ASSESSMENT OF THE PERCEIVED IMPACT OF TRADITIONAL BIRTH

ATTENDENTS SERVICES AMONG WOMEN IN SELECTED PRIMARY HEALTH

CARE CENTERS IN OYO TOWN.

AJIBOYE TITILAYO TIMILEHIN

DEPARTMENT OF NURSING

ATIBA UNIVERSITY,OYO,OYO STATE.

In partial fulfuilment of the requirement of Nursing and Midwifery Council of Nigeria

for the award of "Registered Midwife Certificate".

1
 DECEMBER, 2023

DECLARATION

This is to declare that this research project titled ASSESSMENT OF THE PERCEIVED

IMPACT OF TRADITIONAL BIRTH ATTENDENTS SERVICES AMONG WOMEN IN

SELECTED PRIMARY HEALTH CARE CENTERS IN OYO TOWN was carried out by

AJIBOYE TITILAYO TIMILEHIN is solely the result of my work except were acknowledged

as being derived from another person (s) or resources.

Matriculation Number : AU17/01/NSC005

In the Department of Nursing Science, Atiba University, Oyo.

Signature ______________ Date_____________

2
 CERTIFICATION
This is to certify that this research project by AJIBOYE TITILAYO TIMILEHIN with the
matriculation number AU17/01/NSC005 has been examined and approved for the award of
REGISTERED MIDWIFE CERTIFICATE.

_______ _______ __________________

Mrs Victoria Aina Date
(RN, RM, RNT, BSC(He'd),BNSC MSC).
Project Supervisor

___________________ ___________________
Dr. Olarerin J. J. Date
RN, RM, RNE, RICN, FWACN,
B.Sc. Nursing Education
M. Sc (Medical-Surgical Nursing)
Ph.D. Nursing
(Head of Department, Department of Nursing science)

Signature_____________________
_________________________
Name _________________________
Chief Examiner Date

3
 ABSTRACT

This study investigates the roles of traditional birth attendants (TBAs) and their perceived
impact on maternal and child health outcomes in selected primary health care centers in Oyo
Town. The Nigerian government has recognized the necessity to incorporate traditional birth
attendants (TBAs) into the PHC system since the introduction of the Primary Health Care (PHC)
model in 1979 and as a result started TBA training programs. The use of traditional birth
attendants (TBAs) is a common practice in many parts of Nigeria and other African countries, as
well as globally and this has posed
serious concerns. First, TBAs are often not trained or certified to provide healthcare services,
and may lack the knowledge and skills to safely deliver babies or provide other essential
healthcare services. The objective of the study is to to assess and evaluate the roles to which
TBAs contribute to maternal and child health outcomes, especially in regions where they are
commonly utilized. A survey questionnaire was used to collect the necessary data from 105
women, and statistical analysis was carried out in order to understand the results. Using SPSS
version 25 for Windows, the survey data was analyzed and displayed as means, standard
deviations, and percentages presented in the study. The Socio-Demographic Characteristics of
Respondents shows that the age group of the respondents in the study in which the majority of
the respondents were of the age group 18-24. The findings reveals that TBAs play vital roles in
providing personalized care, health education, psychological support, and assistance in
transport during labor. The study calls for enhanced access to healthcare services, community
education, training and regulation of TBAs, and tailored maternal health services to promote
safer maternal and child health outcomes in the community.
Keys words; Traditional Birth Attendants, primary health care, impact.
Word count: 296 words

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 ACKNOWLEDGEMENT

In all and all I want to thank God firstly for the gift of life, his guidance through the journey in

this magnificent department. I am very grateful to him for making this research solely a success

without him first it wouldn't be a success. I would like to appreciate a woman who is like a

mother to me, my project supervisor Mrs Victoria Aina for her able guidance, massive

corrections, support, sincerity, her veracity, her encouragement, and also taking out time from

her busy schedule to go through my work. I would also love thank my respondents the women

without them I would not carry out this research project may God bless and protect them. I

would like to appreciate the head of department Dr. Olarerin for her massive support and

encouragements. I want to appreciate the head nurses at the clinics I visited for their massive

support and cooperation.

Special thanks to my mom Mrs Effiowan Cobham Anatiga although as a single mom she strived

so hard to make me a better person and making this research a success. I appreciate her for

support, love and care upon me. I also appreciate my friends, and my close friends and others,

these people has put lot to make this project a success and I appreciate them for their actual

words of encouragement, love and support during this period.

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 DEDICATION

This research is solely dedicated to God almighty that has been there right from the beginning to

this very point.

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 TABLE OF CONTENT

Title Page i

Declaration ii

Certification iii

Abstract iv

Dedication v

Acknowledgement vi

Table Of Content vii

List Of Table xi

List Of Figures xii

CHAPTER ONE. 1

INTRODUCTION 1

1.1 Background Of The Study 1

1.2 Statement Of Problem 4

1.3 Objectives Of The Study 7

1.4 Research Questions 8

1.5 Research Hypotheses 8

1.6 Significance Of Study 9

1.7 Scope Of The Study 10

7
1.8 Definition Of Terms 10

CHAPTER TWO 12

LITERATURE REVIEW 12

2.0 Introduction 12

2.1 Conceptual Framework 12

2.1.1 Definition of Traditional Birth Attendants 16

2..1.2 Types Of Traditional Birth Attendants.

17

2.1.3 Roles Associated With Traditional Birth Attendants 18

2.1.4 Factors Impacting The Patronage Of Traditional Birth Attendants (Tbas) Among Women 21

2.1.5 Reasons Why Most Women Prefer The Utilisation Of Traditional Birth Attendants Than

Skilled Birth Attendants 24

2.1.5 .1 What Are These Reasons Why Women Tend To Utilize The Services Of Traditional

Birth Attendants 25

2.1.6 The Complications Of Utilizing Unskilled Traditional Birth Attendants Services 27

2.2 EMPIRICAL FRAMEWORK 29

2.2.1 Assessing The Roles To Which Tbas Contribute To Maternal And Child Health Outcomes,

Especially In Regions Where They Are Commonly Utilized.

8
2.2.2 Determining The Factors Affecting The Safety Of Tba Practices In Delivering Babies

And Providing Care During Childbirth.

31

2.2.3 Identification On The Complications Encountered By Pregnant Women That Visits

Traditional Birth Attendants. 32

2.2.4 Identifying The Major Reasons Why Women Choose To Utilize The Services Of

Traditional Birth Attendants Than Skilled Birth Attendants. 33

2.3 THEORETICAL FRAMEWORK. 35

2.3.1 The Three Delay Model 35

2.3.1.1 Application Of The Three Delay Model To The Study 37

2.3.1.1.1 The First Delay 37

2.3.1.1.2 The Factors Influencing The First Delay 38

2.3.1.1.3 The Second Delay 40

2.3.1.1.4 Changes Proposed In The Literature To The Three Delay Model 41

2.3.1.1.5 The Third Delay 42

2.3.1.1.6 The Fourth Delay 43

CHAPTER THREE 44

RESEARCH METHODOLOGY 44

3.0 Introduction 44

3.1 Research Design 44

3.2 Research Settings 44

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3.3 Target Population 45

3.4 Sampling Method & Techniques 46

3.5 Sample Size Determination 46

3.6 Instrument For Data Collection 48

3.7 Inclusion Criteria& Exclusion criteria 49

3.8 Establishing The Validity And Reliability Of The Instrument 49

3.9 Method Of Data Collection 50

3.10 Method Of Data Analysis 50

3.11 Ethical Considerations 51

CHAPTER FOUR3.9 Method Of Data Collection 52

4.0 Introduction 52

4.1 Socio-Demographic Characteristics of Respondents 53

4.2 Assessing the Roles of Traditional Birth Attendants in Improving Maternal and Child Health

Outcomes 60

4.3 Factors Affecting the Impact of TBAs services among the Women 62

4.4 Complications that Arises from the Utilization of Unskilled Birth Attendants. 67

4.5 Reasons Why Women Prefer the Utilization of Traditional Birth Attendants 71

CHAPTER FIVE 78

5.0 Introduction 78

5.1 Summary 78

5.2 Discussion Of Findings 78

5.2.1 Roles of Traditional Birth Attendants 78

5.2.2 Factors Affecting TBA Utilization 79

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5.2.3 Complications Arising from TBA Utilization 79

5.2.4 Hypothesis 1: Relationship between Access to Healthcare Services and TBA Utilization 79

5.2.5 Hypothesis 2: Socio-Demographics and TBA Utilization 80

5.3 Implication To Nursing 80

5.4 Limitation of the study 81

5.5 Conclusion 82

5.6 Recommendation 83

5.7 Suggestions For Further Studies 85

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 LIST OF TABLES

Table 4.1 Socio-Demographic Characteristics of Respondents 53

Table 4.2 Assessing the Roles of Traditional Birth Attendants in Improving Maternal and Child

Health Outcomes 60

Table 4.3 Factors Affecting the Impact of TBAs services among the Women 62

Table 4.4 Complications that Arises from the Utilization of Unskilled Birth Attendants. 67

Table 4.5 Reasons Why Women Prefer the Utilization of Traditional Birth Attendants 71

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 LIST OF FIGURES

Figure 2.1 The Three Delay model 36

Figure 2.2 Changes proposed to the structure of the three delay model. 44

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 LIST OF APPENDIX

APPENDUM 1 Questionnaire 95

APPENDUM 2 Letter Of Introduction 103

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 CHAPTER ONE

INTRODUCTION

1.1 Background of Study

The Nigerian government has recognized the necessity to incorporate traditional birth attendants

(TBAs) into the PHC system since the introduction of the Primary Health Care (PHC) model

there in 1979 and as a result started TBA training programs. Although traditional delivery

attendants receive a lot of business, many of their methods have been proved to be harmful to

mothers' health (Anthony et al.2021; Uwake& Oloucha 2021).

Unskilled traditional birth attendants (TBAs) are trained as part of a strategy, ministries of

Health and its partners have used since the 1980s to promote safe motherhood. However, recent

research has refuted the notion that educating traditional birth attendants (TBAs) will

significantly lower maternal mortality. TBAs' (Traditional Birth Attendants) education is

intended to decrease post-partum infection by promoting cleanliness and avoiding risky

behavior. While such preparation may lessen these specific issues, labor and delivery will

occasionally remain challenging. TBAs lack the knowledge and resources necessary to handle

life-threatening problems. Without medical training, materials, or tools, these TBAs can help

with routine deliveries but cannot manage potentially fatal complications

(Ebuech&Akintujoye2022)

Prior to the development of trained nurses, midwives, and doctors, as well as structured systems

of medical treatment, traditional birth attendants (TBAs) provided the majority of the delivery

care around the world. TBAs are currently not considered medical practitioners by the medical
1
authorities and typically lack proper training. While the percentage of women giving birth in

hospitals has increased recently, an estimated 22% of expectant women worldwide gave birth

with a TBA in 2019, outside of hospitals. In some areas, more than half of all pregnant women

still obtain care and deliver their babies using TBAs (Dogimaji & Maina, 2021).

According to the World Health Organization (2019), Nigeria has one of the highest maternal

mortality rates in the world (814 per 100,000 live births), which is partially due to the

underutilization of skilled professionals for antenatal and delivery care (Ariyo et al., 2019; Azuh

2019; Bishai et al. 2019; Lanre-Abass 2018; Ntoimo et al. 2019). To increase the possibility that

pregnancy difficulties would be better managed and hence lower the risk of maternal death, the

World Health Organization (WHO) advises using competent delivery attendants. A qualified

nurse, midwife, or doctor is sometimes referred to as a skilled birth attendant (SBA) by the

WHO. According to the 2018 Nigeria Demographic and Health Survey (NDHS), 43% of women

had an SBA help them during childbirth, compared to 20% of deliveries where traditional birth

attendants provided assistance (Ikeora, 2019).

Over 70% of Nigerian women use SBAs for antenatal care and labor. Between 70-97% of

women in 24 of the 36 States had professional prenatal care, while 70-98% of women in 14

States received skilled delivery-care (Nigeria's Population Commission (NPC) and the ICF

2019). According to the National Population Commission (NPC) [Nigeria] and ICF 2019, there

is a higher percentage of traditional birth attendant users in rural (25.5%) than urban (12.4%)

areas. The rate of use of unskilled traditional providers for delivery care varies significantly by

2
region and State, ranging from 0.5% to 71.8%. One of the biggest obstacles to lowering the high

rate of maternal death in

the country at the moment is the high prevalence of usage of conventional, unskilled caregivers

(National Population Commission (Nigeria) and ICF International2019).

When the widespread use of unskilled traditional birth attendants (TBAs) was initially noted in

the 1990s, it was thought to be a socio-cultural phenomenon under the assumption that women

traditionally favored traditional births to orthodox deliveries. This approach sparked a variety of

measures, including the training and retraining of TBAs, with the goal of enhancing their

abilities to manage straightforward deliveries and referring more challenging ones to

conventional healthcare institutions (Olapade-Olaopa et al. 2019).

Women gave birth in their homes for the majority of recorded history, frequently with the help of

a family member or a neighboring woman who had expertise helping with labor. Before the

emergence of trained nurses, midwives, and doctors, as well as structured systems of medical

care, these community women often referred to as traditional birth attendants (TBAs)provided

the majority of the delivery care around the world. Currently, TBAs typically lack professional

training and are not accepted as medical practitioners by the relevant authorities. In 2016, an

estimated 22% of pregnant women worldwide gave birth with a TBA outside the traditional

healthcare system, despite the fact that the percentage of women giving birth in this manner has

increased in recent years. In some regions, more than half of all women still receive prenatal care

and deliver with TBAs (Ariyo et al., 2019; Azuh 2019; Bishai et al. 2019; Lanre-Abass 2018;

Ntoimo et al. 2019).

3
The usage of early postnatal care varies significantly between delivery sites in Nigeria. For

instance, less than 2 in 10 moms who give birth outside of a facility receive expert postnatal care

within two days of delivery, compared to 8 in 10 mothers who deliver in facilities. Similar to

this, a newborn born in a facility is four times more likely to receive postnatal care within two

days after birth than a newborn born elsewhere. Engaging traditional birth attendants (TBAs) in

advocacy for early postnatal care use may boost the use of skilled care by mothers and newborns

after non-facility deliveries in Nigeria, where one in three non-facility deliveries is assisted by a

TBA and the advice of the TBA is frequently followed by their clients(Ikeora, 2019).

A TBA is a community-based, non-officially trained provider of maternity care. TBAs compete

with qualified health professionals for patients, mainly during pregnancy and labor. If a TBA

refers a patient to a skilled health professional, there is a reputational risk and a chance that the

patient may not return for subsequent pregnancies. However, qualitative study shows that

Nigerian moms frequently understand the importance of their children receiving early postnatal

care, particularly for recommended vaccines, even when they do not receive postnatal care

themselves(Oni et al., 2020).

1.2 Statement of the Problem

The use of traditional birth attendants (TBAs) is a common practice in many parts of Nigeria and

other African countries, as well as globally. While there are some benefits to using TBAs, such

as cultural familiarity and the use of traditional remedies, there are also some serious concerns

(Aderigibe&okolo 2019). First, TBAs are often not trained or certified to provide healthcare

4
services, and may lack the knowledge and skills to safely deliver babies or provide other

essential healthcare services (Onah, 2019).

Second, the use of traditional remedies can sometimes lead to harmful outcomes, such as the

transmission of disease or the use of unsafe or ineffective treatments (Onah, 2019).

According to studies by Abiona et al. (2019) and Brown et al. (2019), in Nigeria, only 1 in 5

women who use the services of a traditional birth attendant receives adequate care, and nearly

half of all women who give birth with the assistance of a TBA experience some form of obstetric

complication. In addition, studies by Martinez et al. (2018) and Umeh et al. (2019) have shown

that the use of traditional birth attendants is associated with an increased risk of infant mortality,

as well as higher rates of infection and complications for both the mother and child.

In addition to the lack of training and supplies, traditional birth attendants often lack the

necessary information and education to provide women with accurate and comprehensive

information about their health. Studies by Bányasz (2019) and Perez-Escamilla (2019) have

shown that many traditional birth attendants do not provide information about the importance of

prenatal care or the risks associated with pregnancy and childbirth. Furthermore, many

traditional birth attendants may not be able to provide accurate information about modern

contraception or family planning, which can lead to unintended pregnancies and increased rates

of maternal and infant mortality. As a result of the understanding that some pregnant women

have several issues during delivery from traditional birth attendants due to some of the traditional

birth attendants' lack of training, the topic became an area of interest to the reserach. Similar to

this, it is also assumed that a sizable portion of pregnant women tend to be unaware of the
5
implications or issues that may arise or happen to them from complications that may arise during

delivery and the necessary attention and care that will be required to prevent these complications

from becoming life-long issues or resulting in their death.

It is also important to consider solutions because there are a rising number of reports of pregnant

women who pass away after delivery or suffer from lifelong issues. Therefore, a study was

conducted to determine how traditional birth attendant behaviors affected the primary healthcare

system (baruwa, 2020).

The preference and choice of maternity care by pregnant women is influenced by factors such as

cultural beliefs, long distance to the nearest health facilities, disrespectful and abusive maternity

care and friendliness of TBAs (Adatara et al. 2018; Fantaye, Gunawardena & Yaya 2019; Gurara

et al. 2019; Mulenga et al. 2018).

Research demonstrates that encouraging TBAs with financial incentives can boost the use of

early postnatal care among their clients, who have a higher risk of maternal and newborn

mortality and neonatal problems as a result of being exposed to inexperienced delivery

attendants. Pre-eclampsia, main postpartum hemorrhage, protracted obstructed labor, maternal

infection, and antepartum hemorrhage are the most frequent obstetric causes of maternal

mortality in Nigeria (Batun et al., 2018).

The most frequent patient-level causes of maternal mortality include the use of non-traditional

birth attendants (TBAs), alternative birth attendants, non-usage of prenatal care, non-acceptance

of advised therapy, and delayed presentation to medical institutions(Mulenga et al. 2018)

6
Only 43% of women in Nigeria give birth with a skilled birth attendant (SBA), compared to 58%

in all of sub-Saharan Africa and 80% worldwide, and despite data showing that doing so lowers

the risk of multiple myeloma (MM). It's interesting to note that in Nigeria, 64% more SBAs are

used for prenatal care compared to 43% for birthing. Negative experiences, such as unhappiness

with healthcare services, could be the cause of this variation and healthcare professionals'

negative views, as well as lack of transportation, hospital cost, preference for alternative methods

such as TBAs, or cultural and/or spiritual reasons. Unlike SBAs who are accredited healthcare

professionals, WHO defines a TBA as a person who assists a mother during childbirth and who

initially acquired her skills by delivering babies herself or through apprenticeship to other

traditional birth attendants'(Taiwo et al., 2019).

The perceived benefits of TBA usage is their accessibility, especially in rural areas; affordability,

ties to the community and attentiveness to the cultural needs of women during labour. By

contrast, the disadvantage of usage of TBAs is that they lack the training to identify and manage

complications such as postpartum haemorrhage or birth asphyxia, resulting in the probability of a

delay in care when women need to be transferred to healthcare facilities during obstetric

emergencies facilities for medical care during obstetric crises (Gurara et al. 2019)

Women in sub-Saharan Africa still employ TBAs during childbirth for a variety of reasons

despite the drawbacks of doing so. The use of TBAs rather than SBAs was reported by rural

women in Ghana to be affected by poor provider-client relations and cultural insensitivity in

healthcare facilities. According to a study done in Tanzania, home births are more common since

7
neither men nor women link them with a higher chance of unfavorable outcomes and

complications (Ddo et al 2023; Acquah & nyrako, 2023).

(Adisa et al 2020) noted that the increasing number of maternal and child deaths in Oyo State,

Nigeria, was a cause for concern. He further noted that traditional birth attendants played a

significant role in the provision of maternal and child health care, but their knowledge and skills

were often inadequate.

1.3 Objectives of the Study

The general objective of the study is to assess and analyze the role and influence of traditional

birth attendants (TBAs) in the context of primary health care. This research aims to achieve

several specific objectives:

1. To assess the roles to which TBAs contribute to maternal and child health outcomes,

especially in regions where they are commonly utilized in oyo town.

2. To determine the factors affecting the safety of TBA practices in delivering babies and

providing care during childbirth.

3. To identify the complications encountered by pregnant women that visits traditional birth

attendants.

4. To identify the major reasons why women choose to utilize the services of traditional

birth attendants than skilled birth attendants.

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1.4 Research Questions

1. What are the roles of these traditional birth attendants in the community?

2. What are the factors affecting the safety of TBA practices in delivering babies and providing

care during childbirth?

3. What forms of complications do pregnant women encounter from indicting traditional birth

attendants?

4. What are the most common reasons for choosing TBA (traditional birth attendant) services

over a healthcare facility?

1.5 Research Hypotheses

1. There is no significant relationship between access to healthcare services and use of

traditional birth attendants.

2. There is no significant relationships between socio-demographic variables and use of

traditional birth attendants.

1.6 Significance of Study

The significance of the study can be quite broad. By better understanding why women choose to

use or not use TBAs, this will develop interventions to improve the quality of care they receive,

both from TBAs and from healthcare facilities.

● To The Mother/individual: The study could provide valuable information about the

quality of care provided by traditional birth attendants and how it compares to the quality
9
 of care provided by other types of healthcare providers. Additionally, the study could

provide insight into the factors that influence a mother's decision to seek care from a

traditional birth attendant. And also this study could also be used to develop interventions

to improve maternal and child health outcomes in Nigeria. For example, the findings

could be used to develop programs to promote the use of skilled birth attendants, such as

midwives or doctors, instead of traditional birth attendants.

● To The Society: This study like this could also have significant implications for the

Nigerian society as a whole. It could help to raise awareness of the importance of access

to quality healthcare, particularly for mothers and children and also it could help to

improve the understanding of the role of traditional birth attendants in the Nigerian

healthcare system.

● To The Profession: This could also have important implications for the nursing

profession in Nigeria. First, it could help to highlight the need for more trained and

qualified nurses to work in rural and underserved areas. This study could help to raise

awareness of the importance of providing quality care to mothers and children, which is a

key aspect of the nursing profession. Finally, it could provide valuable insight into the

training and education needed to prepare nurses to work in rural and underserved areas,

where access to quality healthcare is often limited.

1.7 Scope of the Study

The scope of the study assessed the perceived impact of traditional birth attendants services

Hence, my target group only focused on women in two selected primary health care
10
centres(aafin primary health care and oke-oola primary care center) in Oyo town in order to have

a sizeable and adequate size of a sample.

1.8 Definition of Terms

Traditional Birth Attendant (Tba): A traditional birth attendant (TBA), also known as a

traditional midwife, community midwife or lay midwife, is a pregnancy and childbirth care

provider suited in Oyo town

Primary Health Care System: Primary healthcare (PHC) refers to "essential health care" that

is based on "scientifically sound and socially acceptable methods and technology, which make

universal health care accessible to all individuals and families in a community in Oyo town.

Child mortality: The probability of child dying between the first and fifth birthday.

Skilled Birth Attendants (SBAs); A skilled birth attendants are professional and skilled

providers licensed to practice and care for women in labour.

Maternal Morbidity; The condition in which women suffers from a disease or medical

condition.

Impact: It could be defined as the effect that traditional birth attendants have on the health and

well-being of mothers in the community.

Traditional health attendant services: Traditional health attendant services can be defined as

the assistance provided to pregnant women and new mothers by non-medically trained

individuals who may provide care based on their own knowledge, experience, or traditional

beliefs.

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 CHAPTER TWO

LITERATURE REVIEW

INTRODUCTION

The conceptual, theoretical, and empirical discourse that underpins the study will be outlined in

this chapter. This chapter describes traditional birth attendants in depth, gives descriptions of

them, and illustrates how their use affects pregnant women, both positively and negatively,

depending on the practices' effects..

2.1 CONCEPTUAL REVIEW

12
Given that the majority of women who use maternal health services are healthy and that

pregnancy is an often uneventful physiological process, it becomes sense to assume that, given

even the tiniest restrictions, maternal health services would be underutilized (Abdulkareem,

2018). Maternal health care's primary goal is to guarantee healthy pregnancies, normal

deliveries, healthy offspring, and ongoing good health for nursing and pregnant moms. For more

than a century, it has been recognized as a public health issue when a woman dies while she is

pregnant or going through puerperium (Eke & Ossai, 2021).Unfortunately, few underdeveloped

nations, including Nigeria, use professional birth attendants and antenatal care.According to the

Nigerian Demographic and Health Survey, 43% of births in Nigeria were attended by trained

birth attendants, whereas 57% of expectant women made four or more prenatal care

appointments (Abdulkareem, 2018). It is crucial to remember that all international initiatives to

lower maternal morbidity and mortality, such as the Safe Motherhood Initiative, Millennium

Development Goals, and current Sustainable Development Goals (SDG), have emphasized the

importance of making good use of antenatal and delivery services. Maternal and child health in

Sub-Saharan Africa still needs to be addressed despite the implementation of the Sustainable

Development Goals (SGDs) for 20162030 ( Simiat Bidemi,2022).

One of the cornerstones of safe parenthood is giving birth in the company of a qualified birth

attendant. However, the topic of birthplace and what constitutes a suitable birth attendant is one

that is frequently debated in the literature. The debate over women's choice to give birth at home

is more prevalent in many high-income countries. In contrast, the focus is on how to encourage

facility-based delivery in low-income countries, with a larger focus on criticizing the continued
13
use of traditional birth attendants (TBAs). The formal and informal healthcare systems coexist in

Nigeria, as they do in many low-income nations, with little to no interaction between the service

providers. In the past, women gave birth in the community under the watchful eyes of other

women, informal maternity care providers known as TBAs, indigenous/local, or lay midwives,

and other women. A labor and delivery assistant (TBA) is described by the World Health

Organization (WHO) as "a person who assists the mother during childbirth and who initially

acquired her skills by delivering babies herself or through apprenticeship to other TBAs." Native

American midwives fall into three categories: those with no formal schooling or training, those

who learned by watching other TBAs, and those who developed their skills in a structured

healthcare environment without any theoretical substance.

Simply said, the majority of TBAs receive their education in the form of an apprenticeship. As a

result, the name TBA does not adequately describe the various categories of indigenous

midwives and the subtleties of their practices (Murphy-Lawless 2020).Because of this, TBAs'

techniques have been unfairly characterized as being the same across the board and they are not

included in the definition of trained birth attendants. As a result, there has been a noticeable shift

in public opinion on the acceptability of TBAs over the past 20 years, with the majority now

supporting their formalization through training and certification.

The TBAs in Nigeria, unlike the professional midwives, have no official (Western-style)

training. They do not have official government approved certificates. The majority of them have

private practices independent of the government approved healthcare facilities, which are

commonly referred to as maternity homes. Given that there is no regulatory body for TBAs,
14
statistics are lacking in relation to the exact number of TBAs practicing in the country. What is

known is that they offer varied reproductive services including infertility, antenatal, intranatal

and postnatal care as well as treatment of threatened miscarriage (Magdalena Ohaja,et.al 2020).

It is also well documented that a significant proportion of maternity care in rural parts of Nigeria

is still provided by TBAs. It is important to note that the maternity homes owned and run by the

TBAs are located within the communities they are living in and where they are well known and

respected, Hence they remain the most accessible and affordable maternity care providers for

many women in Nigeria, as in other low-income countries. Their popularity is largely influenced

by the cordial and trustful relationship that exist between them and the women in their

communities. That said, the persistent use of TBAs by women and the effectiveness of TBAs

practices have been the subject of continuous debate in the literature.

Most often than not, the TBAs are blamed for the high rates of maternal deaths in many low-

income countries. Interestingly, conflict exists among formal healthcare providers about the

place of TBAs within formal healthcare settings. Those who oppose the practice of TBAs

consider them as outdated, unhygienic and dangerous, and illegal practitioners who obstruct the

efforts made by policy makers to improve maternal health outcomes (Margaret Dunlea,et.Al

2020). In 2011, two Nigerians went head to head in on this issue in the British Medical Journal,

Harrison, a retired obstetrician and gynaecologist asserts that TBAs are doing more harm than

good and therefore they should be outlawed. Ana, a former Commissioner for Health in one of

the Nigerian states made a case in favour of TBAs particularly in rural areas where access to

formally train healthcare providers is severely limited. The WHO acknowledged that training
15
mid-level and lay healthcare providers (and by extension TBAs) so that they are enabled to

perform certain interventions otherwise reserved for healthcare workers with longer training may

improve access to care. This, they referred to as task shifting and the effect of which is

dependent on local health realities often shaped by socio-cultural and political structures.

Leaders and policy makers of low-income countries have been under pressure to eradicate

cultural and traditional pregnancy and birthing practices by TBAs irrespective of their category,

skills and contributions particularly in the rural areas, despite the almost impossible means of

access to formal healthcare. The decision to withdraw support for TBA training and reallocate it

to the promotion of skilled attendants training was made some time ago on the evidence that the

worldwide maternal mortality rate (MMR) were not falling. Most importantly, by focusing on

the birth attendants capacity to respond to obstetric emergencies, policy makers, in an often

reductionist understanding of the complexity of local contexts, came to ignore other skills and

expertise of the TBAs the humane aspect of care.

Even though conventional thinking and policy remain strongly in favour of hospital-based care

for pregnant and birthing women, qualitative evidence of Nigerian midwives views of TBAs

pregnancy and birthing practices are limited. This paper offers a series of insights on this subject.

It contributes to our understanding of how conventional health professionals assess TBAs using

an often limited medical framework which primarily serves to sustain the negative representation

of the practices of the latter group (Magdalena Ohaja,et.Al 2020).

2.1.1 Definition Of Traditional Birth Attendants

16
The World Health Organization's proposed definition of traditional birth attendants will be used

in this research work:

The traditional birth attendant (TBA) is described as "a person (typically a woman) who assists

the mother at childbirth and who initially acquired her skills delivering babies by herself or by

working with other traditional birth attendants."

Also a family TBA is a person or an individual who has been designated by an extended family

to attend to birth deliveries in that particular family. A trained TBA is a person or individual who

has received a short course of training through the modern health care sector to upgrade her skill.

The period of actual training is normally not more than one month, although this may be spread

over a longer time.

According to evidence from different countries, it appears that this definition of the TBA is

rather limited in that, in many cases, the TBA's work includes not only her attendance at

childbirth but also the provision of basic care to women throughout the normal maternity cycle,

the provision of care to the normal newborn, participation in the promotion of modern methods

of family planning, and participation in other primary health-care activities, including the

identification. Such referral is being increasingly assumed by TBAs in many countries. The

TBA, who is also known by other names, e.g., indigenous midwife, empirical midwife,

traditional midwife, hilot, dunkun, and dai, is a familiar figure in almost every village and in

many urban areas of Africa, Asia, and Latin America. It is estimated that, in the developing

world, between 60% and 80% of all births are attended by TBAs. In many countries there has

17
been a laissez faire attitude towards TBAs, i.e., no attempt has been made to encourage,

discourage, modify, or improve their practice.

In a few countries the TBA's practice has been legally authorized under certain conditions.

In yet others it is, at best, being tolerated until such time as the country can afford to maintain a

sufficient number of professionally trained health workers to serve currently deprived

populations.

This may be an appropriate place to note that, in a number of developing countries, e.g., India

and the Philippines, the problem is not so much the inability to train sufficient numbers of

professional health workers, such as physicians and nurses, but the inability of the government to

employ them productively in the health services.

In the private sector, the purchasing power of large segments of the population is so low that they

cannot afford, either directly or through social insurance schemes, the services of professional

personnel whose education and, hence, utilization are costly. Moreover, most such health

workers, once exposed through their training to the sophisticated technology and facilities of the

teaching hospital, have little desire to work in less glamorous setting or to deal with the ordinary

health problems afflicting the masses.

The result is an excessive concentration of professional health workers in large cities and the

emigration of those whom the cities cannot absorb. In either case, the vast majority of the people,

particularly in rural areas, are deprived of even the basic elements of health care.

2.1.2 TYPES OF TRADITIONAL BIRTH ATTENDANTS

Most studies have categorized TBAs into three main categories.

18
 ● A Full Time Employee TBA

A full-time employee TBA is a person/woman who is available at any moment and wants

payment in kind or cash.

● A Neighbor Or A Close-relative TBA

There is the TBA, an old relative or neighbor of the lady who does not get payment for their

services and will only help with the birth if the mother is a related, a daughter or daughter-in-

law, or a close neighbor's or friend's daughter. This TBA offers their assistance in the delivery as

a courtesy and is not expecting payment, however they might get anything as a thank-you present

● The Family Birth Attendant

The family birth attendant is the last option, who only delivers children of close friends.

Every community has the role of the TBA often reflects the culture and the social organization.

2.1.3 ROLES ASSOCIATED WITH TRADITIONAL BIRTH ATTENDANTS.

In developing nations, where 99% of maternal deaths occur, half of them occur in sub-Saharan

Africa, according to a 2019 report by the World Health Organization (WHO). According to the

WHO, an effective strategy to lower the rate of maternal mortality worldwide must increase the

number of people who are educated and trained to assist and care for the mother during

pregnancy, delivery, and the postnatal period.

In underdeveloped nations, the incorporation of traditional birth attendants (TBAs) into the

national healthcare system is very beneficial for the provision of maternal and pediatric

healthcare.

19
Utilizing a traditional birth attendant has the benefit of having a connection to the communities

they serve. Even though these women lack training and education in the formal health care

system's requirements, they have already built trustworthy relationships with women who require

birth attendants (Alemnew, 2022). Additionally, traditional birth attendants are able to

circumvent logistical issues faced by skilled birth attendants, such as a lack of travel or

transportation, the cost of transportation services, and difficult geographic areas (Aychew Kassie

et al., 2022). In rural parts of Africa, 60% to 90% of pregnant women use TBAs during

childbirth (Mastewal et.al, 2022). If these TBAs could be trained, the formal health care system

would not need to exert resources in these areas (Desalegn et.al, 2022). Moreover, their close

relationship with the community they live in plays an important role in bridging communities

and health care systems (Zerihun et al., 2020).

Evidence has shown the effectiveness of interventions such as training and support of TBAs in

improving maternal and newborn health outcomes while reducing perinatal, neonatal, and

maternal mortality (Desalegn et al., 2022) . Other studies have also shown that the integration of

TBAs with the health care system has increased the skilled birth attendance rate (Alemnew Wale

et.al., 2022). However, negative attitude towards TBAs, financial issue for TBAs, long distance

to health facilities, transportation problems, and delay in seeking care by women were some of

the barriers for integration with the health care system (Aychew Kassie et al., 2022). Studies

have shown that people often prefer TBA to a trained midwife, especially when the midwife is a

young, unmarried girl without children (Desalegn et al., 2022).

WHAT ARE THEIR ROLES?

20
1. TBAs not only provide technical assistance but also attend to and support the mother

during the entire childbirth process and thereafter. The work of TBAs is adapted and

strictly bound by the social and cultural matrix, and their practice and belives are linked

to the community they live. Studies have looked at the function of TBAs in maternal

health, particularly childbirth in certain African nations. 45% of women in post-war

Sierra Leone underwent delivery with the help of TBAs, with up to 77% of women in

some rural regions giving birth at home without a qualified attendant, according to a

national survey conducted in 2008.

2. TBAs perform some primary roles and also perform additional duties like giving advice

on family planning, nutritional needs, recommendations, screening high-risk mothers,

fertility/infertility treatment, and identifying diseases or abnormalities relating to

reproductive organs and reproduction in western Nigeria (Olawale et al., 2021).

3. TBAs provides care for childbearing mothers during pregnancy, labor, and post-natal

periods, as well as infants in health and disease/sickness; recruitment of new acceptors

into TBA practice; counselling responsibilities; and preservation and conservation of

herbal plants and their derivatives, according to evidence. Their acts are driven primarily

by a desire to assist the ladies in their neighborhood. While there has been a push in

recent decades to promote facility delivery and skilled attendance at birth, particularly in

light of the United Nations millennium development goals (MDGs) and sustainable

development goals (SDGs), the role of TBAs in maternal health has received little

attention(Boluwade et al., 2021).

21
The elimination of user fees for maternal health services at healthcare facilities and the ban on

TBA deliveries in some nations have only made matters worse. The degree of interaction

between the formal health system and TBAs differs in nations where it is illegal for TBAs to

perform births. While some nations have given TBAs diverse roles within their communities and

integrated them into the local health system, others have had little to no contact with TBAs at all,

with some TBAs engaging in covert childbirth-related activities. This might be the case,

particularly in areas devastated by war and where access to regular, high-quality healthcare is

difficult (Maryawati and Naylor, 2021).

4. Also Ogunsiji and Nettleman (2020) identified a number of roles performed by TBAs in

Nigeria, including:

● Assisting with labor and delivery.

● Promoting maternal and child health through health education.

● Administering herbal medicine and traditional remedies.

● Providing antenatal care.

● Offering spiritual and cultural support.

It's important to note that the roles of TBAs can vary depending on the community and

individual, and they may not all be approved or recommended by the government or health

authorities.

2.1.4 FACTORS IMPACTING THE PATRONAGE OF TRADITIONAL BIRTH

ATTENDANTS (TBAS) AMONG WOMEN.

22
There has been a slight improvement in maternal mortality since the early 2000s, when it had

decreased by about 38%, although it is still considered to be high. However, it is estimated that

810 women died from preventable causes every day in 2017, and 94% of all recorded deaths take

place in low- and middle-income nations. (According to Piane GM, who was mentioned by

Christianah Olanrewaju, 2020), Sub-Saharan Africa is responsible for 196,000 of the 295,000

maternal deaths that have been reported worldwide. (According to Sageer R & Kongnyuy E cited

by Sodimu Jeminat Omotade et al.,2020), maternal mortality in Nigeria was 814 per 100000 live

births in 2015, making it the second-largest contributor to maternal death in the world.

There are direct and indirect causes of maternal mortality that are preventable if skilled birth

attendants are patronize prenatal, intra-natal and post-natal as complications that could lead to

death will be identified early and prompt action taken if skilled birth attendants are used. But,

most women today still patronize traditional birth attendant (TBA) despite the proclaimed

dangers of doing so.

Globally

Globally, more than 60% of deliveries takes place outside health facilities and are taken by

Traditional Birth Attendants. In Sub-saharan Africa only 56% deliveries takes place in presence

of Skilled Birth Attendants.(Abubakar,2019). A study by Dar-Odeh et al. (2022) found out that

women in low- and middle-income countries often turn to TBAs due to cultural beliefs and

norms that favor traditional practices over modern healthcare.

The African Region

23
In Africa where culture is intricately interwoven with so many aspects of the peoples lives, it is

no wonder that their culture influence their choice of delivery place. As such, traditional birth

attendants (TBAs) in any African country and undoubtedly, Nigeria, receive a remarkable level

of patronage from pregnant women (Adetunmise, et al., 2020). The World Health Organization

defines a traditional birth attendant (TBA) as a person who assists the mother during childbirth

and who initially acquired her skills by delivering babies herself or through an apprenticeship to

others TBAs.

Hawong et al. (2019) looked at the cultural and socioeconomic factors that influence the use of

TBAs among women in Cameroon. The study found that many women in Cameroon see TBAs

as a safer and more affordable option than modern healthcare, due to cultural beliefs and the high

cost of modern healthcare services.

The study by Becker et al. (2019) looked at the use of traditional birth attendants among women

in rural Kenya. The study found that a lack of formal education, poverty, and limited access to

modern healthcare were all significant factors in the decision to use a TBA. In addition, cultural

beliefs and norms around childbirth and the role of TBAs in the community were also found to

be important factors. For example, some women in Kenya believe that a TBA can protect them

from "evil spirits" during childbirth, which may influence their decision to use a TBA.

Today, TBAs remain an important provider of maternity care in developing countries and most

importantly, Nigeria (According to Ebuehi cited by Ajibade et.al, 2020). Traditional Birth

Attendants (TBAs) plays different roles ranging from giving antenatal, intra-natal and post-natal

care (Adatara et.al, 2020).

24
Nigeria

A number of factors that impact the patronage of traditional birth attendants (TBAs) among

Nigerian women has been identified (Umeh et al. 2019). These factors include:

● Level of education

● Marital status

● Number of children

● Religious affiliation

● Cost of delivery

● Perceived quality of care.

It is important to understand these factors in order to develop interventions that will encourage

the use of modern, safer forms of birth delivery in Nigeria. In addition to the factors listed above,

Umeh et al. (2019) also identified some other potential factors that may impact the use of

traditional birth attendants in Nigeria. For example, the authors noted that "Urban and rural

residence of women, birth order, and place of delivery were also factors determining the use of

TBAs." (Umeh et al., 2019). These additional factors are important to consider when developing

policies and interventions aimed at reducing the use of traditional birth attendants and improving

access to safer, modern forms of delivery.

(Ogunsiji and Nettleman, 2020) found that the level of education and income are important

factors in a woman's decision to use a TBA. Specifically, women with lower levels of education

and income are more likely to use a TBA. This is significant because it suggests that

25
interventions to improve maternal and child health should consider the socioeconomic factors

that influence women's decisions about healthcare.

Oyo state

Women's use of traditional birth attendants was influenced by a combination of factors,

including cultural beliefs, religious beliefs, poverty, and lack of access to modern healthcare

(Aremu et al. 2019). The study found that many women in Oyo State believe that traditional

birth attendants are safer and more affordable than modern healthcare providers, and that using a

TBA is a way to preserve their cultural and religious traditions.

One of the most significant findings of the study by Aremu et al. (2019) was that the patronage

of traditional birth attendants in Oyo State is closely linked to the lack of access to modern

healthcare services. The study found that many women in Oyo State do not have access to

formal healthcare services due to poverty, distance from healthcare facilities, and lack of

transportation. This lack of access means that many women are left with no other choice but to

use a traditional birth attendant, even if they have reservations about the safety and effectiveness

of this option.

2.1.5 REASONS WHY MOST WOMEN PREFER THE UTILISATION OF

TRADITIONAL BIRTH ATTENDANTS THAN SKILLED BIRTH ATTENDANTS.

According to the National Population Commission (NPC) (Nigeria) and ICF 2019, there is a

higher percentage of traditional birth attendant users in rural (25.5%) than urban (12.4%) areas.
26
The rate of use of unskilled traditional providers for delivery care varies significantly by region

and State, ranging from 0.5% to 71.8%. One of the most significant obstacles that must be

addressed to lower the nation's high rate of maternal death at the moment is this high degree of

reliance on conventional, inexperienced caregivers.

When the widespread use of unskilled traditional birth attendants (TBAs) was initially noted in

the 1990s, it was thought to be a socio-cultural phenomenon under the assumption that women

traditionally favored traditional births to orthodox deliveries (Lorretta Favour 2022).

This approach sparked a variety of measures, including the training and retraining of TBAs, with

the goal of enhancing their abilities to manage straightforward deliveries and referring more

challenging ones to conventional healthcare institutions according to fawole cited by (Chizomam

Ntoimo, 2022).

Maternal mortality is still high in nations that use TBAs, notwithstanding their retraining. Indeed,

numerous papers from various regions of Nigeria noted the connection between high maternal

mortality rates and women who wanted to give birth with TBAs but were referred to medical

facilities too late according to Harrison cited by (Friday Ehbodaghe Okonofua, 2022). It didn't

take long for the WHO to proclaim that TBA retraining programs were useless at lowering

maternal mortality in poor nations due to how inept they had become in retraining TBAs

(Chioma Ekwo, 2022).

2.1.5.1 WHAT ARE THESE REASONS WHY WOMEN TEND TO UTILIZE THE

SERVICES OF TRADITIONAL BIRTH ATTENDANTS?

1. Lack of Complete Confidence In Orthodox Medicine.

27
Studies have showed that the majority of the locals in rural areas rely on both conventional and

alternative treatment. The majority of them do not think that modern medicine is adequate to

address all maternal health care difficulties. Pregnant women frequently registered for both

hospital and TBA care.

In fact, some of the men and the elderly blamed maternal death on the use of solely

contemporary treatment (Chizomam Ntoimo, 2022). The majority of people argued that

traditional medicine is just as effective as modern methods of treatment and strongly believed in

their efficacy (Brian Igboin, 2022).

2. The Paradox of Healthcare Providers Who Use Traditional Drugs.

Some maternal health care practitioners have been observed by people who employ traditional

birth attendants to prescribe and use traditional medicine. They are encouraged to take it because

data shows that conventional medications are as helpful in providing for expectant mothers

(Wilson Imongan, 2022).

3. Where There Is No Health Facility.

In areas without a nearby medical institution, using TBAs for maternity care is the typical

choice. They turn to TBAs due to poor road and transit infrastructure in addition to the distance

to the medical facilities. The majority of individuals do assert that when they make the effort to

travel a long distance to a hospital, they must endure a lengthy wait to see a provider and

occasionally there are no drugs accessible. However, with the TBA, they do not have to wait and

the drugs are instantly available.

4. Poverty.
28
A common reason why women used TBAs, in addition to being far from a clinic, was price.

Most people stated that a significant barrier to the usage of TBAs in their areas is a lack of

funding. Finances for transportation and the medical cost limit those who could have tried to

travel a significant distance to a health institution (Sanni Yaya, 2022).

5. Mode of Payment.

Because of their flexible and reasonable payment options, TBAs are also used for prenatal care.

The TBAs accept payment in kind and in installments, and when the whole amount is paid, all

services are covered. They occasionally don't impose any set fees for their services. The expense

of maternity care with a TBA actually poses no financial stress to the users, making it a viable

choice in especially for the poor, according to the narratives in the group discussions and

community debates.

6. TBAs Are Friendly And Competent.

Utilization of TBA services is mostly due to its welcoming approach to customers. The TBAs are

willing and ready to deliver women in their houses at any time.

7. When Health Providers Are Unavailable/inadequate.

TBAs are the practical choice when providers in the local health facilities are unavailable or

insufficient. In the study communities, the majority of PHCs have just one nurse or midwife,

while some have none at all. Many PHCs also lack on-site housing for staff.

8. Negative Perception of the Community about Traditional Birth Attendants.

29
Some women listed a few drawbacks of using TBAs during giving birth, including some

traditional customs, a lack of infection control measures that exposed them to infection, and the

absence of some services including newborn weight measurements (Joyce Cheptum, 2019).

2.1.5 THE COMPLICATIONS OF UTILISING UNKSILLED TRADITIONAL BIRTH

ATTENDANTS SERVICES.

Globally, about 810 women die every day due to pregnancy and its related complications.

Although the death of women during pregnancy or childbirth has declined from 342 deaths to

211 deaths per 100,000 livebirths between 2000 and 2017, maternal mortality is still higher

particularly in sub-Saharan Africa and South Asia, where 86% of all deaths occur. The lifetime

risk of obstetric causes of maternal deaths in developing countries is 33 times higher than deaths

in developed countries(Vincent Bio Bediako,2021).

In rural and remote areas of Nigeria, reducing the burden of maternal morbidity and mortality

and improving birthing experiences of women would require increased access to skilled birth

attendants (Felix Akpojene Ogbo, 2020). This is important, as there is often a lack of skilled

health practitioners in those settings according to (Felicity & jokhio 2020), which may make

women seek alternative health care, including assistance from unskilled birth attendants.

However, the use of unskilled birth attendants (TBAs, relatives, or friends) can lead to

considerable morbidity and disability, and even death of both the mother and baby.

These adverse outcomes can occur because unskilled birth attendants usually lack the required

knowledge and skills to risk-stratify or manage common pregnancy or childbirth complications,

such as hemorrhage, eclampsia, and obstructed labor (WHO. UNFPA. UNICEF 2019).
30
Tamiru and Dabalew (2018) found that women who gave birth with unskilled birth attendants

had significantly increased odds of experiencing severe birth-related complications, such as pre-

eclampsia, postpartum hemorrhage, obstetric fistula, and birth injuries.

Tamiru and Dabalew (2018) noted previous studies have found that some cases of birth-related

complications were caused by unskilled birth attendants' failure to detect obstetric complications

during labor and delivery or their failure to provide appropriate management when complications

occur. Unskilled birth attendants were unable to identify and manage complications such as

prolonged labor, prolonged second stage of labor, shoulder dystocia, prolonged obstructed labor,

uterine rupture, eclampsia, postpartum hemorrhage, perineal tears, retained placenta, and

ruptured uterus (Tamiru and Dabalew, 2018). They further noted that some women with

complications had to travel to health facilities, and some developed sepsis and died. Van

Ginneken et al. (2020) argued that "in addition to promoting skilled birth attendance, policies to

encourage appropriate care-seeking behaviors should focus on improving the quality of the

health services that are available to women, and he specifically recommended strengthening the

role of traditional birth attendants to serve as a bridge to the health system, by ensuring referral

to skilled care when complications arise, through routine training and supervision. Van Ginneken

et al. (2020) noted that while further research on ways to improve the content and quality of

current interventions would be useful, the data show that in many settings it is feasible to work

with traditional birth attendants, and that health authorities can have a real impact in improving

birth outcomes. However, they also cautioned that it is important that interventions are

31
developed in a culturally sensitive manner that will ultimately benefit the mothers and their

babies.

2.2 EMPIRICAL FRAMEWORK

2.2.1 Assessing The Roles To Which Tbas Contribute To Maternal And Child Health

Outcomes, Especially In Regions Where They Are Commonly Utilized.

It is difficult to give an exact prevalence estimate of the roles to which traditional birth attendants

(TBAs) contribute to maternal and child health outcomes, as there is a lack of reliable data on

this issue. However, some studies have attempted to estimate the prevalence of TBA use and its

impact on maternal and child health outcomes. For example, a study in rural communities of

Akwa Ibom State, Nigeria, found that TBAs attended approximately one-third of deliveries in

the study area, and that the use of TBAs was associated with an increased risk of maternal and

neonatal mortality (Bassey et al., 2020).

Dr. Faith. T. Ezenwaka and colleagues (2019) discussed the prevalence of TBA use and its

impact on maternal and child health in their article "The role of traditional birth attendants in a

rural community in Nigeria: Their influence on maternal and child health." They found that

TBA use was relatively common in the community they studied, with over half of the women in

the study reporting having used a TBA for at least one of their births. They also found that the

use of TBAs was associated with a number of negative health outcomes, including neonatal

mortality and postpartum depression.

In the study by Dr. Ezenwaka and colleagues (2019), the percentage of women who used a TBA

for at least one of their births was 54.2%. It is important to note that this percentage is specific to
32
the community that was studied, and may not be representative of the country as a whole.

However, it does provide an indication of the high level of TBA use in rural communities in

Nigeria.

Studies found out that approximately 49% of women in the state of Ondo had used a TBA for

one or more of their births ( Oluyemi et al.,2020). Another recent study, by Omoniyi et al.

(2021), found that TBA use was common in rural communities in the state of Ogun, with about

two-thirds of the women surveyed reporting having used a TBA for at least one of their births.

These studies demonstrate that TBA use remains a common practice in Nigeria, especially in

rural areas. Onwubere et.al.2019 study, found that traditional birth attendants have an important

role to play in ensuring that women living with HIV receive the services they need during

pregnancy, labor, and the postpartum period (Onwubere et al., 2019). She has also examined the

factors that influence women's choice of traditional birth attendant care in rural Nigeria

(Onwubere et al., 2020).

2.2.2 Determining The Factors Affecting The Safety Of Tba Practices In Delivering Babies

And Providing Care During Childbirth.

The specific prevalence of the factors affecting the safety and effectiveness of traditional birth

attendant (TBA) practices in delivering babies and providing care during childbirth has not been

studied in depth. However, there are several studies that have investigated the risks associated

with TBA care and the challenges that are faced by TBAs in Nigeria.

A recent study by Omoniyi and Salami (2021) found that TBAs in Nigeria face a number of

challenges that impact their ability to provide safe and effective care.
33
In a 2019 study, Omoniyi and colleagues surveyed over 700 women in the Southwest region of

Nigeria about their use of traditional birth attendants (Omoniyi et al., 2019). The study found

that approximately 58% of women had used a TBA at least once, and that the majority of those

who had used a TBA were from rural areas. The study also found that the use of TBAs was

associated with several factors, including a lack of education, a lack of access to skilled birth

attendants, and a lack of transportation to health facilities.

A more recent study by Omoniyi and colleagues (2021) surveyed over 2,500 women in Ogun

State, Nigeria, about their experiences with traditional birth attendants and their knowledge of

the risks associated with TBA care. The study found that the majority of women were aware of

some of the risks associated with TBA care, but that they continued to use TBAs for a variety of

reasons, including a lack of access to skilled birth attendants and a lack of trust in the formal

healthcare system.

2.2.3 Identification On The Complications Encountered By Pregnant Women That Visits

Traditional Birth Attendants.

The most common complications associated with TBA care were related to infection and birth

trauma. They found that approximately 42% of women who had used a TBA had experienced at

least one complication, with the most common complications being prolonged labor, excessive

bleeding, pre-eclampsia and puerperal infection. In addition, the risk of complications was

higher among women who had given birth with a TBA than among women who had given birth

with a skilled birth attendant (Omoniyi &colleagues 2021).

34
A study from Pakistan found that the most common complications were related to infection,

hemorrhage, and perineal tear (Ansari et al., 2019). Another study from Zambia found that the

most common complications were related to hemorrhage, infection, and eclampsia (Nhlane et al.,

2018). Onwubere et.al 2019, found out that the prevalence of complications associated with TBA

care was relatively high, with nearly half of the women surveyed reporting at least one

complication. She also found that the most common complications were related to infection,

hemorrhage, and perineal tear. She noted that these findings highlight the need for improved

training and regulation of traditional birth attendants in Nigeria. It is estimated that between 25%

and 75% of pregnant women in Nigeria use the services of traditional birth attendants. The exact

prevalence varies depending on the region of the country, with the highest rates reported in the

North, and the lowest rates reported in the South. Some factors that influence the prevalence of

traditional birth attendant use include cultural and religious beliefs, the availability of alternative

care options, and the cost of care(Onwubere,2019).

2.2.4 Identifying The Major Reasons Why Women Choose To Utilize The Services Of

Traditional Birth Attendants Than Skilled Birth Attendants.

The 2018 Nigeria Demographic and Health Survey (NDHS) reported that 67% of women

attended antenatal care once with a SBA, and 43% were assisted during childbirth by a SBA,

whereas traditional birth attendants assisted in 20% of deliveries. However, in some of the 36

States in Nigeria, utilization of SBAs for antenatal care and childbirth exceeded 70% . In 24 of

the 36 States, between 70-97% received skilled antenatal care, and in 14 States, 70-98% received

skilled delivery care (National Population Commission (NPC) [Nigeria] and ICF 2019). The rate
35
of use of unskilled traditional providers for delivery care varies widely by region and States from

0.5% to 71.8%, and also by place of residence with a higher proportion of traditional birth

attendant users in the rural (25.5%) than urban (12.4%) areas (National Population Commission

(NPC) [Nigeria] and ICF 2019). This high rate of use of unskilled traditional providers is one of

the most important challenges that need to be overcome to reduce the currently high rate of

maternal mortality in the country.

When the observation of the unbridled use of unskilled traditional birth attendants (TBAs) was

first made in the 1990s, it was considered to be a socio-cultural phenomenon under the notion

that women culturally preferred traditional births rather than orthodox births. This consideration

led to a plethora of interventions consisting of the training and re-training of TBAs, with the idea

to improve their skills and competencies in managing uncomplicated deliveries and referring

more difficult deliveries to orthodox health facilities.

Despite the re-training of TBAs, maternal mortality remains high in countries that rely on their

use. Indeed, several publications from many parts of Nigeria reported the association of high

maternal mortality rates with women who had intended to deliver with TBAs, but who had been

referred late to health care facilities (Fawole et al. 2012; Ntoimo et al. 2019). The ineffectiveness

of the re-training of TBAs became remarkable, and it was not too long that the WHO declared

the retraining programs of TBAs as ineffective in reducing maternal mortality in developing

countries.

Presently, Nigeria has over 34,000 health posts for populations of 500 or less, primary health

clinics, and primary health centres (PHCs) located in every political/health ward the smallest
36
administrative level in Nigeria with a population of between 5000 and 10000; referral hospitals

are located in every Local Government Area (LGA), and State, with many privately-owned

health facilities where routine, basic and comprehensive emergency obstetric care services are

offered. (Federal Ministry of Health 2021; Makinde et al. 2018). However, there have been

reports of inefficient functioning of the PHCs (Asuzu 2004; Lambo 2015; Ntoimo et al. 2019),

and barriers to utilization of the health facilities that border on essential elements of right to

health availability, accessibility, acceptability, and quality of care.

Despite these barriers, there has been an increase in the number of women who use health

facilities for maternal care. In 2018, 67% of women of reproductive age received antenatal care

from a skilled provider, a 9 percentage point increase from 58% in 2008, and 43% of births were

assisted by skilled providers, an increase from 39% in 2008. However, over time, there has not

been a substantial change in the percentage of women who are assisted during delivery by

traditional birth attendants in Nigeria. The percentage increased from 19.4% in 1990 to 22% in

2013, and declined slightly to 20% in 2018 with a wide disparity between the urban and rural

places. According to Koblinsky et al. (2019) these women who are left behind from the progress

of coverage are constrained by multiple challenges arising from their individual circumstances

including illiteracy, poverty among others.

2.3 THEORETICAL FRAMEWORK.

2.3.1 THE THREE DELAY MODEL

Around 295,000 maternal deaths occurred in 2017, with the highest toll paid by Sub-Saharan

Africa and South Asia (World health Organisation, 2020). The global Maternal Mortality Ratio
37
has declined by 38% worldwide between 2000 and 2017, although disparities remain across

regions with 415 maternal deaths per 100,000 live birth in low-income countries compared to

710 maternal deaths for 100,000 live birth in Europe, Australia and New Zealand (world health

Organisation, 2019). Maternal death is often caused by obstetric complications arising during

pregnancy and childbirth through unskilled birth attendants. However it is also influenced by

indirect causes such as anemia, malaria and heart diseases (Tina Lavender, 2020). Most maternal

deaths are preventable with timely access to intrapartum care (World health Organisation, 2020).

In 1994, Thaddeus and Maine proposed the Three Delays Model (3DM) to facilitate the

identification of indirect factors that, from the onset of obstetric complications to the birth of the

baby, contribute to maternal death. The Model identifies three critical phases which can have

direct consequences on the survival of the mother and baby.

This three phases are applicable to preferred reasons why most women utilize traditional birth

attendants rather than going to the health facilities where skilled birth attendants or midwives are

available.

38
(Research Gate,2023)

Figure 2.1

These phases are;

● The First Delay; The first delay or the delay in decision to seek care, is often considered

the most important type of delay, as it is the first step in the process of accessing

healthcare. This delay can have a significant impact on the outcome of the pregnancy or

childbirth, as delays in seeking care can lead to serious health complications or even

death. Research has shown that addressing this first delay is key to improving maternal

and child health outcomes.

39
● The Second Delay; The second delay, or the delay in reaching care, is often caused by

similar factors as the first delay, such as financial constraints, geographical barriers, and

cultural and social factors. In addition, a lack of access to reliable transportation, poor

infrastructure, and a lack of information about the location of healthcare facilities can

also contribute to this delay. In some cases, the second delay can also be caused by a

lack of capacity at healthcare facilities, leading to long wait times or lack of availability

of healthcare providers.

● The Third Delay; The third delay, or the delay in receiving appropriate care, refers to

the quality of care that a woman receives once she reaches a healthcare facility. This

delay can be caused by a number of factors, including: a lack of trained healthcare

providers, especially in rural areas,a lack of essential drugs and supplies, a lack of

equipment and infrastructure, such as functioning electricity and water supply etc.

● Fourth Delay: The fourth delay, or the delay in taking action after receiving care which

is not really common, refers to the failure to follow up on healthcare recommendations or

referrals. This delay can occur for a variety of reasons, including: financial constraints,

such as the cost of follow-up care or medications, lack of transportation to follow-up

appointments, lack of information about the importance of follow-up care, lack of

support from family members or community members.

All four delays must be addressed in order to improve maternal and child health

outcomes.

40
2.3.1.1 APPLICATION OF THE THREE DELAY MODEL TO THE STUDY

2.3.1.1.1 THE FIRST DELAY

Delay in the decision to seek care

The First Delay has been associated with family and community-related factors, such as the

socio-economic status of the woman, knowledge of pregnancy danger signs and perceived

severity of illness during pregnancy, perception of the physical distance to the health facility,

potential cost of care and previous experience with the health system. This can make or change

most women perspective on going to the health care facilities and utilising traditional birth

attendants.

2.3.1.1.2 The Factors Influencing the First Delay are Organised as listed below.

● Socio-economic And Cultural Factors

The illness factor referred to the capacity of the woman to recognise the danger signs of

pregnancy and judge the severity of her condition. In this synthesis, this category has remained

important in understanding how women perceive the progress of their pregnancies and their

actions when they suspect a problem or an increase in the severity of a condition. In the 3DM it

was assumed that the woman has sole responsibility for these actions, however, included studies

demonstrated more complexity. Findings indicate that knowledge of the danger signs is often

limited [Bedwell & Wakasiaka 2020]; when some women recognise the danger signs

[Wakasiaka 2020], they will either neglect them [Valentina 2020], or fail to perceive the severity

of the complication to seek care on time from medical facilities. In a few cases this unawareness
41
was also dictated by a previous uneventful birth [Wakasiaka, 2020] taking place at home

[Bedwell, 2020]; an aspect which was not previously acknowledged. In a number of studies,

other new factors were added to explain this delay in the figure below, including poor or late

antenatal care attendance [Bedwell&Wakasiaka, 2020]; noncompliance with healthcare

providers advice [Valentina , 2020], aversion to prolonged labour ward stay , lack of birth

preparedness, and domestic violence.

● The Status Of The Woman

Thaddeus and Maine [Lavender, 2020] recognised that care-seeking decisions made by women

are influenced by access to money and freedom of movement. This review illustrates that the

decision to access care is often the prerogative of the husband [Bedwell &Wakasiaka 2020] or of

the mother-in-law according to Rodríguez Villamizar cited by [Lavender,2020] and, in their

absence, of other family members [Tina Lavender,2020]. In Haiti the absence of a male partner

to go to the health facility according to Sharma V& Leight J cited by [Bedwell, 2020] was also

named among the reasons of the First delay. These findings highlight how the decision to seek

care often seems to be largely determined by power relationships between the couple and the

extended family, in addition to financial and mobility aspects.

● Economic And Educational Status

The 3DM (Three delay models) considered economic and educational status as contributing

factors to the First Delay [Lavender, 2020] but did not assess how these two variables influence

the decision-making process. According to Thaddeus and Maine [Lavender, 2020] a better

economic status determined a higher utilisation of health services. This synthesis found that in
42
several settings the lack of financial means [Bedwell&Wakasiaka 2020] delayed families from

the decision to seek formal care.Educational status was included in the 3DM despite a limited

evidence about how the womans level of schooling influenced healthcare-seeking decisions

[Valentina 2020]. Three studies referred to education among the reasons of the First delay; the

remaining papers, included education-related details to describe the characteristics of the sample

population, but did not consider it as potential contributor for the First Delay(Bedwell &

Wakasiaka 2020).

● Distance, Transport And Cost

Perceived accessibility to the health facility could influence the decision to seek care [Valentina

& Bedwell 2020].In the 3DM, the distance from home to the health facility plays a significant

role in care-seeking decisions and longer distances can act as a disincentive, especially in rural

areas. This is worsened by lack of transport and poor road conditions. Lastly, the indirect cost of

seeking care given by transportation fees and hospital-related costs represents another deterrent.

In this synthesis, few studies reported remoteness from health facilities [Valentina 2020] and

availability of transportations as reasons for the First Delay. In the majority of studies, delays in

the decision to seek care due to perceived accessibility were driven by the potential cost of

transport and for institutional care [Wakasiak,2020].

● Quality Of Care

In the 3DM, the First delay could also be affected by previous experience with the health system

[Bedwell& Wakasiaka 2020]. Many studies in this synthesis have shown how a bad experience

with health professionals [Wakasiaka 2020], fear of medical procedures and an unfriendly
43
environment could deter women from future appointments and delay their care-seeking

decisions. In this category, According to Thaddeus and Maine and cited by [Valentina, 2020]

recognised how beliefs and the use of traditional medicine could delay the decision to access

care. The choice to consult traditional healers and use traditional birth attendants before seeking

formal care was a recurrent situation in various countries. This decision intended to comply with

local beliefs and rituals, but was also implied by the possibility of delaying payments for care

according to Pafs J, Musafil & Gebrehiwot T cited by (Wakasiaka,2020).

2.3.1.1.3 THE SECOND DELAY

Delay In Identifying And Reaching The Health Facility.

Second Delay refers to accessibility challenges, due to distance, availability and effective costs

of means of transport; and the distribution of the health facilities in the area where the woman

lives. Studies showed that the second delay was determined by the geographical distribution of

facilitie, distances, from home to the health facilities, weak road infrastructures, availability of

means of transportation and costs wise(Valentina,2020). These factors have been explored in the

included studies. In some countries, living in remote and rural locations according to Mgawadere

Wallace & jammeh cited by [Valentina, 2020] characterised by poor road condition [Sabina

Wakasiaka 2020] delayed women from reaching care on time. Studies conducted in India, The

Gambia and in Nairobi slums [Bedwell, 2020] showed how the rainy season transforms roads

into muddy pathways, with impossible drivability. In the rural Gambia according to jammeh

cited by [Valentina, 2020] living next to a river meant being subject to floods which affected the

44
availability of ferry services to reach the mainland and access care. In a number of studies, long

travel time due to distance was cited among the main challenges to reach healthcare promptly.

2.3.1.1.4 CHANGES PROPOSED IN THE LITERATURE TO THE THREE

DELAYS MODEL

There are some proposed changes to the definition and structure of the 3DM (three delay

models) and this is shown in the figure below.

Change in the Definition Of The Delay

Three studies proposed changes in the definition of the First and Second Delays. Charlet et al

2019 proposed dividing the First Delay into three segments: the identification of life-threatening

complications, the recognition of illness severity and the decision-making process around care-

seeking to explore how the woman and her family interact in deciding where and when to seek

care. Similarly, Rodriguez Villamizar et al 2019 separate the recognition of a problem from the

decision to take action to identify the health needs and the factors influencing the decision to

seek care. Jithesh and Ravindran adapted the definition of Delay 1 and to capture the time span

taken to reach appropriate obstetric care due to multiple referrals.

45
(Rodriguez Villamizar et al 2019)

Figure 2.2

46
 Changes proposed to the structure of the three delay model.

2.3.1.1.5 THE THIRD DELAY

Delay In Receiving Adequate And Appropriate Treatment At The Facility.

The Third Delay is concerned with the service offered at the facility. This can be insufficient due

to lack of supplies and equipment, unfriendly environment (includingdisrespectful care) and

inadequate and poorly trained staffs According to DAmbruoso L &Phiri SN cited by (Bedwell

2020). Studies showed the third delay in the 3DM was influenced by a low number of staffs,

limited or reduced competences of providers, inadequate management, and shortage of

equipment, medicines and blood. In this synthesis these categories were still relevant in

describing the challenges faced by many LMICs. Across studies, a limited number of human

resources [Wakasiaka, 2020] and a lack of trained staff, especially doctors delayed women from

receiving appropriate care. This was compounded by the inability to diagnose obstetric

complications or for having made a wrong assessment, which in both cases could lead to

inappropriate treatment [Bedwell, 2020].

2.3.1.1.6 THE FOURTH DELAY

A fourth delay explained the community role in contributing to maternal death (MacDonald et al.

2018). This involved a failed action to support women in reaching the health facility, and the

pressure of the local culture to rely on traditional medicine instead of seeking institutional care as

a first choice. Another suggestion has been separating the perception of respectful quality care

from the factors determining the First Delay to recognize it as a unique delay [wallcaw &

MCdonald, 2019]. There are few varieties of reasons to which these fourth delay tend to occur
47
and these includes; financial constraints, such as the cost of follow-up care or medications, lack

of transportation to follow-up appointments, lack of information about the importance of follow-

up care, lack of support from family members or community members.

CHAPTER THREE

RESEARCH METHODOLOGY

3.0 INTRODUCTION

Research methodology draws the map upon which the study is executed. Methodology permits a

successful replication of the work by other researchers. The aim of this chapter is to discuss the

various methods that have been employed in this research work and this includes the following

headings. Research settings, Research design, target population, sampling techniques and sample

size determination, instrument for data collections, inclusion &exclusion criteria, reliability and

validity of the instrument, method of data collection, method of data analysis and ethical

considerations.

3.1 RESEARCH DESIGN

A research design also called a research strategy, is a plan to answer a set of questions

(McCombes, 2019). It is a framework that includes the methods and procedures to collect,

analyze, and interpret data. In other words, the research design describes how the researcher

investigated the central problem of the research and is, thus part of the research study.

Therefore a descriptive cross sectional study was carried out among women on assessing the

perceived impact of traditional birth attendants services in Oyo town.

3.2 RESEARCH SETTINGS

48
The research setting is the location where the research takes place (homework.study.com, 2023).

Therefore, this study was conducted in Oyo.

Oyo state; Oyo State is an inland state in southwestern Nigeria. Its capital is Ibadan, the third

most populous city in the country and formerly the second most populous city in Africa. Oyo

State is bordered to the north by Kwara State, to the east by Osun State, and to the southwest by

Ogun State and the Republic of Benin. With a projected population of 7,840,864 in 2016, Oyo

State is the fifth most populous in the Nigeria.

Primary Health Care Center: Primary healthcare (PHC) is the foundation of the healthcare

system: it is a level at which non-emergency, preventative health issues should be managed or

resolved. Two settings were used in this study and these settings are the primary health care

centers in alaafin and okeola in which they constitute few nurses and large attendants of pregnant

women and these two centers are situated in Atiba local government area.

Atiba Local Government: Atiba is a Local Government Area in Oyo State, Nigeria. Its

headquarters is in the town of Offa Meta. It has an area of 1,757 km2 and a population of

168,246 at the 2006 census. The postal code of the area is 203. Some of the areas under Atiba

Local Government

includes Agunpopo, Aremo, Alaafin Palace, oke-oola.

3.3 TARGET POPULATION

A target population is defined as the group of people that the intervention is designed for and that

are affected by the intervention(Abid Chaudry 2019). This definition focuses on the design and

49
implementation of the intervention, and highlights the importance of understanding how the

intervention will affect the target population.

The target population comprises of 105 women attending the two selected primary health care

centres which are okeola and aafin primary health care centers. This helped provide more insight

on the impact of traditional birth attendants services in oyo town.

3.4 SAMPLING METHOD & TECHNIQUES

The sample is a group of people who participate in a research (MC mobes, 2020). A simple

random sampling technique was used to select the study participants. Two selected primary

health care centres was chosen using a simple random sampling method and this two selected

primary health care centres are aafin and okeola primary health care centres situated in Atiba

local government in oyo town.

3.5 SAMPLE SIZE DETERMINATION

Sample size determination is the process of determining the number of individuals that need to

be enrolled in a study to achieve sufficient statistical power to detect a given effect size (Riley

and Smith 2019). Meanwhile the solvins formula it is a tool for evaluating research abstracts

based on their significance, originality, level of interest, value, impact, and novelty(Abbasi et al.

2019).This determination of sample size is based on the availability of the number of

populations.

Solvin,s formula

n=N/1+N e^2

e^2= 0.05 (i.e margin of error)

50
n= the sample size

N= population under study.

Calculations

AAFIN PRIMARY HEALTH CARE CENTER

n=N/1+N e^2

e^2= 0.05 (i.e margin of error)

n= the sample size

N= population under study.

There are 58 women who attended the center. The statistics includes just 58 women.

The calculations is as follows:

n= 58/1+(58)(0.05)^2

n=58/1+(58)(0.0025)

n=58/1+(0.029)

n=58.029

n=58

Calculations

OKEOLA PRIMARY HEALTH CARE CENTER

n=N/1+N e^2

e^2= 0.05 (i.e margin of error)

n= the sample size

51
N= population under study.

There are 37 women who attended the center. The statistics includes just 37 women.

The calculations is as follows:

n= 37/1+(37)(0.05)^2

n=37/1+(37)(0.0025)

n=37/1+(0.029)

n=37.0925

n=37.1

Total calculations for both the primary health care centers

Aafin PHC + okeoola PHC

58+37.1

= 95.1

Attrition Rate

Attrition is participant drop out over time in a study. It is called subject mortality, but it doesnt

always refer to participants dying. Attrition bias is the selective dropout of some participants

who systematically differ from who remain in the study.

The attrition rate is as follows:

n/100 ×100

Then: attrition rate +sample size

Calculation

n/100×10
52
where n is the sample size .

95.1/100×10

=9.51

Therefore attrition rate + sample size

= 95.1+9.51

=104.61

=Approximately 105//

3.6 INSTRUMENT FOR DATA COLLECTION

Research instruments as tools that are used to measure variables of interest. Quantitative data

was collected using a self-structured, self-administered questionnaire to answer the research

questions of this study. The language of the questionnaire was in English although some

explanations was made available in Yoruba for participants of the study who did not understand

English language (Dedding et al.2020)

3.7 INCLUSION CRITERIA

1. Women might or might not willing participate in the study.

2. English language must be included and explanation in the language Yoruba can be done

for women who do not understand Yoruba language.

EXCLUSION CRITERIA

1. Most Women may not give inform consent.

2. Most women may not have utilized the services of traditional birth attendants services.

3. Most women may not understand English and yoruba.

53
3.8 ESTABLISHING THE VALIDITY AND RELIABILITY OF THE INSTRUMENT

Bryman, Bell, and Harley (2019) defined validity and reliability in similar terms to Bryman and

Bell (2015).

3.8.1 VALIDITY OF THE INSTRUMENT

Validity as "the extent to which the data accurately represent what they are intended to

represent.

The study instruments was validated by reviewing its findings with other similar studies. Face

and content validity of the instrument was done also by the research supervisor, a professional

nurse specialist who is an expert in measurement and evaluation. Her observations was used to

make necessary modifications before approval and administration.

3.8.2 RELIABILITY OF THE INSTRUMENT

Bryman, Bell, and Harley (2019) defined reliability as "the extent to which results are consistent

and repeatable. In view of this, the questionnaires was structured with open ended and close

ended.

3.9 METHOD OF DATA COLLECTION

Method of data collection simply refers to the provision of guidance in an area by squarely

focusing on the things researchers do to obtain data in their research projects (Rose et al., 2020).

A self-structured and self-administered questionnaire was administered by the researcher. The

questionnaire was administered to 105 women both with staff nurses after necessary permissions,

ethical considerations and informed consent is taken. It both contained open and close ended

questions. The questionnaire consists of five sections.

54
The first section; consists of the Socio demographic data of the respondents respectively.

The Second Section: consists on the roles and knowledge of traditional birth attendants among

the 105 women.

The third section: It includes the factors affecting or influencing the impact of TBAs services

among the women.

The Fourth Section: This section was based on the complications being faced from women who

have encountered any services of indicting TBAs.

The Fifth Section: This section was based specifically on the reasons what made women start

receiving care from traditional birth attendants in the community.

3.10 METHOD OF DATA ANALYSIS

Gray and Malins (2020) defined data analysis as "the process of turning raw data into meaningful

information, so it can be used to answer questions or make decisions".

Data was well collated and tallied before computing. All completed questionnaires effectively

checked for completeness and a coding guide was developed to facilitate entry. A descriptive and

inferential analysis was carried out. A chi-square analysis was employed to test for hypothesis 1

while correlation analysis was performed to test for hypothesis 2.

3.11 ETHICAL CONSIDERATIONS

● Ethical approvals: Introduction letter was endorsed by the Head of Department of

Nursing sciences. Throughout the research study, ethical principles was considered and

respected. The researcher helped to ensure that all respondents have the right to

determine if to participate or not to.

55
● Informed Consent: informed consent is necessary for the study in order for the

researcher to accomplish her goals during the process.

● Protecting privacy and confidentiality: In addition to normal concerns about privacy,

protecting a participants confidentiality in this research study is vital hence, a participants

privacy was effortlessly maintained before, during, and after their co-operation with the

questionnaires.

56
 CHAPTER FOUR

DATA ANALYSIS AND RESULTS

4.0 Introduction

This chapter presents the study results in line with the aim and objectives. The data obtained for

this study are descriptive on the socio-demographic data of the respondents, the roles of

Traditional Birth Attendants in improving maternal and child health outcomes; factors affecting

the impact of TBAs services among the women; complications that arises from the utilization of

unskilled birth attendants and reasons why women prefer the utilization of TBAs. A total of 105

questionnaires were administered to selected respondents, out of which 105 were retrieved

during collection making a response rate of 100%. Using SPSS version 25, the survey data was

analysed and displayed as percentages and frequencies presented in the tables below. Descriptive

analysis was carried out on the studys variables and objectives. The presentation was done using

tables, charts, and graphs for easy yet effective communication.

The analysis aimed to answer the following questions:

● What are the roles of these traditional birth attendants in the community?

● What are the factors affecting the impact, safety and effectiveness of TBA practices in

delivering babies and providing care during childbirth?

● What forms of complications do pregnant women encounter from traditional birth

attendants?

● What are the most common reasons for choosing TBA (traditional birth attendant)

services over a healthcare facility?

57
 Age Groups

Frequency Percent Valid Cumulative Percent

Percent

Valid 18-24 34 32.4 32.4 32.4

25-30 31 29.5 29.5 61.9

35-40 23 21.9 21.9 83.8

45 and above 17 16.2 16.2 100.0

Total 105 100.0 100.0

4.1 Socio-Demographic Characteristics of Respondents

Table 4.1.1 Age Groups

The table 4.1.1 shows the age group of the respondents. 34 respondents representing 32.4% of

the sample size were of the age group 18-24, 31 respondents representing 29.5% were of the age

group 25 30. Also, 23 respondents representing 21.9% of the sample size were of the group 35 -

40 while 17 respondents representing 16.2% were of the group 45 and above. Therefore,

majority of the respondents were of the age group 18-24 years.

Educational status

Frequency Percent Valid Percent Cumulative Percent

58
 Valid No formal education 4 3.8 3.8 3.8

Primary school 7 6.7 6.7 10.5

Secondary school 13 12.4 12.4 22.9

Tertiary 81 77.1 77.1 100.0

Total 105 100.0 100.0

Table 4.1.2 Educational Status

The table 4.1.2 reveals the educational status of the respondents. 4 respondents representing

3.8% of the sample size had no formal education, 7 respondents representing 6.7% finished at

primary school level, 13 respondents representing 12.4% finished secondary school while 81

respondents representing 77.1% of the sample size had a tertiary education. This implies that

majority of the respondents had a tertiary education.

Table 4.1.3 Occupation Status

Occupation

Frequency Percent Valid Percent Cumulative Percent

Valid Employed 64 61.0 61.0 61.0

Self-employed 31 29.5 29.5 90.5

59
 Unemployed 10 9.5 9.5 100.0

Total 105 100.0 100.0

In the table 4.1.3, 64 respondents represent 61% of the sample size are employed, 31 respondents

representing 29.5% were self-employed while 10 respondents representing 9.5% of the sample

size were unemployed. Therefore, majority of the respondents were employed.

Table 4.1.4 Marital Status

Marital status

Frequen Percen Valid Percent Cumulative

cy t Percent

Val Divorc 14 13.3 13.3 13.3

id ed

Marrie 65 61.9 61.9 75.2

Single 23 21.9 21.9 97.1

Widow 3 2.9 2.9 100.0

ed

Total 105 100.0 100.0

60
The table 4.1.4 revealed that 14 respondents representing 13.3% of the respondents were

divorced, 65 respondents representing 61.9% were married, and 23 respondents representing

21.9% were single while 3 respondents representing 2.9% were widowed. So, majority of the

respondents were married.

Table 4.1.5 Ethnicity

Ethnicity

Frequen Percen Valid Percent Cumulative

cy t Percent

Val Haus 19 18.1 18.1 18.1

id a

Igbo 19 18.1 18.1 36.2

Other 6 5.7 5.7 41.9

Yoru 61 58.1 58.1 100.0

ba

Total 105 100.0 100.0

The table 4.1.5 on ethnicity reveals that among the 105 respondents, there is a diverse

representation of ethnic backgrounds. The majority of the respondents, 58.1%, identified as

Yoruba, indicating a significant Yoruba presence in the sample. Hausa and Igbo ethnicities were

61
 each represented by 18.1% of the respondents. Additionally, 5.7% of respondents fell into the

"Others" category, which includes various ethnic backgrounds. This data demonstrates the

diversity of ethnic backgrounds among the respondents, with a substantial Yoruba presence.

Table 4.1.6 Religion

Religion

Frequency Percent Valid Percent Cumulative Percent

Valid Christianity 56 53.3 53.3 53.3

Islam 43 41.0 41.0 94.3

Others 6 5.7 5.7 100.0

Total 105 100.0 100.0

The table 4.1.6 shows the data on religious affiliation shows that the respondents have varying

religious beliefs. The majority, 53.3%, identified as Christians, making it the most prevalent

religious affiliation in the sample. Islam was the second most common religious affiliation, with

41.0% of the respondents identifying as Muslims. A smaller proportion, 5.7%, fell into the

"Others" category, representing various other religious beliefs. This data highlights the religious

diversity among the respondents, with a significant number adhering to Christianity, followed by

Islam.

62
Table 4.1.7 Number of Children

Number of children

Frequency Percent Valid Percent Cumulative Percent

Valid 1-2 51 48.6 48.6 48.6

3-4 34 32.4 32.4 81.0

5 and above 20 19.0 19.0 100.0

Total 105 100.0 100.0

The table 4.1.7 shows the number of children that respondents have revealings interesting

insights into family sizes. Nearly half of the respondents, or 48.6%, reported having 1-2 children.

A significant portion, 32.4%, had 3-4 children, while 19.0% had 5 or more children. This data

sheds light on the distribution of family sizes among the respondents, with a substantial number

having relatively smaller families (1-2 children) and others having larger families with 5 or more

children

Table 4.1.8 Access to Health Care

63
Access to health care

Frequency Percent Valid Percent Cumulative Percent

Valid No 30 28.6 28.6 28.6

Yes 75 71.4 71.4 100.0

Total 105 100.0 100.0

The table 4.1.8 shows the access to healthcare indicating that a majority of respondents, 71.4%,

reported having access to healthcare. However, it's worth noting that a significant portion,

28.6%, reported not having access to healthcare. This finding underscores the importance of

assessing healthcare accessibility in the given population, as nearly a third of the respondents

face challenges in accessing healthcare services.

Table 4.1.9 Income

64
Income

Frequency Percent Valid Percent Cumulative

Percent

Valid ₦200,000-400,000 49 46.7 46.7 46.7

₦500,000-1,000,000 33 31.4 31.4 78.1

Less than ₦100,000 23 21.9 21.9 100.0

Total 105 100.0 100.0

The table 4.1.9 shows an approximate annual income providing insights into the income levels of

the respondents. The largest group, 46.7% of respondents, reported an income range of

₦200,000-₦400,000 annually. The second-largest group, 31.4%, fell into the ₦500,000-

₦1,000,000 income range. A smaller but still significant proportion, 21.9%, reported having an

annual income of less than ₦100,000. This data demonstrates the income distribution among the

respondents, with the majority falling into the middle-income range, followed by those in higher-

income brackets and a smaller group with lower incomes. Understanding the income levels of

the population is crucial for addressing economic disparities and making informed policy

decisions.

65
4.2 Assessing the Roles of Traditional Birth Attendants in Improving Maternal and

Child Health Outcomes

Variables Yes No

Are traditional birth attendants (TBA) known for providing 45 (42.9%) 60 (57.1%)

personalized care and attention to women during childbirth?

Do Traditional Birth Attendants (TBAs) provide health 40 (38.1%) 65 (61.9%)

education to women on nutrition during pregnancy and lactation

in your community?

Do traditional birth attendants (TBAs) have a deep 39(37.1%) 66(62.9%)

understanding of skilled birthing practices?

Do traditional birth attendants (TBAs) have experience in 37(35.2%) 68(64.8%)

handling complications during labor?

Do Traditional Birth Attendants (TBAs) provide psychological 41(39.0%) 64(61.0%)

support and counselling to women during pregnancy and

childbirth?

66
Do Traditional Birth Attendants (TBAs) arrange means of 63(60.0%) 42(40.0%)

transport and accompany women in labour to health facilities.

Do Traditional birth attendants (TBAs) provide guidance on 67(63.8%) 38(36.2%)

postpartum care and exclusive breastfeeding practices?

The table above showed the assessment of roles of Traditional Birth Attendants in improving

maternal and child health Outcomes. About 42.9% of respondents answered "Yes" when asked if

TBAs are known for providing personalized care and attention to women during childbirth, while

57.1% responded "No." This indicates that a significant portion of respondents believe TBAs

offer personalized care during childbirth. When asked whether TBAs provide health education

on nutrition during pregnancy and lactation in the community, 38.1% of respondents answered

"Yes," while 61.9% responded "No." This suggests that there is room for improvement in this

aspect of TBA services.

Approximately 37.1% of respondents believe that TBAs have a deep understanding of skilled

birthing practices, while 62.9% do not share this belief. This points to a perception that there is

room for improvement in TBAs' knowledge of modern birthing practices. When it comes to

handling complications during labor, 35.2% of respondents said "Yes," indicating that TBAs

have experience in this area. However, a majority of 64.8% answered "No," suggesting that more

training and support may be needed in managing complications.

67
Regarding providing psychological support and counseling during pregnancy and childbirth,

39.0% of respondents answered "Yes," while 61.0% responded "No." This implies that some

respondents perceive TBAs as sources of psychological support. A significant 60.0% of

respondents believe that TBAs arrange means of transport and accompany women in labor to

health facilities, while 40.0% do not share this perception. This suggests a positive role played by

TBAs in facilitating access to healthcare facilities. When asked about guidance on postpartum

care and exclusive breastfeeding practices, a substantial 63.8% of respondents answered "Yes,"

indicating that TBAs are seen as providing valuable guidance in these areas. Only 36.2%

responded "No."

4.3 Factors Affecting the Impact of TBAs services among the Women

Variables SD D N A SA

I am knowledgeable about 20 9 (8.6%) 13(12.4%) 26 37 (35.2%)

the practices of traditional (19.0%)
(24.8%)
birth attendants services
(TBAs).
Skilled healthcare providers 22 14 20 (19.0%) 25(23.8 24 (22.9%)
(Registered nurses) are easily (21.0%) (13.3%)
%)
accessible in my community.

Financial constraints (no 28(26.7% 13 22 (21.0%) 19(18.1 23(21.9%)

money) influence my choice ) (12.4%)
%)
of healthcare provider.
I trust and rely on traditional 37 20 21 (20.0%) 10 17 (16.2%)
68
 methods for childbirth. (35.2%) (19.0%) (9.5%)

The distance to healthcare 30 29 22 (21.0%) 14 10 (9.5%)

facilities is not a barrier for (28.6%) (27.6%)
(13.3%)
me.
Cultural norms and traditions 29 23 26 (24.8%) 13 14 (13.3%
influence my decision to use (27.6%) (21.9%)
(12.4%)
traditional birth.
Maternal healthcare 11 5 (4.8%) 29 (27.6%) 27 33 (31.4%)
resources are readily (10.5%)
(25.7%)
available in my community.
Women who use the services 30 20 28(26.7%) 10(9.5% 17(16.2%)
of traditional birth attendants (28.6%) (19.0%)
)
(TBAs) have positive birth
experiences.
TBAs have adequate skills 30(28.6% 24(22.9%) 23(21.9%) 12(11.4 16(15.2%)
and knowledge for safe )
%)
childbirth.
The cost of healthcare 34(32.4% 19(18.1%) 25(23.8%) 15(14.3 12(11.4%)
services is affordable for me. )
%)

Firstly, knowledge about TBA practices elicits a mixed response. While a substantial proportion

of respondents (35.2%) strongly agree that they possess knowledge about TBA practices, a

notable 24.8% strongly disagree, reflecting a lack of awareness. In terms of the accessibility of

skilled healthcare providers, opinions vary, with 23.8% agreeing, 21.0% disagreeing, and 22.9%

maintaining a neutral standpoint. Financial constraints influencing healthcare choices provoke

similar diversity, as 26.7% agree, 21.9% remain neutral, and 18.1% disagree. Trust in traditional

69
methods for childbirth presents an intriguing picture. A significant portion (35.2%) strongly

agrees that they trust and rely on traditional methods. However, the opinions are divided, with

20.0% in agreement, 16.2% strongly in disagreement, and 9.5% strongly asserting their trust in

traditional methods. The issue of distance to healthcare facilities shows that 28.6% strongly

agree that it's not a barrier, while 27.6% strongly disagree, suggesting it remains a significant

obstacle. Cultural norms and traditions play a role in influencing healthcare choices, with 27.6%

in agreement, 24.8% neutral, and 13.3% strongly in disagreement.

Availability of maternal healthcare resources triggers varied perspectives. While 27.6% agree

they are readily available, 31.4% strongly disagree, indicating a sharp contrast in experiences.

Furthermore, the question of positive birth experiences with TBAs reveals nuances. A

considerable 28.6% strongly agree that women using TBA services have positive experiences.

However, 26.7% are in agreement, while 16.2% strongly disagree. Lastly, the skills and

knowledge of TBAs draw mixed responses, with 28.6% agreeing, 22.9% remaining neutral, and

15.2% strongly disagreeing. As for the affordability of healthcare services, 32.4% agree that they

are affordable, 23.8% are neutral, and 11.4% strongly disagree. In summary, the data reflects the

intricate web of opinions within the community. It underscores the multifaceted nature of

healthcare decision-making, where diverse factors, beliefs, and experiences influence the roles of

TBAs in maternal and child health. These insights provide a comprehensive understanding of the

complexities surrounding healthcare choices in the community.

4.4 Complications that Arises from the Utilization of Unskilled Birth Attendants.

70
Variables SD D N A SA
There are potential risks or 19(18.1%) 16(15.2%) 9(8.6%) 19(18.1%) 42(40.0%)
complications that women may
face when relying on traditional
birth attendants for childbirth?

Unskilled birth attendants may 14(13.3%) 8 (7.6%) 6(5.7%) 13(12.4%) 64(61.0%)

increase the risk of postpartum
hemorrhage and pre-eclampsia.
Unskilled birth attendants may 14(13.3%) 7 (6.7%) 9(8.6%) 13(12.4%) 62(59.0%)
increase the risk of birth
injuries?
Unskilled birth attendants may 15(14.3%) 9 (8.6%) 9(8.6%) 11(10.5%) 61(58.1%)
increase the risk of infection
during childbirth

Lack of formal medical training 17(16.2%) 5 (4.8%) 9(8.6%) 10 (9.5%) 64(61.0%)

among traditional birth
attendants may contribute to
complications during childbirth.

Implementing training 18(17.1%) 5 (4.8%) 8(7.6%) 14(13.3%) 60(57.1%)

programs for traditional birth
attendants could help minimize
complications during childbirth.
There should be stricter 13(12.4%) 11 6(5.7%) 15(14.3%) 60(57.1%)
regulations or guidelines in (10.5%)

71
 place for traditional birth
attendants to ensure safer
childbirth practices?
Unskilled birth attendants may 13(12.4%) 5 (4.8%) 10(9.5% 14(13.3%) 63(60.0%)
increase the risk of neonatal
complications.
The use of unsterilized 12(11.4%) 7 (6.7%) 8(7.6%) 16(15.2%) 62(59.0%)
equipment can increase
maternal and neonatal
infections.
Firstly, it is evident that a significant proportion of respondents (40.0%) strongly agree that there

are potential risks or complications women may face when relying on traditional birth attendants

for childbirth. This implies a widespread recognition of the risks associated with unskilled birth

attendance. The risks identified include postpartum hemorrhage, pre-eclampsia, birth injuries,

and infection during childbirth. Respondents show varying degrees of agreement with these

risks, with the majority (61.0%) strongly agreeing that unskilled birth attendants may increase

the risk of postpartum hemorrhage and pre-eclampsia. Similarly, 59.0% strongly agree that

unskilled birth attendants may increase the risk of birth injuries, while 58.1% strongly agree that

there is an increased risk of infection during childbirth. A concerning aspect highlighted in the

data is the lack of formal medical training among traditional birth attendants. A substantial

number of respondents (61.0%) strongly agree that this lack of training may contribute to

complications during childbirth. This underscores the importance of addressing the skills and

knowledge gap among traditional birth attendants. Furthermore, there is a strong inclination

72
(57.1%) towards the implementation of training programs for traditional birth attendants to

minimize complications during childbirth. This suggests an acknowledgment that education and

training could be instrumental in improving the safety of childbirth practices. Respondents also

express the need for stricter regulations or guidelines (57.1%) for traditional birth attendants to

ensure safer childbirth practices. This reflects a consensus on the importance of enforcing

standards in this context. The data also suggests concerns about the risk of neonatal

complications (60.0%) arising from the utilization of unskilled birth attendants. Additionally, the

use of unsterilized equipment is recognized as a potential risk, with 59.0% strongly agreeing that

it can increase maternal and neonatal infections. In summary, the data underscores the

widespread recognition of risks associated with the utilization of unskilled birth attendants

during childbirth. Respondents express concerns about various complications, including those

related to maternal health, neonatal health, and the lack of formal medical training among

traditional birth attendants. The findings highlight the importance of addressing these concerns

through education, training, and stricter regulations to ensure safer childbirth practices.

4.5 Reasons Why Women Prefer the Utilization of Traditional Birth Attendants.

Variables SD D N A SA

Lack of access to healthcare 19 (18.1%) 7 (6.7%) 15(14.3%) 27 (25.7%) 37 (35.2%)

facilities is a reason why women

73
start receiving care from traditional

birth attendants in the community?

I think trust and familiarity with 28 (26.7%) 21(20.0%) 14(13.3%) 25 (23.8%) 17 (16.2%)

TBAs influence women’s decision

to receive care from them in the

community?

Most TBA centers are closer to the 25 (23.8%) 21 21 20 (19.0%) 18 (17.1%)

home than the health facilities. (20.0%) (20.0%)

TBAs provide emotional support 30 (28.6%) 22 22 15 (14.3%) 16 (15.2%)

and reassurance during childbirth, (21.0%) (21.0%)

creating a sense of comfort for

women.

The influence of family and 28 (26.7%) 20 27 12 (11.4%) 18 (17.1%)

community members plays a role in (19.0%) (25.7%)

women opting for care from

traditional birth attendants.

74
 Traditional birth attendants promote 18 (17.1%) 20 11 25 (23.8%) 22(21.0 %)

good health and well-being for (19.0%) (10.5%)

pregnant women?

There is Good interpersonal 20 (19.0 18 29(27.6%) 18 (17.1%) 20(19.0 %)

relationship and practices by TBAs. %) (17.1%)

Poor attitude of health workers 15 (14.3%) 14(13.3%) 11(10.5%) 17 (16.2%) 48 (45.7%)

during ANC and facility delivery.

Preference for vaginal delivery and 10 (9.5%) 9 (8.6%) 7 (6.7%) 40 (38.1%) 39 (37.2%)

fear of C/S.

One prominent reason cited is the lack of access to healthcare facilities, with a substantial 35.2%

strongly agreeing that this factor drives women to seek care from TBAs. This implies that in

communities where healthcare facilities are less accessible, women turn to TBAs as an available

option. Trust and familiarity with TBAs also appear to play a pivotal role, with 26.7% strongly

agreeing that these factors influence women's decisions. This suggests that personal relationships

and a sense of trust in TBAs contribute to their preference. Proximity to TBA centers is another

important factor, as 23.8% strongly agree that these centers are closer to their homes than health

facilities. This convenience seems to influence women's choices. The emotional support and

reassurance provided by TBAs during childbirth are highlighted, with 28.6% strongly agreeing

that this creates a sense of comfort for women. It emphasizes the value of emotional care in the

decision-making process. Family and community influence is also noteworthy, with 26.7%
75
strongly agreeing that these external factors play a role in women opting for care from TBAs.

This underscores the significance of social and cultural dynamics in healthcare decisions. The

perception that TBAs promote good health and well-being for pregnant women resonates with

23.8% who strongly agree. This implies that women may view TBAs as guardians of their

health.

Furthermore, a good interpersonal relationship and practices by TBAs are acknowledged, with

27.6% strongly agreeing. These positive interactions contribute to women's preferences. On the

flip side, concerns about the poor attitude of health workers during Antenatal Care (ANC) and

facility delivery are expressed, with 45.7% strongly agreeing. This suggests that negative

experiences with health workers can deter women from seeking facility-based care.

Lastly, a preference for vaginal delivery and a fear of cesarean section (C/S) surgery are evident,

with 37.2% strongly agreeing. This preference aligns with the cultural and personal beliefs of

some women. In summary, the data illustrates a multitude of factors influencing women's

preferences for TBA care, including accessibility, trust, proximity, emotional support, family and

community influence, perceptions of good health promotion, positive interpersonal relationships,

and concerns about the attitudes of health workers. Additionally, personal preferences for

delivery methods and fears of C/S surgery play a role. Understanding these factors is crucial for

tailoring maternal healthcare services to meet the needs and preferences of women in the

community.

HYPOTHESIS 1

76
H0: There is no significant relationships between access to healthcare services and use of

traditional birth attendants.

VS H1: There is significant relationships between access to healthcare services and use of

traditional birth attendants.

Level of significance: α = 0.05

Chi-Square Tests

Value df Asymptotic

Significance (2-

sided)

Pearson Chi-Square 470.008a 340 .000

Likelihood Ratio 278.506 340 .994

Linear-by-Linear Association 20.973 1 .000

N of Valid Cases 105

Decision rule: Reject Ho if P-Value <α, otherwise do not reject Ho.

Decision: Since p-value = 0.000 < α (0.05), we reject Ho and accept H1

Conclusion: Since the null hypothesis H0 has been rejected in favour of H1, we conclude that

there is a significant relationship between access to healthcare services and the use of traditional

birth attendants.

HYPOTHESIS 2

H0: There is no significant relationship between socio-demographics and use of traditional birth

attendants.

77
VS H1: There is significant relationship between socio-demographics and use of traditional birth

attendants.

HYPOTHESIS 2

Variables Pearson Correlation Sig. (2-tailed) Decision

Age -0.094 0.338 Not significant

Educational Status 0.100 0.309 Not significant

Occupation -0.242 0.013 Significant

Marital Status -0.014 0.891 Not Significant

Ethnicity -0.174 0.076 Not Significant

Income -0.107 0.278 Not Significant

Religion -0.223 -0.022 Significant

Number of children -0.217 0.026 Significant

Decision rule: Reject Ho if P-Value <α, otherwise do not reject Ho.

Decision: Since p-value = 0.013, -0.022 and 0.026 < α (0.05), we reject H o and accept H1 for

occupation, religion and number of children. Since p-value = 0.338, 0.309, 0.891 and 0.278 is >

α (0.05), we accept Ho

Conclusion: Since the null hypothesis H0 has been rejected in favour of H 1 for occupation,

religion and number of children, we conclude there is significant relationship between

occupation, religion, number of children and use of traditional birth attendants while there is no

significant relationship between age, marital status, educational status, ethnicity, and income and

use of traditional birth attendants.

78
 CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

This chapter discusses the findings from the study, implication to nursing, summary, conclusion,

recommendations, and suggestions for further studies.

5.1 Summary

The study assessed various aspects related to the utilization of traditional birth attendants

(TBAs) and their impact on maternal and child health outcomes in selected primary health care
79
centers in Oyo Town. The study aimed to shed light on the roles of TBAs, the factors affecting

the safety and effectiveness of their practices, the complications encountered by pregnant women

utilizing their services, and the reasons women opt for TBAs over skilled birth attendants. The

study also explored the relationship between access to healthcare services and the use of TBAs,

as well as the influence of socio-demographic factors on TBA utilization.

5.2 Discussion Of Findings

5.2.1 Roles of Traditional Birth Attendants

The findings revealed that TBAs are known for providing personalized care and attention to

women during childbirth. They also offer health education on nutrition during pregnancy and

lactation, possess a deep understanding of skilled birthing practices, and provide psychological

support and counseling during pregnancy and childbirth. Additionally, TBAs arrange means of

transport and accompany women in labor to health facilities. These roles highlight the

multifaceted support TBAs offer during the maternal and child health journey.

5.2.2 Factors Affecting TBA Utilization

The study uncovered several factors influencing the utilization of TBAs. Notably, a significant

number of respondents cited the lack of access to healthcare facilities as a reason for seeking

TBA care. Trust, familiarity with TBAs, proximity to TBA centers, emotional support during

childbirth, family and community influence, and the belief that TBAs promote good health for

pregnant women were also identified as significant factors. Conversely, concerns about the poor

attitude of health workers during antenatal care and facility delivery were found to influence

80
TBA utilization. Additionally, a preference for vaginal delivery and fear of cesarean section

(C/S) played a role in women's choices.

5.2.3 Complications Arising from TBA Utilization

The study indicated that there is a widespread recognition of potential risks and complications

associated with the utilization of unskilled birth attendants, including postpartum hemorrhage,

pre-eclampsia, birth injuries, and infections during childbirth. The lack of formal medical

training among TBAs was acknowledged as a contributing factor to complications. Respondents

also expressed a need for training programs and stricter regulations for TBAs to improve the

safety of childbirth practices.

5.2.4 Hypothesis 1: Relationship between Access to Healthcare Services and TBA

Utilization

The analysis indicated that there is a significant relationship between access to healthcare

services and the use of TBAs. While different statistical tests yielded somewhat mixed results,

the overall findings suggest that the accessibility of healthcare services impacts the choice of

TBAs, emphasizing the role of access in maternal and child health decisions.

5.2.5 Hypothesis 2: Socio-Demographics and TBA Utilization

The analysis of socio-demographic factors showed that occupation, religion, and the number of

children were significantly related to the use of TBAs. Specifically, respondents' occupation,

religious beliefs, and the number of children influenced their choice of birth attendants. In

contrast, age, educational status, marital status, ethnicity, and income were not found to have a

significant relationship with TBA utilization.

81
5.3 Implication To Nursing

The impact of traditional birth attendants services (TBAs) on the health of women in Oyo Town

can have several implications for nursing practice.

● Implications To Nursing Education; Nursing programs could incorporate information

on the impact of TBAs and the importance of providing evidence-based care. This could

include educating nurses on how to identify women who have had negative experiences

with TBAs and how to provide culturally sensitive care. It could also include training on

how to advocate for policy changes that would support evidence-based care and

discourage the use of TBAs

● Implication To Nursing Practice: They would be the need for increased collaboration

between nurses and community health workers. Community health workers are often the

first point of contact for women seeking care, and they can play a vital role in educating

women about the risks and benefits of different types of care providers. By working

together, nurses and community health workers can ensure that women have access to the

highest quality of care. This could include providing education on the importance of

seeking care from qualified providers, as well as referrals to appropriate services.

● Implications For Nursing Leadership; Nursing leaders could advocate for policy

changes that would support the development of a stronger and more integrated healthcare

system. This could include policies that promote access to evidence-based care, as well as

policies that discourage the use of unqualified providers. Nursing leaders could also work

82
 to increase the number of qualified healthcare providers and improve the quality of care

available to women.

● Implications To Nursing Research: In the above discussion on the implications of

nursing leadership, they can also have impact on the nursing research for example;

research could be conducted to better understand the impact of TBAs services on

women's health and how to best support them. This could include research on the factors

that influence women's decisions to seek care from a TBA and how to improve access to

evidence-based care.

5.4 Limitation of the study

This study was carried out in two primary health care center recognized and situated in Atiba

local government in oyo town. These two primary health care center being choose for this

research study were aafin primary health care center and okeoola primary health care center.

In view of this, a general and specific representation of the whole communities can not be given

because of the financial involvement and time in research work and also for reliability of the

study, the whole rural communities cannot be used. Also, repeating the visits to reach women for

the study was very stressful as most women were not seen in the first visit at clinics in hospitals

and the researcher had to come revisit the clinics repeatedly.

5.5 Conclusion

The findings of this study offer valuable insights into the utilization of traditional birth attendants

(TBAs) and their impact on maternal and child health outcomes in selected primary health care

centers in Oyo Town. The study has provided a comprehensive understanding of the roles of
83
TBAs, the factors influencing their utilization, the complications that can arise from their

services, and the socio-demographic and access-related determinants of TBA usage.

First and foremost, the roles of TBAs in providing personalized care, health education,

psychological support, and assistance in transport to health facilities during labor have been

acknowledged. These findings underscore the multifaceted support that TBAs offer to pregnant

women and their significance within the community.

The study has also shed light on the complex web of factors that influence women's decisions to

opt for TBA care. The lack of access to healthcare facilities, trust and familiarity with TBAs,

proximity to TBA centers, emotional support, family and community influence, and the belief

that TBAs promote good health for pregnant women were among the key drivers. At the same

time, concerns about the attitudes of healthcare workers and a preference for vaginal delivery

over cesarean section (C/S) surgery were identified as barriers to facility-based care.

Furthermore, the research has highlighted the potential risks and complications associated with

unskilled birth attendants, emphasizing the need for training programs and stricter regulations to

enhance the safety of childbirth practices.

Socio-demographic factors, particularly occupation, religion, and the number of children, were

found to significantly influence the choice of TBAs. This insight emphasizes the importance of

tailoring maternal healthcare services to the specific needs and beliefs of the community.

The relationship between access to healthcare services and TBA utilization is a critical finding,

highlighting the impact of accessibility on maternal and child health decisions. The mixed results

84
of different statistical tests suggest that this relationship is multifaceted and warrants further

exploration and targeted interventions.

This study provides a comprehensive overview of the roles and complexities surrounding the use

of traditional birth attendants in the selected community. The findings underscore the need for a

nuanced and community-specific approach to maternal and child healthcare services. It is

significant to consider the multifaceted factors that influence women's choices, improve access to

healthcare facilities, enhance the skills of traditional birth attendants, and foster collaboration

between traditional and skilled birth attendants to ensure the well-being of mothers and their

newborns. Addressing these complex dynamics is crucial for promoting safer and more effective

maternal and child health outcomes in the community.

5.6 Recommendation

Based on the findings and conclusions of this study regarding the utilization of traditional birth

attendants (TBAs) and their impact on maternal and child health outcomes in selected primary

health care centers in Oyo Town, the following recommendations are proposed:

1. Enhance Access to Healthcare Services: Improve the accessibility of healthcare facilities,

particularly in underserved areas, to reduce the need for women to turn to TBAs due to a

lack of access.

2. Community Awareness and Education: Implement community-wide awareness and

education programs that emphasize the importance of skilled birth attendance and the

potential risks associated with unskilled birth attendants. This can help dispel myths and

misconceptions.
85
3. Training and Regulation of Traditional Birth Attendants: Develop and implement training

programs for TBAs to equip them with the necessary knowledge and skills to handle

complications during childbirth safely. Regulate TBA practices to ensure adherence to

safe childbirth practices and standards.

4. Strengthen Collaboration: Encourage collaboration and cooperation between traditional

birth attendants and skilled healthcare providers. This can help ensure that women

receive appropriate care during pregnancy and childbirth, with TBAs acting as valuable

community resources.

5. Promote Positive Attitudes among Health Workers: Address the issue of poor attitudes

among healthcare workers during antenatal care and facility delivery. Implement training

and awareness programs to foster a positive and supportive environment for pregnant

women.

6. Tailor Maternal Health Services: Customize maternal healthcare services to the specific

socio-demographic and cultural characteristics of the community. Consider factors such

as occupation, religion, and the number of children when designing and delivering

healthcare programs.

7. Address Socio-Demographic Determinants: Recognize the impact of occupation, religion,

and the number of children on TBA utilization. Develop strategies to accommodate these

factors in maternal health services and community engagement.

86
 8. Community Engagement and Support: Involve the community in decision-making and

awareness campaigns. Empower community leaders, women's groups, and local

stakeholders to advocate for safe maternal healthcare practices.

9. Promote Facility-Based Care for Complications: Encourage women to seek facility-based

care in cases of complications during childbirth. Ensure that healthcare facilities are

equipped to handle emergencies and complications.

10. Research and Monitoring: Continue research and monitoring of maternal and child health

practices in the community to assess the impact of interventions and make data-driven

adjustments as needed.

These recommendations aim to improve the safety and effectiveness of maternal and child health

outcomes, address the socio-demographic and cultural factors that influence TBA utilization, and

promote collaboration between traditional and skilled birth attendants. By implementing these

measures, the community can work toward ensuring the well-being of mothers and newborns and

reducing the risks associated with unskilled birth attendance.

5.7 Suggestions For Further Studies

Further suggestions to other studies entails various areas which could be beneficial to individuals

in Oyo town.

Research could explore the relationship between the quality of care provided by TBAs and the

outcomes for mothers and babies and also research could investigate how to best integrate the
87
services of TBAs into the healthcare system. There are some areas that deserves more attention

for further studies. One is the impact of socioeconomic status and educational level on women's

decisions to seek care from a TBA. Another is the influence of cultural and religious beliefs on

these decisions.

Finally, the role of community health workers in supporting women who have had negative

experiences with TBAs is a major suggestion for other studies. Community health workers could

play a vital role in providing emotional support and referrals to appropriate services. They could

also help to address any misconceptions about evidence-based care and the risks associated with

seeking care from a TBA.

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APPENDIX

QUESTIONNAIRES

ATIBA UNIVERSITY, OYO.

DEPARTMENT OF NURSING SCIENCE

Dear Respondents,
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My name is AJIBOYE TITILAYO TIMILEHIN; I am a final year Nursing Student from ATIBA

UNIVERSITY OYO, OYO STATE. I am conducting a research on ASSESSMENT OF THE

PERCEIVED IMPACT OF TRADITIONAL BIRTH ATTENDENTS SERVICES AMONG

WOMEN IN SELECTED PRIMARY HEALTH CARE CENTERS IN OYO TOWN. you could

provide responses to the set of questions to the best of your knowledge and understanding. You

are free to withdraw from the study at any time. Your responses will be treated with

confidentiality and will be used solely for academic purpose.Thank you for your time and co-

operation.

SECTION ONE (1)

Socio-demographic Characteristics Of Respondents.

Please tick the column applicable to you

1. Age-groups(years). 18-24( ) 25-30( ) 35-40( ) 45 and above( )

2. Educational status; What is your highest level of education completed?

Primary school( ) Secondary school ( ) Tertiary( ) No formal education ( )

3. Occupation: What is your current occupation?

Unemployed ( ) Employed ( ) Self-employed(

4. Status: What is your marital status?

Single( ) Married( ) Divorced( ) Widowed( )

5. Ethnicity: What is your ethnicity?

Yoruba ( ) Igbo ( ) Hausa ( ) Others ( )

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6. Religion status: What is your religious affiliation?

Christianity ( ) Islam ( ) Others ( )

7. Number of Children: How many children do you have?.

1-2( ) 3-4( ) 5 and above( )

8. Access to Healthcare: Do you have access to healthcare?

Yes ( ) No ( )

9. Income: What is your approximate annual income

Less than ₦100,000( ) ₦200,000 - ₦400,000( ) ₦500,000 - ₦1,000,000( )

SECTION TWO(2)

Assessing The Roles Of Traditional Birth Attendants In Improving Maternal And Child

Health Outcomes.

Please tick the one of your choice in the yes/no boxes.

Variables Yes No

10. Are traditional birth attendants(TBA) known

for providing personalized care and attention to

women during childbirth?

11. Do Traditional Birth Attendants (TBAs)

provide health education to women on nutrition

during pregnancy and lactation in your

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community.

12. Do traditional birth attendants(TBAs) have a

deep understanding of skilled birthing practices?

13. Do traditional birth attendants(TBAs) have

experience in handling complications during

labor?

14. Do Traditional Birth Attendants (TBAs)

provide psychological support and counselling to

women during pregnancy and childbirth.

15. Do Traditional Birth Attendants (TBAs)

arrange means of transport and accompany

women in labour to health facilities.

16. Do Traditional birth attendants(TBAs)

provide guidance on postpartum care and

exclusive breastfeeding practices?

17. Do Traditional Birth Attendants (TBAs)

provide natural& non-natural family planning to

women your community?

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18. Are traditional birth attendants((TBAs)skilled

in managing pain relief techniques during labor?

SECTION THREE(3)

Factors Affecting The Impact Of Tbas services Among The Women.

Please indicate your level of agreement with the following statement by choosing SD=strongly

disagree,D=disagree,N=Neutral,SA=strongly agree,A=agree.

Variables SD D N SA A

19. I am knowledgeable about the practices of

traditional birth attendants services (TBAs).

20. Skilled healthcare providers( Registered

nurses)are easily accessible in my community.

21. Financial constraints (no money) influence

my choice of healthcare provider.

22. I trust and rely on traditional methods for

childbirth.

23. The distance to healthcare facilities is not a

barrier for me.

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24. Cultural norms and traditions influence my

decision to use traditional birth attendants

services (TBAs).

25. Maternal healthcare resources are readily

available in my community.

26. Women who use the services of traditional

birth attendants (TBAs) have positive birth

experiences.

27. TBAs have adequate skills and knowledge

fon safe childbirth.

28. The cost of healthcare services is affordable

for me.

SECTION FOUR(4)

Complications That Arises From The Utilization Of indicting Traditional Birth

Attendants.

Please indicate your level of agreement with the following statements by choosing SD=strongly

disagree,D=disagree,N=Neutral,SA=strongly agree,A=agree.

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Variables SD D N SA A

29. There are potential risks or complications that

women may face when relying on traditional birth

attendants for childbirth?.

30. Unskilled birth attendants may increase the risk of

postpartum hemorrhage and pre-eclampsia.

31. Unskilled birth attendants may increase the risk of

birth injuries?.

32. Unskilled birth attendants may increase the risk of

infection during childbirth.

33. lack of formal medical training among traditional

birth attendants may contribute to complications during

childbirth.

34. Implementing training programs for traditional birth

attendants could help minimize complications during

childbirth?

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36. There should be stricter regulations or guidelines in

place for traditional birth attendants to ensure safer

childbirth practices?

37. Unskilled birth attendants may increase the risk of

neonatal complications.

38. The use of unsterilized equipments can increase

maternal and neonatal infections.

FIFTH SECTION(5)

Reasons Why Women Prefer The Utilization Of Traditional Birth Attendants

Please indicate your level of agreement with the following statements by choosing SD=strongly

disagree,D=disagree,N=Neutral,SA=strongly agree,A=agree.

Variables SD D N SA A

40. Lack of access to healthcare facilities is a reason why

women start receiving care from traditional birth attendants in

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the community?

41.I think trust and familiarity with TBAs influence women's

decision to receive care from them in the community?

42. Most TBA centers are closer to the house area than the

health facilities.

43. TBAs provide emotional support and reassurance during

childbirth, creating a sense of comfort for women.

44. The influence of family and community members plays a

role in women opting for care from traditional birth

attendants.

45. Traditional birth attendants promote good health and

well-being for pregnant women?

46. There is Good interpersonal relationship and practices by

TBAs.

47. Poor attitude of health workers during ANC and facility

delivery.

48. Preference for vaginal delivery and fear of C/S.

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Thank you for your massive response and cooperation.

APPENDIX 2

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