) claimed that TBAs services are cheaper than government hospital services 300(81.3%) only 69(18%) disagreed with the assertion. On whether TBAs services are culturally acceptable in the area, 297(80.5%) agreed with the assertion while only 18% disagreed. 340(92.1%) affirmed that TBAs centers are closer to their homes than government hospitals, only 29 (7.9%) were not of the view. On whether TBAs service should be banned, the majority of the respondents 349(94.6%) disagreed with the assertion only 20(5.4%) agreed. The majority of the respondents, equally affirmed that TBAs service are effective but should be improved with some forms of training 340(92.1%) agreed while only 29(7.9%) of them disagreed with the assertion. On their level of satisfaction with the TBAs services, the majority of them 320 representing 86.7% claimed they are satisfied with the services of TBAs in the area only 49(13.3%) disagreed. It can therefore be referred from the above analysis that majority of the respondents have good reasons for patronizing the TBAs in the area. The findings of this study are similar to the findings of the study conducted by Ndambuki and Kambi (2007) in Migor County, Kenya where it was concluded that activities of the TBAs are good but needed to be pepped up with modern training. However, the findings contradicted the findings of the study carried out by Chelo, Zulu and Nzala (2016) in rural district of Kazungula in Zambia where they concluded that the majority of the participants enlisted in the study were of the opinion that services of TBA’s in the area are below standard and should be banned. However, the future research can provide information on the influence of Traditional Birth attendants (TBAs) activities on maternal mortality which was not investigated by this study. CONCLUSION The study concluded that the majority of women of reproductive age in Ifedore Local Government Area of Ondo State have a good perception of the services of traditional birth attendants. However, there is a necessity for TBAs knowledge and skills to be improved with adequate training through a sustained partnership between the TBAs and the orthodox health system. Therefore, with due juxtaposition to the locations of the previous studies with this study, the following that will foster a health collaboration between providers of orthodox and traditional maternity services which will translate into improved maternal and neonatal health outcomes in relevant settings are hereby recommended. RECOMMENDATIONS 1. Government should as a matter of necessity foster partnership between TBAs and orthodox medical practitioners with a view to have robust health care services. This is because of the strategic position occupied by the TBAs in most rural areas. 2. Government should embark on training and retraining of the TBAs to asquint them with the modern skills in the field of midwifery 3. Government should constitute enforcement team to monitor the activities of the TBA’s both nationally and locally with a view to make them comply with the acceptable standard as laid down by the regulations 4. Providing adequate training to the TBA’s by government and other stakeholders will go along way in helping them know their scope and limitation and possibly refer mothers and their infants for immunization, family planning, and emergency services. 5. Policies should be enacted by the government that will incorporate an ecological system view which will acknowledge and recognize the contributions of TBAs and socio-historical factors that encourage their utilization. 6. Stakeholders should improve on the role of men in pregnancy and postpartum period by providing education, incentives and support for men that can be instrumental in reducing maternal mortality and thus increase health care usage. This is because if men gave their wives more permission to go to a health care center, healthcare utilization will increase. 7. Government should make the health care services affordable so as to increase the patronage of government health institutions as the present public health care services are expensive to access by the pregnant women 8. Governments should establish many more hospitals in the rural and semi-urban communities REFERENCES Abiodun, O., Sotunsa, J.,Olu- Abiodun, O., Ani, F., Taiwo, A. and Taiwo, O. 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