, , , , ,

There was this news that an auxiliary Nurse pulls off baby’s hand during delivery”, and a good friend, Bayo Salau, posted the following on Facebook in reaction:

over to you guys. How can we stop the patronage of unprofessional birth attendants? Is it truly poverty that is fuelling the patronage or culture. Martin i know you have special interest in maternal and child health. Thuto de Ral Grazia Gabagaya Kitalima Martin Omedo Abraham Idokoko Abraham

Then, Grazia Gabagaya Kitalima responded thus:

“The issue of Traditional birth attendants is quite complicated. Much as I am well aware we have health system challenges with low coverage of health facilities and poverty such that women are unable to foot their transport fare to far placed health units or to pay hospital bills, culture/local practice also has a role to play. Further more, sometimes we the health workers  push these mothers to the TBA’s  when we are very rude and are perceived not to care. China and Pakistan have registered success in reduction of MMR through training TBA’s while Bangladesh on the other hand did not benefit much from training TBA’s. I worked somewhere where communities would do all they could to protect their TBAs from the long arm of the law and they had their reasons. This one time , it had rained so bad and coupled with the bad roads and emerging seaonal rivers in an area where the nearest health unit is about 20km away, mothers could not access a health facilty and were at the mercies of the TBAs who even lack basic infection control skills. But what options did they have?None! I feel simply banning them may not help unless the underlying social determinants and health system challenges are addressed. In the meantime perhaps we should equip them with some basic skills and also train them on complications and when to refer. Referral  though can  be effective  if the referral systems are strong…..over to you Martin Omedo!! Come share how you have been dealing with this and any successes gained.”

Having being mentioned in the post by Bayo Salau, i did respond in the following manner:

“Good questions, Bayo Salau. First, it’s important to highlight that the newspaper report above named the culprit as Oyekanmi, the auxillary nurse, and not a TBA. Infact, the word TBA was not used in the entire report. Now, that difference is important so we don’t judge outright illegality/criminality as unprofessional conduct or malpractice….

An auxillary nurse is a person taught to perform remedial nursing duties under the close supervision of another qualified medical professional, usually a doctor or nurse/midwife. They are never expected to work independently, on their own. Usually, they work in conventional health facilities (most commonly, privately owned facilities) to alleviate the short supply of qualified personnel, as some extra-hand….

TBA, on the other hand, are alternative medical practitioners, usually culture or faith-based. They are legal, fully backed by law and recognised part of the health system, worldwide and in Nigeria. Banning them doesn’t come in, they are legal. You can only ban illegality. Infact, they are allowed to use the title “Dr.” There is a regulatory framework for their practice and modality for their monitoring, even in Nigeria. To be candid, the MDCN is suppose to regulate their practice in Nigeria…..

But, a big flaw in the enabling Medical and Dental Practitioners Act says alternative medical practitioners do not need to register or go through any certification training. They only need to be recognized in their communities or be well known in their totheir people as possessing skills in their chosen area of practice. So, how do you regulate people you don’t register or determine their training? And as expected, the MDCN do not seem to be regulating anything alternative medical practice in reality. Neither does any other regulator doing so because as long they stay alternative or tradition, your control is limited. It is only if they impersonate regular health professionals that you can hold them accountable by the law regulating that particular profession. Otherwise, TBAs and other alternative practitioners are largely on their own in Nigeria…

Like any other law enforcement issues in Nigeria, loopholes in the laws and failure of regulation is the bane of TBA malpractice in Nigeria. For more details about this issues, download and read this article titled “Alternative Medicine in Nigeria: The Legal Framework”. A good attempt was made to highlight and summarize matters arising therein.

More remarks from me included the following:

“About the question of stopping patronage of non-conventional medical outlets, i will say it is simple and complex at the same time. As already clarified, the alternative practitioners have the right of existence by law. And the government’s ability to regulate them is flawed in Nigeria. You can only wait until they kill somebody and then charge them for murder under general laws. Otherwise, specific regulatory frameworks in Nigeria are merely advisory. CHANGING  OR MODIFYING THE LAWs AND ENFORCING THE NEW LAW IS THE SIMPLE PART but, traditionalist are a very powerful lobby. So, don’t expect an easy sail…

A viable and immediate measure would be to launch a campaign to persuade people not to use alternative medical services. And that is a very complex task because the practice is strongly tied to belief systems: religion/faith/culture/fears. I agree with the submissions made by Grazia Gabagaya Kitalima above. In addition, i want to re-emphasize that people do not patronize TBA simply because they are poor or there are no conventional medical facilities. No, not that straight forward…

In Nigeria, Lagos in particular, many of the clients delivering at TBAs registered for routine ANC in proper hospitals and some attended all ANC appointments. The overriding problem is fear coupled with ignorance of delivery methods, particularly C/S. An average woman is usually scared of the process of normal delievery, the pains, the risks to her and baby, and the fear of “dying”. At this point in their life, they cherish spiritual protection, some message of hope that the enemies from their village or in-laws won’t finally kill them. And the TBAs usually offer assurances of protection from these unseen forces. Conventional medicine do not recognise these fears or offer any protection from them.

Worse still, there is this highly prevalent erroneous belief that abdominal delivery/Caesarian Section is some bad omen, contrary to evidence that a planned elective c/s is the safest way to deliever a baby, with better outcome for mother and child. But, most of our women do not want to hear of C/S. While you are speaking English in your clinic during ANC, they are busy plotting how to escape having to do c/s. And many on the streets believe once you go to hospital for delievery, they will do c/s for flimsy reasons, and they may die.

These fears drive them into the arms of their pastors/Imams/native doctors, whose advice are superior to those of any health practitioners, whatsoever. And wherever they say the woman should deliever, there they will go, irrespective of what the hospital says. The rest is the stories we all know of.

So, the health system need to vigorously identify, re-orientate and train the TBAs, continually, since you cannot ban them. It is important to acknowledge that for a long time, the ministries of health in Nigeria, at the national and state levels, as well as development partners, have been working hard to train, equip and integrate TBAs in Nigeria with good results in many places. But, these efforts must be sustained and scaled up, particularly at the local level of implementation in the local government health departments.

Moreso, the spiritualist, pastors/imams/traditional priest, have to be carried along as well. They may not be TBAs themselves but, are significant gatekeepers to people using TBAs. Imagine if the spiritual leaders are pro-hospital, TBAs will be out of business in no time.

Conventional health personnel need to be more friendly to spirituality and the socio-cultural concerns of patients, particularly in Africa. Humans are evidently spiritual beings, no degree of modernization will un-knot that truth. Medicine and spirituality should not be at war, the two should not be parallel. They can coexist for perfect results. And the more people perceive this, the better for us all.

Hopefully, we will get to the point, like in many other climes, where alternative medicine is better structured and modernized to such an extent that training, certification and regulation can become easier. For those who think they will  disappear with time, forget it, they won’t as long as man thinks spiritually. Look at the developed countries for example, these guys are still  there with fanciful names and strong institutional regulation. Infact, an average person cannot different them from regular medical practice because they are well trained and sophisticated, working within clear guidelines, engaging the services of specialist medical  practitioners as necessary.

Lastly, i vehemently support that no woman should have to pay for using delivery services, anywhere. As much as prior factors are important, financial cost of hospital delivery can be prohibitive. ANC and delivery services in hospitals must be provided free (not just in rhetoric, as in, truly free) by the state for all citizens, irrespective. We can eliminate cost as a factor by doing so.

With that, longlive the mothers and their new borns. Amen!!”