Training for Quality Delivery: Brown Button’s drive to improve TBAs skills in Lagos
Alhaji Sulaimon Junaid wakes up at 5:30 a.m. every day to spend time with pregnant women waiting to deliver their babies in his birthing home — a brown concrete block bungalow in the rural suburb of Epe on the north of Lekki Lagoon in Nigeria’s commercial capital, Lagos. His birthing home has an office space, an antenatal and delivery room, and a section where he combines herbs for the women.
Alhaji Junaid says his decision to become a Traditional Birth Attendant (TBA) was driven largely by values instilled in him by his father, a renowned TBA himself back in Ijebu in neighbouring Ogun State — It’s sort of a dedication that he has devoted himself to. “Birthing babies, for me, has always been a calling as well as a privilege. This is something I inherited from my father, having watched him take deliveries of babies as a devoted apprentice thirty years ago,” he says with a twinge of pride.
Today he has improved on his father’s craft in a significant way; He is one of over 5,000 Traditional Birth Attendants who have been trained by the Brown Button Foundation, a non-governmental organization which provides “safe delivery and contraceptive options, training of healthcare providers, and provision of maternal health tools to health facilities.” The World Health Organisation defines a trained TBA as one who has received a short training course through the formal health sector.
Brown Button Foundation was founded in 2011 by Adepeju Jaiyeoba, a lawyer who lost a friend that year, after undergoing an elective Caesarean section. While looking into the causes of maternal deaths in Nigeria, Jaiyeoba learnt that lack of access to sterile supplies during delivery, especially in rural communities, could be one factor contributing to the large number of women dying during childbirth. She noted particularly that there were cases where midwives would tie the plastic “nylon” bags over their hands in place of gloves. This prompted her to create a simple, low-cost delivery kit — a white box with a pink and red logo of a mother cradling a child printed across the front, which reads, “Mother’s Delivery Kit”.
The kit, which costs N2,500, contains misoprostol, a drug used for prevention of postpartum haemorrhage (PPH), which is bleeding after delivery. It also includes a handful of basic sterile supplies that a woman needs at childbirth — a delivery mask, a blanket to receive the baby, medication, infant mucus extractor used to prevent asphyxia in new-borns, cotton wool, sterile gloves, antiseptics, surgical blades and scissors.
In addition to developing the Mother’s Delivery Kit, the Brown Button Foundation focuses on training Traditional Birth Attendants, Community Health Extension Workers (CHEWs) as well as nurses and midwives across rural communities in Nigeria. “Our target populace are low and middle-income women in rural and semi-urban communities across Nigeria while our mission is to connect these women to the life-saving supplies, tools, support and information they require to have a clean safe and hygienic delivery while living a healthy life afterwards,” the Brown Button website says.
So far, Brown Button Foundation has trained a total of 5,200 TBAs across the country, including Alhaji Junaid. Prior to the training, Junaid used to take deliveries of babies on the bare floor with the aid of herbs, using nylon bags as gloves, with unsterilized blades and scissors — a clearly unhygienic practice that could pose danger to both the mother and baby.
Today, the training has improved his work — having learnt that his old practice was ‘unhygienic,’ he now uses sterile gloves, surgical blades and scissors provided in Brown Button’s Mother’s Delivery Kit, while taking deliveries. The pregnant women who come to his home now lie in beds to be delivered of their babies, rather than on the floor. Abiola Muritala who delivered three of her children in Alhaji Junaid’s birthing home says his services are efficient and reliable, and that she has lost trust in the General Hospital.
For many formal health professionals, the training of TBAs is considered controversial, because of equivocal evidence of their impact on health outcomes. However, other evidence indicates that most women in rural communities do not go to the health facility to give birth, but give birth at home or go to a Traditional Birth Attendant or a faith home. A 2008 survey conducted by the WHO showed that only 36% of childbirths were assisted by a skilled birth attendant in Nigeria, of which the majority were in urban areas.
Dr. Ephraim Ohazurike, an obstetrician and gynecologic oncologist at the Lagos University Teaching Hospital (LUTH), notes that having a skilled birth attendant is still best practice, but concedes that trained TBAs have become a necessity due to an inadequate number of skilled birth attendants, especially in rural areas. He further argues that a number of the women who patronize the TBAs are driven away by unfriendly services rendered by some health workers.
Kafayat Alade had her first child in Junaid’s birthing home back in 2014. “I got to know about this place through my sister in-law who also had her baby here”, Alade, who is pregnant with her second child, says. She believes that TBAs when compared to the formal health facilities, provide more psychological support and flexible payment options, and exhibit more patience while conducting deliveries. Now she hopes to also have her second baby under Junaid’s care.
In Lagos where Alhaji Junaid lives, he is one of only 3,061 trained and registered TBAs are licensed to take deliveries. In 2014, 809 trained TBAs attended to 23,229 deliveries while in 2015, 342 TBAs delivered 14,536 babies, according to Partnership for Transforming Health System 11 data.
The Lagos State Government through the Lagos State Traditional Medicine Board (LSTMB), established under the Lagos Ministry of Health to oversee the activities of the TBAs, is also making efforts to improve the capacities of the TBAs in the areas of hygiene and standard practice. The Board has three separate courses designed to orientate and expose TBAs to a code of ethics and help familiarize them with harmful practices that could be dangerous to pregnant women and their newborns. Two of the courses are mandatory courses created to teach TBAs basic human anatomy and physiology, health statistics, primary health care, traditional medicine and food nutrition for nutritional medicine, and each course runs for six weeks. Junaid has completed all three courses as his certificates, license and awards show.
Where there’s a breach of the code of conduct; the Lagos State Health Sector Reforms Law 2006 ensures that offenders are fined. The LSTMB has a monitoring task force which goes round birthing homes in search of unregistered/untrained attendants. The code of ethics also bars TBAs from attending to any pregnant woman who has had a miscarriage or undergone a caesarean section before or if they see danger signs like oedema (swelling of the hands and feet), high blood pressure, and bleeding. The code of ethics authorizes them in these cases to refer these women to the nearest general hospital for proper care. The TBAs are also mandated to alert the nearest General Hospital in case of any emergencies while conducting deliveries, and an ambulance will be dispatched from the hospital to their birthing homes.
In 2018, Lagos State Governor, Akinwunmi Ambode launched the state’s health insurance scheme which offers health insurance with a flexible payment plan of N40,000 a year for a family of 6, to enable residents to access health care without going into financial ruin. If implemented effectively, it will minimise out of pocket expenditure and could encourage women to deliver in the hospital. In the long run, this is expected to improve maternal and child health services in the state.
Other states are also finding innovative ways to address how TBAs function. In Ogun State, TBAs are being trained in the area of pregnancy complications like prolonged labour, bleeding during pregnancy and pre-eclampsia. The state recently launched a free community-based health insurance scheme called Araya Scale-up for expectant mothers and children under 5. Araya means “stay healthy,” in Yoruba.
Ondo State has a safe motherhood programme called Abiye, established in 2014. The Agbebiye (Safe Birth Attendant) Initiative intends to phase out the role of TBAs in delivery altogether by offering TBAs a small payment each time they bring a mother to a health facility to give birth. At the same time, the TBAs are offered training in alternative occupations such a soap making, catering, and tie-dying, along with microfinance loans to help them establish small businesses.
Alhaji Junaid says he has carried out over 10,000 deliveries from his birthing home and the training and support he has gotten from Brown Button Foundation, in addition to the support from the Lagos State Government has obviously helped his work. He now understands the importance of proper hygiene, the use of sterile equipment, good nutrition and basic anatomy and physiology, as well as the critical need for referral to the general hospital in case of emergencies.
More states in the country could use Lagos State’s approach of training and regulating Traditional Birth Attendants to improve their work and contribute their quota towards the global goal of reducing maternal mortality.
For Jaiyeoba and the Brown Button Foundation team, their vision continues to be to bring maternal and child mortality in Nigeria to its lowest ebb, and to eventually eradicate it through access to skilled healthcare services and personnel. Training TBAs to make their services better is just one step towards getting to this goal.
Do you know of an organisation or state who is engaging with TBAs in an innovative way? Let us know in the comments.
About the author
Valentine Iwenwanne is a Nigerian journalist writing about politics, global health and development. His work has been published in South Africa’s Mail & Guardian, Devex, TRT World, Ozy, Women Under Siege and more. He tweets as @valentineiwen