Traditional Birthing Practices Still Flourish in Nigeria

Poverty, cultural practices and a shortage of primary healthcare services are forcing women in Nigeria to seek the help of untrained traditional birth attendants, despite the serious risks involved.

According to the World Health Organisation’s figures for 2013 on maternal mortality, 560 women die per 100,000 births in Nigeria. That figure includes women who die during or within 42 days of giving birth.

Figures for Nigeria published by the World Bank in 2011 show that 49 per cent of births were attended by trained healthcare workers.

Didikankide Joseph is a traditional birth attendant in the Bomadi area of Nigeria’s Delta State. He has a good reputation in his community and he is always ready to help women to give birth.

In an interview with TELL magazine, he recalled how he once helped a woman who had been told by doctors that she needed a Caesarean section that would cost 40,000 naira. Unable to afford this, the woman came to Joseph’s makeshift clinic where he charges no more than 10,000 naira to deliver a child.

Joseph’s clinic is in a small hut at his home. It has no mattresses or any equipment besides a pair of gloves and needles. There is no ventilation, and the hut is so small that two pregnant women can barely squeeze in at once.

Expectant mothers have to wait outside for their turn even if they are already in labour.

In the first nine months of 2014, Joseph delivered 68 babies.

“Sometimes [women coming to the clinic] are so many that I don’t have chance to attend to them,” he said. “I tell some of them to leave my house, but they choose to wait.  If any one of them starts experiencing labour pains, I command the baby to wait for its turn, and the labour will stop for a while. When I am through with the first woman, I will come back to others.” 

Joseph has been practising as a traditional birth attendant since 1991, and his business is growing. He says he has never received any formal training from anyone “except God”. 

If complications occur, his normal response is to use mysticism or appeal for divine intervention. In any tough situation, Joseph prays to God for assistance. There are times when a woman’s labour ceases by the time it is her turn. In such a situation, Joseph says he commands the woman to start labour again.

Over the years, he has attended successful births, while others have been very problematic.  He recalled a case of a mother who gave birth to twins, and the firstborn died after it was delivered legs first. The second twin survived.

Joseph is just one of many traditional birth attendants who operate in Nigeria. Salamotu Jubril, 47, is a birth attendant in Idah, in Nigeria’s northern Kogi State. She practices from home and has been delivering babies for more than 20 years.

She described her methods to TELL magazine.

“When a woman is in labour, I take her to the back of my house, where I have a plantain farm. [The woman] would sit on a [log] facing the river where her blood would be flushed during delivery,” she said. “Then I will start some incantations. When the baby is ready to come out, I will cut the leaves of the plantain and place them on the floor. That would be where I would keep the baby when it is delivered. I will then dig a small hole in the ground where I would bury the placenta.”

Like Joseph, Jubril believes that no woman should give birth by Caesarean section because she can ensure a delivery without this.

When there are complications, Jubril mixes a drink from some local herbs and gives it to the mother. After that she gently pushes a stick into the woman’s mouth three times. On the third push, she claims that the woman will deliver her baby naturally.

Carol Nwankwo, a birth attendant in Anambra State, south-east Nigeria, has a different way of working. Following a successful delivery, she cuts off the placenta with a razor and massages the mother using herbs. She then gives her a herbal drink which she says helps the body to heal quickly.

Despite the dangers that surround traditional births, some women prefer them to going to local medical facilities.

Some say they trust traditional attendants to help them give birth without complications. For others, traditional birth attendants are simply the most affordable option. While some antenatal services are free in Nigeria, women have to pay to give birth at a medical centre.

Victoria Emmanuel, 22, got married at 19, and has lost three children while in the care of traditional birth attendants. However, she delivered her fourth child alive at Joseph’s clinic. Her subsequent children have also survived.

Emmanuel says she has the option of giving birth at the local healthcare centre in nearby Kpakiama, but it lacks adequate equipment. The facility is also a long way from where she lives, and she cannot reach it by car. Other women in the area said the centre closed early and did not cater for women who gave birth at night.

Emmanuel says her husband, too, is opposed to using the health centre.

 “My husband is always scared that I might die if I give birth in the primary healthcare centre in our village,” she said. “He said women are abandoned in pain to die, so he vowed never to have his babies in any hospital.”

Blessing Avwotu, 30, from near the city of Sapele in Delta State, gave birth to all seven of her children at traditional birth clinics because she cannot afford to use the local hospital. She would rather go to a family friend who is a traditional birth attendant. She can also pay her fee in instalments.

Other women cite cultural reasons for using traditional birth attendants. Mariam Ibrahim, a 30-year-old mother from the capital, Abuja, gave birth to all five of her children at home. Ibrahim said it was against her culture for another man to see her naked, so her husband arranges for an elderly female birth attendant to deliver her babies at home.

Chenemi Idris, a 24-year-old housewife and a mother, also from Abuja, was forced to go to a traditional birth attendant because her community does not have a properly equipped healthcare centre. She delivered her first son with help from an elderly woman who was introduced to her by her mother-in-law.

“[This woman] is very good at birth delivery,” she said. “My mother-in-law said she delivered most of her babies and she wants me to always deliver my babies with her too.”

Rilwan Mohammed, executive secretary of the Federal Capital Territory (FCT) Primary Health Care Development Board, blames women’s preference for traditional births on on Nigeria’s health system, which he says is not working. He believes that primary healthcare centres are not a priority for the government, which is instead focusing on improving general hospitals.

“In FCT, we have 250 primary health care centres and only 12 general hospitals, and [the hospitals] are working very fine while the primary healthcare centres are not working at all,” he said. “They are not in order in terms of equipment, in terms of facilities, in terms of essential drugs, in terms of electricity. They are closed by four pm. They are not working 24 hours’ service like most of the primary healthcare centres in this country.”

According to Mohammed, a new national health law signed by President Goodluck Jonathan last year [2013] will lead to funds being made available by the federal government to strengthen local health facilities.

Realising that many people in rural areas prefer traditional birth attendants to the local health centres – even in places where there are some health facilities – the federal authorities and some state governments have acted.

In states like Lagos, Ogun and Ondo, the state health authorities are certifying and giving training to traditional birth attendants. The state regulates their activities and links them to the nearest general hospital so that they can refer women who suffer complications during childbirth.

In Anambra state, the authorities are educating traditional birth attendants about when it is unsafe for them to conduct deliveries, and about the dangers they and their clients face.

But Ebere Anene, reproductive health coordinator at the Anambra State health ministry, says one of the challenges is that traditional birth attendants in the state practice in secret.

Anambra state is also providing better equipment to the public healthcare centres.

“Anambra State government has donated 2,000 safe motherhood kits – that is what we call “mama kits” – to about 14 health facilities in the state,” Anene said. However, she notes with regret that there are not enough kits for all mothers.

Rukevwe Ugwumba, special adviser to the governor of Delta State on health affairs, says that the state government’s efforts to improve services at public healthcare centres have so far been unsuccessful. She says some women have continued to use traditional birth attendants in spite of the fact that the Delta State government is providing free antenatal services.

“Some people believe in [traditional birth attendants] no matter what they do,” Ugwumba said. “They will come to our antenatal class, yet they will go and deliver at the traditional birth attendants just because their great-grandmother and their families delivered there.”

Nigerian journalist Chinenye Eseke produced this report with support from Partners for Democratic Change and the Institute for War & Peace Reporting.  This is an abridged version of the story published by TELL magazine on January 5, 2014. It is one of a series of investigative reports produced under the Access Nigeria/Sierra Leone Programme funded by the United States Department’s Bureau of International Narcotics and Law Enforcement.