Asabe Joshua resides in Igu, a suburb of Abuja, Nigeria’s Federal Capital Territory. Located about 15 kilometres from Bwari town of Bwari Local Government Area, the community is as rural as you are likely to find in many other parts of Africa’s largest economy.

A public primary health care centre is located in the village but it could just as well not have been there.

“I delivered my children through Mama (a traditional birth attendant (TBA),” Mrs Joshua, a mother of two, told this reporter.

“She does it better than the nurses in the (community’s) clinic and she is always available whenever we need her.”

It took the reporter a rough ride on a bike that set her teeth on edge to get to Igu. Along the dusty road connecting this rustic side to the glittering main city of Abuja are villages with names like Baragoni, Zuma, Gaba and Danko.

The commercial motorcycle bounced over bumps as the rider swerved from one side to the other, acrobatically avoiding the many ditches on the road. Residents who ply the road daily have accepted the rough ride on bikes as their fate. The earthen road has remained the same for over 10 years, apart from somehow managing to get worse every rain season.

An old wrapper tied around her chest under a blouse that was probably once white, 23-year old Mrs Joshua recollected how the health workers at the primary health centre in the community drove her into the welcoming arms of Mama the TBA.

“Before I had my first child, I attended antenatal on a regular basis. Sometimes, when I and other pregnant women get to the health clinic, it’s either the nurses are not on duty or they would ask us to come back the next day.

“When I began to have labour pains at about 5 p.m., my husband and neighbour went to the clinic to call the nurse. The one on duty told them to go back home and she would prepare to join us soon.

“After about 30 minutes, my husband went back to call her only to meet the clinic locked. My neighbour then called Mama, the traditional birth attendant who she said took delivery of her four children. After the delivery, I gave Mama N1,000 and she was happy,” Mrs Joshua narrated.

A TBA is a person who assists women at childbirth. She acquired her skills mostly by working with other birth attendants. They are usually old and experienced women who see their assignment primarily as helping their community with their skills.

WHY TURN TO TBAs

Women in parts of Nigeria, especially in rural communities, prefer being delivered of babies at home by a TBA than at a health clinic. The usual complaints are about the long walk to the clinic or the fees they charge. Some women think health workers are aggressive and so prefer the soft touches of the TBA who lives with them in the community.

Many health centres lack adequate medical facilities to take care of women during and after childbirth anyway, so many women do not see the sense in taking the long trip to such facilities.

Binta Nuhu is the Mama or TBA at Igu that Mrs Joshua spoke glowingly about. The reporter met her by the roadside sitting near a pile of greasy bottles and containers from which her daughter was selling engine oil. After the introduction, Mama excitedly dragged a plastic chair for the reporter to sit on beside her.

Mrs Nuhu said she is 55 years old and had been a TBA for over 25 years. She has seven children of her own, six of whom she proudly disclosed are adults blessed with children of their own.

Speaking in Hausa, Mama told PREMIUM TIMES about her experience and the challenges of being a TBA in Igu.

“I had a seven-month training at Rural Health Centre, Kafi Koro in Niger State. That was where I learnt how to take deliveries of children. I have taken deliveries of over 400 children and most of them are already married and have their own children,” Mrs. Nuhu said as she gleefully reeled out her professional profile.

“I used to collect N1,000 per delivery. But because of how difficult and expensive things are in the country now, I take N2,000 and sometimes N1,500. Whether they are twins or just one baby, I charge the same amount.

“Apart from farming, it is what I do for a living. I was also selling drugs but I stopped that last year because people always don’t pay for the drugs.

“I give injections and also treat malaria and Typhoid. When a patient comes to me, from the look on their face, I know the illness the person has so I collect money from them and go to a chemist to buy drugs and injections, if needed,” she said.

“When there are complications that I cannot handle, I refer the patient to the health clinic. But most times, the health workers are not available so we look for a vehicle or a bike to take the patient to the general hospital in Bwari.

“No woman has died under my care because I take action fast. Once I see that the woman is not responding well, I quickly call her relatives to rush her to the general hospital,” Mama said.

Hannatu Sunday was delivered of two of her children by Mama. Speaking in Pidgin English, she said she relied on Mama’s service because nurses at the health centre do not treat patients well “and they collect too much money.”

“Even during antenatal, they treat us harshly. Also, the delivery fee is N5,000, compared to the N1,500 we pay Mama.”

Mrs Sunday said she was delivered of only the first of her three children at the health centre in Igu.

“My church member introduced me to Mama. I had my second and last baby through Mama. She comes to the house to take deliveries, you don’t have to go to her place.

“I didn’t have any complications after delivery. My baby and I were okay. After delivery, we took the child to the clinic to weigh him and also for immunization. That is the only thing the PHC does for us,” she said.

Mama also took delivery of many of her grandchildren.

Joyce Zaka is Mama’s third child. Mama took delivery of her four children, she told the reporter.

“The PHC is not functional and there is no vehicle to take us to town. Another good thing is that Mama comes to your house to take the delivery. Just call her and she will come immediately. She is my mother, so I didn’t pay but she collects between N1,500 and N2,000 from other women.

“After delivery, we take the child to the health clinic for weighing. And we also take the child for immunisation at the recommended time,” Mrs Zaka said.

A visit to Igu PHC shows why the women who spoke to PREMIUM TIMES would rather be delivered of their babies by the TBA.

The centre was opened but empty when the reporter arrived. After about 30 minutes, Eunice Gagare, a woman in her late 30s, entered.

Mrs Gagare is a nurse at the clinic. She explained she was away at the next community to deliver a message.

She said most residents of Igu prefer the general hospitals in town.

“The women attend antenatal here but when it is time for delivery, we don’t see them. We will only hear that they have delivered or see them with babies. Sometimes when they have complications from the TBA, they rush them to the clinic but since we do not have equipment here to handle complications, we refer them to the hospital in Bwari town,” she said

On why the facility was closed when it should be attending to patients, Mrs. Gagare said: “There is no light in this community. So around 5pm, we close for the day because even if we stay till night, there is no light to work with.

“We only use our torch lights sometimes, when they call us for emergencies. But right now, our torch lights and phone lights are dead, until we see someone going to town to charge and bring them back the next day.”

LIKE IGU, LIKE SHERE KORO

This reporter next visited Shere Koro, near Igu where some residents also said they prefer TBAs to the community’s health facility because the TBAs’ services are cheaper and better.

Evelyn Mba, a mother of two, said she was charged N500 by the TBA who took delivery of her kids.

“She is very nice and friendly. She treats us like her daughters and tells us to pay whenever we have the money. But when you visit the health centre, you must pay immediately and it is N5,000. It is too much, most of us do not have such amount,” she said.

Another resident, Hannah Lazarus, said the distance of the PHC in Shere Koro was not a problem. “But people prefer the TBA because she sometimes take deliveries free of charge.

“If you tell her you do not have money, she will tell you to leave it. So sometimes after delivery, we give her foodstuff in appreciation,” she said.

The officer in charge of the PHC, Christiana Kagbu, however, said the women were not cooperating with health workers and do not appreciate their presence in the community.

“During antenatal, we advise them to come to the clinic when it is time for delivery but they never listen. They prefer the TBA to attend to them, but when complications arise they bring them to the centre. This makes our work really difficult because we don’t know what the TBA had touched or cut,” Mrs. Kagbu said.

“When we cannot handle a case we just refer it to the general hospital in town and it is far. We do not have ambulance, so the patients get people that have vehicles to take them to the hospital,” she said.

The TBA in Shere Koro was out of town at the times PREMIUM TIMES visited.

GOVERNMENT STREAMLINING TBAs

The Executive Director, National Primary Health Care Development Agency (NPHCDA), Faisal Shuaib, said the government appreciates the place of TBAs in primary health care but is taking steps to streamline their services under the Community Health Influencers, Promoters and Services (CHIPS) programme recently launched by government.

According to Mr Shuaib, in an interview with PREMIUM TIMES, part of the initiatives of the CHIPS scheme is to identify TBAs and empower them to handle deliveries without complications.

He said the CHIPs are different from the traditional birth attendants, “who are typically not educated.”

“When a TBA takes births, they sometimes lead to complications such as death of the mother or child. The reason is because, they do not have the right skill.

“Now we want to be more rigorous in their selection. Now we want to set a bar below which we will not accept for Nigerians.”

“The CHIPS are community-based individuals who have been selected in collaboration with traditional leaders, religious leaders, opinion leaders, youth and community based organisations.

“Once that person has been identified and selected by the community members, they are trained over the course of three to six months. Not only in classroom-based training, but also practical field experience. These individuals will be responsible for basic interventions in the community.

“We are harmonising all those different interventions that are community-based and calling them CHIPS agents,” he said.

A public health practitioner, Qua’alar Katty, warned that women who patronise TBAs face a higher risk of having complications during delivery.

She said most complications in such situations lead to both child and maternal death.

“TBAs use tools that are not properly sterilized, which in turn causes infections that may lead to infertility,” she said

Ms Katty urged pregnant women especially those in the rural areas to always visit health facilities, because doing so benefits mother and child.