|Year : 2015 | Volume
| Issue : 1 | Page : 4-8
An audit of postpartum referrals by traditional birth attendants in rural Southeast Nigeria
Odidika U Umeora1, Justus N Eze2, Gabriel O Igberase3, Boniface N Ejikeme1
1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Ebonyi State University, Abakaliki; St. Vincent's Hospital, Ndubia-Igbeagu, Ebonyi State, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Ebonyi State University, Abakaliki, Nigeria
3 Department of Obstetrics and Gynaecology, Delta State University, Abraka, Nigeria
|Date of Acceptance||31-Dec-2015|
|Date of Web Publication||20-Jul-2015|
Odidika U Umeora
P.O. Box 980, Abakaliki 480001, Ebonyi State
Source of Support: None, Conflict of Interest: None
Context: Immediate recognition of postpartum complications, prompt, and due management are key to reduction in maternal mortality ratio (MMR). Aims and Objectives: To evaluate the pattern and outcomes of postpartum referrals from traditional birth attendants (TBAs) in rural Nigeria. Materials and Methods: A prospective observational study of patients referred after delivery from TBAs to a Mission Hospital in rural Nigeria. Analysis was by Epi Info statistical software. Results: Two hundred and sixty-two patients were so referred. Perineal injury (29.4%) was the most common diagnosis followed by pyrexia (22.5%), postpartum hemorrhage (18.3%), and genital sepsis (10.3%). The MMR was 4961.8/100,000 live births with PPH accounting for the majority (53.8%). Conclusion: Delay in referral and transportation difficulties were major impediments to prompt access of care from the Mission Hospital. TBAs should be encouraged to refer all cases to well-equipped orthodox medical facilities and get paid for each case as if managed by them.
Keywords: Complications, mortality, postpartum, rural
|How to cite this article:|
Umeora OU, Eze JN, Igberase GO, Ejikeme BN. An audit of postpartum referrals by traditional birth attendants in rural Southeast Nigeria. Niger J Surg Sci 2015;25:4-8
|How to cite this URL:|
Umeora OU, Eze JN, Igberase GO, Ejikeme BN. An audit of postpartum referrals by traditional birth attendants in rural Southeast Nigeria. Niger J Surg Sci [serial online] 2015 [cited 2019 Dec 12];25:4-8. Available from: http://www.njssjournal.org/text.asp?2015/25/1/4/161212
| Introduction|| |
The fifth target of the Millennium Development Goals (MDGs) aims at reducing global maternal mortality rates by three-quarters by 2015. In sub Saharan Africa, very high maternal death rates persist  and continues to rise, further enlarging the wide gap that exists between the rates recorded for African countries and those of Europe and the developed world. Global strategies such as the Safe Motherhood Initiative launched in Nairobi Kenya in 1987, and the Women and Children Health Care Initiative of 2004 have been largely ineffective.
Nigeria accounts for about 1% of the world population but contributes about 10% to the maternal mortality figures.  The majority of the population live in the rural areas where healthcare facilities are inadequate and few trained healthcare professionals are available. Only about a third of pregnant Nigerian women are attended by trained medical staff at delivery;  the rest are supervised by alternative obstetric care providers most of whom are traditional birth attendants (TBAs) who attract a large clientele from the rural areas and occasionally from the urban centers. ,, The negative contribution of the TBAs to maternal survival among the un-booked pregnant women in the rural areas of Nigeria has been well-documented. ,
The major factors responsible for and contributing to, maternal mortality are well-known. , Postpartum complications especially account for the most cases of maternal death. Prompt referral of patients with postpartum hemorrhage (PPH) is crucial to their survival since death of the women frequently occurs within 2 h of onset of the bleeding. , An earlier study that reviewed intrapartum referrals by TBAs to a Mission Hospital in Southeastern Nigeria observed that such referrals resulted in over 60% of the maternal deaths recorded at the hospital.  The present investigation is an audit of referrals to the hospital by the TBAs for postpartum complications. This will form a basis for rational suggestions for management of such cases.
| Materials and Methods|| |
The St. Vincent Catholic Hospital serves the rural communities of Ndubia-Igbeagu and her environs. It is staffed by a complement of nurses, midwives, medical officers, and a specialist obstetrician and gynecologist. Since 2013, it has served as an outpost to the Federal Teaching Hospital, Abakaliki for residency training in obstetrics/gynecology as well as family practice departments.
The local population is mainly agrarian with low literacy and high poverty rates. Christianity, the African traditional religion and animism form their major belief systems. TBAs, herbalists and spiritualists serve as the first point of contact for health care. Referrals are hardly made to the Mission Hospital till late in the disease process. Documented maternal mortality ratio (MMR) of the region is well above the Nigerian national average of 1000/100,000 live births. 
Data were prospectively collected on mothers who presented from outside the facility with intrapartum or postpartum maternal complications over a 3-year interval, January 2011 to December 2013. The study pro forma sought information on the sociodemographics of the parturients, points from where they presented, referrals, delays in unorthodox care centers and outcome of management in terms of maternal mortalities. The medical officer who was trained as a research assistant and was conversant with the local dialect interviewed the parturients where their clinical condition permitted, using a pro forma. Otherwise, information was obtained from a close relative. Ethical clearance was obtained from the hospital management and consent sought and obtained from the subjects on enrolment into the survey. They were specifically informed that declining from the study will not stop or change their management in whatever way. For this study, the Kuti classification  of the clinical condition of the patient at presentation was adopted as follows: Stable, when women presented with stable vital signs and without added complications from previous mismanagement or delay in presentation; and poor, when the patients were admitted with abnormal vital signs or superimposed complications. They were also referred to as moribund, when they presented with severely compromised vital signs and circulatory collapse. The Olusanya et al.  formula for social class which takes into consideration the woman's educational status and her spouse's income was employed for the social stratification here.
Data were entered into and analyzed using the Epi Info statistical software package version 3.3.2 (CDC, Atlanta USA). The Chi-square test was employed for statistical association and a P < 0.05 taken as significant.
| Results|| |
A total of 1268 mothers accessed care at the referral center during the study period. 750 (59.1%) of these were referred from other facilities. Mothers with postpartum complications comprised 263 or 20.7% of all cases managed during the interval. Majority of these, 262 (99.6%) were sourced from the TBAs.
The youngest and the oldest of the mothers were aged 17 years and 43 years, respectively. The mean age was 30.0 ± 11.2 years (±2 standard deviation). Majority of the women were in the age range of 30-39 years, 12.2% were teenagers and 12.6% above 40 years of age. There were 38 primiparas (24.5%) and 33 grandmultiparas (26.3%). The mean parity was three.  All but one of the mothers (99.6%) resided within the rural communities and majority belonged to the lower economic strata of the society. These sociodemographic variables are displayed in [Table 1].
[Table 2] reveals that perineal tear was the most common diagnosis on presentation representing 29.4% of all diagnoses referred. This was followed by pyrexia 22.5%, PPH 18.3%, genital sepsis 10.3% and retained placenta 7.3%. Other diagnoses included eclampsia, obstetric palsy, diabetic coma, uterine inversion, and osteitis pubis in that order.
In most of the instances, the subjects presented to the mission facility on self-referral 72.9% [Table 3]. The remainder, 27.1% were referred verbally. There was not a single case with written referral. Employing the Kuti classification, 85 of the patients were in stable clinical condition, 167 (63.7%) were in a poor state while 10 (3.8%) were moribund. Majority (54.6%) presented after 24 h of delivery while only 12.2% presented within 12 h to the referral center. Similarly, labor had lasted more than 24 h in almost half of the patients. In 27.5%, the labor lasted between 12 and 24 h and in 22.9% <12 h.
|Table 3: Mode of referral; duration of labor; clinical condition, and referral-presentation interval|
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During the period under review, the institutional MMR was 2366/100,000 live births and comprised de facto hospital patients (4), and 26 among patients from various referring centers including the traditional birth homes. A total of 650 mothers were from the TBAs (388 with intrapartum complications and 262 with postpartum complications). Nine of the women with intrapartum complications died giving a specific MMR of 2319.6/100,000 live births while 13 of those with postpartum complications suffered maternal death giving a specific MMR of 4961.8/100,000 live births. In general, women with postpartum complications constituted 59.1% of deaths among referrals from the traditional birth homes [Table 4]. Obstetric hemorrhage (53.8%), sepsis (30.8%), and eclampsia (15.4%) were the causes of maternal mortality among the subjects in that order. Six of the seven women that died from obstetric hemorrhage were grandmultiparous.
Among those who presented in poor or moribund clinical states, delay in referral by the TBA was cited in 86.4% of cases as the cause of delay in presentation to the referral center [Table 5]. Transportation difficulties (72.3%), financial constraints (45.8%), lack of confidence in the orthodox medical facilities (18.1%), and strong belief in the ability of the TBA to resolve all complications (9.0%) were other reasons given as well as prior sojourn through the spiritual houses before presentation (2.3%).
| Discussion|| |
Over 50% of the women admitted to the Mission Hospital during the study interval were referred by the TBAs. The participation of this group of obstetric care providers should be considered as essential in any program aimed at reduction of maternal mortality in Nigeria. The World Health Organization-sponsored large scale training of the TBAs from the 1970s to the 1990s in an effort to reduce maternal deaths has been largely unsuccessful, although a meta-analysis of the studies of the effectiveness of the program suggests that it resulted in an 8% reduction in maternal deaths and an improvement of the TBAs' knowledge, attitude, behavior, and advice.  The outcome of the subsequent plan to train skilled birth attendants to work among the rural communities where the majority of the women live and medical facilities are sparse remains to be evaluated. Obuna et al.  have however observed that even when such facilities are available, uptake has been poor. Reasons adduced for the poor uptake are detailed under the results. The TBAs have consequently remained the first point of medical contact for many pregnant women in rural Africa. 
Postpartum complications as shown in this study account for most cases of maternal morbidity and mortality in the developing world. PPH, the most common of these complications, is globally the leading factor in maternal death  and leads to maternal demise within 2 h of its onset.  Therefore, recognizing this complication as well as other postpartum morbidities and ensuring prompt access to adequate care are key to reducing maternal deaths consequent upon those. Unfortunately, the risk factors for the complications are not recognized by the TBAs, who are barely literate and depend on family tutelage and/or traditional apprenticeship for their management of cases.
Perineal lacerations of different degrees were the most common findings on admission and demonstrated a lack of the requisite knowledge and skills by the TBAs. None of the women was given an episiotomy during delivery. Most of the patients with pyrexia were dehydrated and required fluid infusion. Gestational diabetes mellitus was diagnosed in the antenatal period in the four women who presented with postpartum coma. They were successfully resuscitated and revived in the referral center. Genital sepsis developed early in the postpartum period and resulted in four deaths revealing the lack of aseptic technique in intrapartum patient care. Many of the TBAs in the rural areas perform vaginal examinations with bare hands or recycle non sterile gloves. They do not have sterilizing units or autoclaves. 
A lack of knowledge of the possible fatal outcome of postpartum complications was shown in the outright refusal by the TBAs to refer ill patients in 72.9% of the cases. In the women reluctantly referred (27.1%), referral took the form of verbal communication. It was not surprising, therefore, many patients were moribund or in poor clinical condition on arrival at the hospital. PPH accounted for 59.1% of the deaths in our review and 43.3% of all deaths recorded at the center. These women came in circulatory collapse, and some cases died even before blood transfusion could be given or the shock could be reversed. In Nigeria, the TBAs, who are not recognized by government, should be trained to refer. At the 42 nd Annual General Meeting of the Society of Gynaecology and Obstetrics of Nigeria held in Enugu-Nigeria, it was suggested that the TBAs be encouraged to refer all cases and get paid fully for each case as if they rendered the service in question. This may be worthwhile since most of the traditional practitioners are in the business for economic gains.
Health education is important for the rural women who are poor, illiterate, and ignorant and belong to the lower rungs of the socioeconomic class. Aversion to modern medical management still exists in the rural areas as seen in this study. Most respondents in an earlier study equated orthodox facilities with blood transfusion and surgical operations which should, therefore, be avoided.  Other reasons for poor utilization of the orthodox medical facilities included the negative attitude of medical staff and unavailability of medical personnel and drugs on a 24 h basis. Following health education, 74% of the women would deliver an orthodox medical facility while 12% and 14%, respectively, would still prefer the TBAs and home delivery.  Making orthodox health care free or more affordable will impact positively on the health seeking behavior of the women and ultimately on the maternal mortality figures.
| Conclusion|| |
Postpartum events are major causes of maternal morbidity and should be given prompt and adequate attention. The TBAs, who are strongly patronized in the rural communities have poor knowledge and skill for optimal labor/delivery management, do not recognize postpartum danger signals and fail to refer ill patients promptly. While the Nigerian government's effort at increasing the number of skilled birth attendants is commendable, encouraging the TBAs to refer all cases to orthodox medical facilities should be considered. In the short-term, reduction or elimination of user fees for pregnant women, improvement in transportation, communication, and health education are also advocated if the fifth goal of the MDGs is to be achieved.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]