Perception and utilization of traditional birth attendants among women attending primary healthcare centres in Ilishan-Remo, Ogun State, Nigeria

Despite the introduction of modern health facilities and safe motherhood initiative programs, some women still patronize TBAs, especially in developing countries which has caused a lot of havoc on the health of the mother and the child. This has triggered the interest of the researchers to assess the perception and level of utilization of traditional birth attendants among women in Ilishan Remo, Ogun State, Nigeria. This study adopted a descriptive survey design, 126 women were selected using a simple random sampling technique. Two (2) research questions and two (2) hypotheses were formed for the study. The hypotheses were analyzed using PPMC and Chi-square respectively. The findings revealed a negative perception and a low utilization among women towards Traditional Birth Attendants services. The study further showed a positive insignificant relationship between utilization and perception of women (r = 0.130.; p=0.147> 0.05), also showed a positive significant relationship between the level of education and the utilization of traditional birth attendant with a p-value <0.05 (21, X 2 =.132.195, r=0.594). In conclusion, antenatal health education should be effective in raising awareness of issues surrounding the well-being of women and unborn children and the need to constantly make use of approved healthcare centers and skilled birth attendants for delivery. Based on these findings, the researchers recommend that this study be replicated in other communities in Ogun State and even other parts of the country and that the federal government subsidize the price of maternity care to all pregnant women irrespective of their religion, age or economic status.


Introduction
Pregnancy is a physiological state and period of potential risk, with potential complications during the delivery period.World Health Organization, (2023), noted that every two minutes worldwide, a woman dies due to complications arising from pregnancy and childbirth.All around the world, the reduction of maternal mortality rate is being constantly emphasized as an area for greater attention by health experts and global health organizations respectively.Several campaigns and efforts have been put in place by many organizations; including the United Nations and the international community's resolve through Goal 3.1 of the Sustainable Development Goals (SDGs) which aimed to reduce the global Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births by 2030 (United Nations, 2018).
Maternal mortality refers to deaths due to complications from pregnancy or childbirth.UNICEF, (2023), shows that from 2000 to 2020, the global maternal mortality ratio (MMR) declined by 34 per cent -from 342 deaths to 223 deaths per 100,000 live births, according to UN inter-agency estimates.This translates into an average annual rate of reduction of 2.1 per cent.While substantive, this is about one-third of the 6.4 per cent annual rate needed to achieve the Sustainable Development Goal (SDG) of 70 maternal deaths per 100,000 live births by 2030.In a report by the International Centre for Investigative Reporting, (2023), to date, maternal mortality remains a global concern in the developing world, out of which, Nigeria is ranked the second highest number of maternal, neonatal and child deaths worldwide, losing 82 women 'per thousand.
According to the Integrated African Health Observatory, (2023), in 2017, Nigeria's maternal mortality rate was estimated at 917 per 100,000 live births; it increased by nearly 14% in 2020 to reach 1047 deaths.In 2020, the maternal mortality ratio in the African Region was estimated at 531 deaths per 100,000 live births.Countries with extremely high maternal mortality rates are South Sudan with 1223 deaths, followed by Chad with 1063 deaths and Nigeria with 1047 deaths per 100,000 live births.Ntoimo, et. al., (2018) opined that this is somewhat ascribable to a lack in the patronage of skilled health professionals for antenatal and delivery care.This is undoubtedly because over the last decade, the average indicators for attaining safe motherhood have not improved in the country.Looking at these appalling indicators of maternal health care, it is not startling that no substantial achievements have been made over the past decade in reducing maternal mortality in Nigeria.Chinkhumba, et. al., (2014) alleged that because of the poorly responsive healthcare system, most births in Nigeria take place in the homes of unlicensed and unorthodox personnel.However, the World Health Organization (WHO) advocates the use of Skilled Birth Attendants (SBAs) to improve the prospect that pregnancy complications will be properly managed, thereby, reducing the risk of maternal mortality.Hence, a Skilled Birth Attendant (SBA) is defined by the WHO as a trained nurse, midwife, or medical doctor, (no one else) who is qualified and certified to handle birth-related issues (World Health Organization, 2016).Ronsmans, et. al., (2006) found that countries with high rates of SBAs have lower rates of maternal mortality, while those with lower SBAs have higher rates of maternal mortality.This means that the increase in the use of SBAs is presently one of the most significant interventions for reducing maternal mortality.The significance of Skilled Birth Attendants (SBAs) at birth lies in the fact that access to and use of maternity care facilities and skilled professionals, particularly skilled attendants at birth is often linked with substantial reductions in mortality rate.
Despite this acknowledgement, Awotunde, et.al., (2017) submitted that increased maternal and infant mortality rate is blamed on many deliveries that took place at home with the help of untrained attendants, such as Traditional Birth Attendants (TBAs).According to the World Health Organization (1992), the unchecked use of unskilled Traditional Birth Attendants (TBAs) was first known in the 1990s, it was considered to sociocultural phenomenon under the view that women culturally preferred traditional births rather than orthodox births.History has shown that TBAs have been the main human resource for women during childbirth, and even today, they account for the majority of deliveries in rural areas of developing countries (Jemal, et.al., 2010).The WHO observed that TBAs can potentially improve maternal and newborn health at the community level and, while the role of TBAs in caring for pregnant women and conducting deliveries is acknowledged, it is noted that they are generally untrained.Lane, et.al., (2016) observed that this consideration led to the interventions consisting of the training and re-training of TBAs, to improve their skills and competencies in managing uncomplicated deliveries and referring more difficult deliveries to orthodox health facilities.Essentially, Ntoimo et al. (2018) asserted that many studies from different 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 healthcare facilities.Harrison (2011) stated that the futility of the re-training of TBAs became remarkable and consequently the WHO declared the retraining programs of TBAs as ineffective in reducing maternal mortality in developing countries (World Health Organization, 2017).
The practice of traditional birth attendants has caused a lot of havoc on the health of mother and child.Despite the introduction of modern health facilities, safe motherhood initiative programs, free medical services etc., statistics showed that the majority of children are born by TBAs both in rural and urban areas.The majority of deliveries are being carried out by TBAs which indicates that several deliveries still occur outside hospitals and health facilities.The Nigeria Demographic and Health Survey (2018) reported that 67% of women attended antenatal care at least once with SBAs, and 43% were attended to at birth by SBAs (National Population Commission [Nigeria] and ICF 2019).The high patronage rate of unskilled traditional providers for delivery care varies; place of residence with a higher proportion of traditional birth attendant users in the rural (25.5%) than in urban (12.4%) areas (National Population Commission (NPC) [Nigeria] and ICF 2019).This high patronage rate of unskilled traditional delivery care providers is one of the most daunting challenges that needs to be subdued to reduce the current high rate of maternal mortality in the country.
The researchers' interest in this study is to assess the perception and utilization of traditional birth attendants among women attending primary health care centres in Ilishan-Remo, Ogun state.

Objective of the study
The objectives were to:  assess the perception of women towards Traditional Birth Attendants among women attending primary health care centres in Ilishan-Remo, Ogun state. assess the level of utilization of Traditional Birth Attendants among women attending primary health care centres in Ilishan-Remo, Ogun state.

Research Questions
What is the perception of women towards Traditional Birth Attendants among women attending primary healthcare centres in Ilishan-Remo, Ogun state?
What is the level of utilization of Traditional Birth Attendants among women attending primary healthcare centres in Ilishan-Remo, Ogun state?

Research Hypothesis
 Ho1 There is no significant relationship between the perception and utilization of traditional birth attendants among women  Ho2: There is no significant relationship between the educational qualification and the level of utilization of traditional birth attendants among women.

Ethical Consideration
Ethical clearance for this study was gotten from Babcock University Health and Research Ethical Committee (BUHREC).1, revealed that more than half of the respondents were between the ages 25-30years (68.3%), with mean age of 28years ±0.59, the majority were married (94.4%),Christian by religion (57.9%) and most of the respondents were from Yoruba land (61.9%), one-third of the respondents' highest educational level is of secondary (41.3%) and majority of the respondents were mothers of one-two children.

Research Question 1
What is the perception of women towards Traditional Birth Attendants?Table 2 shows the perception of women towards traditional birth attendants.Perception towards traditional birth attendants was rated on the 15-point rating scale.The mean perception of the respondents towards traditional birth attendants was 9.51 ±4.09 and more than the average of the respondents had a negative perception towards traditional birth attendants (55.6%) while few had a positive perception towards the concept (44.4%).

Research Question 2
What is the level of utilization of Traditional Birth Attendants among women?Table 3 shows the level of utilization of women towards traditional birth attendants.Utilization towards traditional birth attendants was rated on the 15-point rating scale.The mean level for utilization of the respondents towards traditional birth attendants was 7.0 ±1.82 and more than average of the respondents were low in utilizing traditional birth attendants (59.5%) while few were high in level use towards traditional birth attendant utilization (40.5%).

Test of hypothesis
Hypothesis 1 (Ho1): There is no significant relationship between the perception and utilization of traditional birth attendants among women.The result in Table 4, revealed a positive insignificant relationship between perception and utilization of traditional birth attendants among women (r = 0.130.; p=0.147> 0.05).The hypothesis which stated that "There is no significant relationship between perception and utilization of traditional birth attendant is hereby accepted by this finding.
Hypothesis 2 (Ho2): There is no significant relationship between the educational qualification and the level of utilization of traditional birth attendants among women.Table 5 shows that there is a positive significant relationship between the level of education and the utilization of traditional birth attendants with a p-value <0.05 (21, X 2 =.132.195,r=0.594).Therefore, the null hypothesis is hereby rejected by this finding.

Discussion
This study projects the majority of the respondents are within the age range of 25-30 years, the majority academic qualification of respondents is no formal education qualification at 33.3%, followed by Tertiary education at 30.4%, while the greater part of the respondents are married 94.4%, and on religion, the respondents were majorly Christians at 57%.
The perception of respondents on Traditional Birth Attendants was examined and the majority of the respondents affirmed that Traditional Birth Attendants were not skilled birth attendants.This is in line with Awotunde, Awotunde, Fehintola, Adesina, Oladeji, Fehintola and Ajala (2017) who submitted that increased maternal and infant mortality rate is blamed on many deliveries that took place at home with the help of untrained attendants, such as Traditional Birth Attendants (TBAs).
It was also found that Traditional Birth Attendants do not have the necessary equipment to handle pregnancy complications or emergencies.The majority also affirmed that Traditional Birth Attendants also contribute to maternal mortality and there's a higher risk of maternal mortality if an expectant mother patronizes the services of TBAs.This was buttressed by WHO (2015) which stated that one of the major ways of reducing maternal mortality is to ensure skilled attendance at delivery and strengthen the health system to ensure nonstop emergency obstetric care.This was summed up to mean that respondents have a negative perception of traditional birth attendants.This result was found the same with the current study due to the level of knowledge the participant gained through health talks, seminars, and health exposure by public health workers in social gatherings like churches, mosques etc. educating them on the effect of traditional birth attendants.
The study further shows that majority of the women had low patronage of TBAs, also, the women agreed that they would not encourage the patronage of TBA services.The women also affirmed that all their deliveries were not undertaken by TBAs, Meanwhile, the majority of the women stated that they may only visit TBAs on the condition that there are no Health Centres available.This statement is similar to a statement of Ntoimo et al. (2018) who asserted that many studies from different parts of Nigeria reported the association of high maternal mortality rates with women who had intended to deliver with TBAs.These studies were found consistent with the current study due to the level of education of the participants and the rate of development in the community.

Conclusion
The study was quantitative research that utilized a simple random sampling method to assess the perception and utilization of TBA services by women attending Primary Health Care Centers in Ilishan-Remo.The theory of reasoned action was adopted for the study.A total of 126 women participated in the study and the findings from the study revealed a negative perception of traditional birth attendants by the women and low utilization of their services.

Nursing implication
Healthcare workers especially nurses and midwives should henceforth inculcate the caring attitude they are known for to encourage women to come for pregnancy care in Primary Health Centers.
Nurses should be more patient and respectful to the patient when providing care.

Suggestion for further studies
 This study could be replicated in other Ogun State communities and other parts of the country. A larger population could be used to replicate this study in other geographical areas

Recommendations
 Based on the findings of this study, the following recommendations were made:  The federal government should strive harder to equip health facilities, especially the primary healthcare centres  Cost for maternity should be subsidized to all pregnant women irrespective of their religion, age or economic status. The government should get involved with communities and provide the necessary health amenities to dispense better health practices. Traditional birth attendants could be trained for safe maternal and child health practices. Maternal healthcare providers should be more intentional in providing health education to pregnant women continuously as this will go a long way in impacting their health and state of mind and also empowering them to be actively involved in watching out for and preventing activities or practices that can either harm them or their child.

Disclosure of conflict of interest
There are no conflicts of interest by the researchers to declare

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.

Table 2
Level of perception of respondents towards Traditional Birth Attendants

Table 3
Level of utilization of respondents towards Traditional Birth Attendants

Table 4
Correlation between perception and utilization of traditional birth attendants among women.

Table 5
Relationship between Educational qualification and utilization of traditional birth attendants