After losing her fourth child during delivery at the house of her regular traditional birth attendant (TBA), 42 year–old Kemi Ariyo contracted spiritualists to get to the root of her problems. “I was widely accused to be a witch as a result of the demise of my babies,” Kemi said. “So I approached the spiritualists who pray for pregnant women and see to the delivery of their babies”.
The delivery of the fourth happened in a thatched roof house with three spiritualists around her in her native Ode Ugbo, a riverine community of Ondo State. But in spite of their weekly prayers and their presence during the delivery, the baby was lost to still birth .
Ariyo's case may be extreme but generally indicative of the problems that women in rural Nigeria face. Almost on a daily basis, women in her situation consult spiritualists who charge between 15000 naira and 25000 ($48 -$79 ) per delivery – who claim to be praying and fasting and would consistently administer local herbal concoctions (Agbo) to these women between the period of pregnancy and delivery.
According to the National Demographic Health Survey, 2008, Ondo state had a maternal mortality ratio of 742 per 100,000 live births with worse indices at the facility level. Nigeria records one of the world’s highest rates of maternal deaths, with the country being the largest contributor of maternal deaths globally and second largest of under – five deaths with India being the first.
Most families especially those in rural communities – characteristically uneducated and economically disadvantaged - are at the mercies of spiritualists, and unskilled traditional birth attendants that they consult to deliver their babies. “We trust the outcome will be divine, we never trusted government hospitals” explains 60 year- old Taye Idowu in Yoruba.
One day however, Madam Taye, a former traditional birth attendant now maternal health evangelist approached Mrs Ariyo and appealed to her to stop patronizing spiritualists, “I told her that the unskilled birth attendants are the reasons she has been childless” she said.
Taye is part of a corp of maternal health evangelists, mostly reformed traditional birth healers under the Ondo state government's 'Agbebiye' programme – an incentive based referral programme. The TBAs are encouraged to refer their ‘patients’ to the orthodox clinics and earn money. She and others in the 18 local governments of Ondo State are part of the Agbebiye Initiative – a community – based approach and a primary health care model aimed to further improve community ownership to reduce maternal health to zero.
When questioned how she succeeded in persuading the health care providers to stop tending to Ariyo, she explains that she simply reiterated the birth techniques and the dangers she was now aware of. “We were all together in the same community, and I was part of the trade – we use broken bottles to cut the umbilical cord immediately the women deliver their babies, some get home and die from infection. We did not know it was bad.”
I paid a visit to a Comprehensive Health facility Centre in Oba’ile – Ondo South where a 34 year- old trader, Aderoju Fumilayo strapped her new-born baby who was obviously dazed with the heat and noise to her back. As she waited within the premises while women gathered for antenatal care to be attended to, she narrated her experience birthing three of her four kids. She compared those births by the traditional birth attendants to what is obtainable at the health Centre.
“I was normally asked to give them kerosene, Omo, Dettol, Detergent, and 10,000 naira as payment and conduct my babies naming ceremony there before they deliver my babies – I lie on a bench (typically made of wood) sometimes on the bare floor to deliver my babies”, she said.
Standing beside Funmilayo at the health Centre is a 65 – year –old, Olayiwola Fagoroyo, observing as a middle age nurse attends to Funmi. I am told she’s an “Agbabiye Vanguard” – she moves around with the women she refers to this health Centre’ making sure they go for antenatal, deliver the babies at the referred health Centre’s, and ensure the children are properly immunized to prevent mortality.
Dr. Dayo Adeyanju, the state Health Commissioner explained that ‘Abiye’ (safe motherhood program is a prelude to “Agbebiye” a word in Yoruba that means “Safe Birth Attendant” which could also mean “Safe Pregnancy Delivery”, and conducted in partnership with Traditional Birth Attendants (TBAs).
“The Programme strives to ensure Universal Health Coverage for comprehensive sexual, reproductive, maternal and newborn health care” he said. “The traditional birth attendants refer their clients to the health facilities for a cash reward and training on vocational skills acquisition (soap making, hat and bead making, catering services and tie and dye making”.
For the commissioner, the incentive provided by government was the major driver in a country like Nigeria that ranks amongst the 10 worst countries in sub-Saharan Africa to birth a child – according to Save the Children Mothers’ index.
But for Madam Kikelomo, a former traditional midwife now registered with government in downtown Akure, “we’ve seen that traditional birth attendant methods are harmful to our women which is why we had to enroll in the “Agbebiye program” – reducing the number of women and children dying during child birth”.
With two dedicated Mother and Child Hospitals, the Ondo State Government has been able to reduce Maternal Mortality Ratio (MMR) by 84.9 per cent. From 745 per 1000,000 live births in 2009 the indices have drastically reduced to 112 per 100,000 live births in 2016 – a feat which made the state a recipient of a 400 million dollars grant from the World Bank.
“The women are treated free, from natural births and those that undergo caesarian operation, it is also done at no cost – that has helped us to scale – up the numbers”, the Chief Medical Director, Dr Adesina Akintan of the Referral centre (mother and child hospital) Oke’ Aro in Akure tells me. “Our objective is to make sure no woman dies during pregnancy or trying to birth a child”.
Another expectant mother, Mrs Oluwakemi Fagbe at the referral centre in Oba’ile, within Akure Municipality, tells me, “- They have specialists in this place and that is why I am here, Pregnant women from neighbouring states also visit this place to deliver because it is free, they even provide free blood donation for our children from age zero to 5 years.”
Outgoing governor Olusegun Mimiko of Ondo, a medical doctor, boasts of meeting the United Nations Millennium Development Goals (MDGs) targets “between 2010 and 2016, we were able to crash maternal mortality by over 75% since we came on board and of course that can be linked to the Abiye and Agbebiye scheme we introduced”.
“We created an incentive scheme, with every referral by the Traditional birth attendants to access healthcare by expectant women, they are given a coupon, which is N2000 each per referral - with that method, they convinced most of their clients to orthodox hospitals for proper care" said the governor.
For Mrs Ariyo and Mrs Fagbe the knowledge gained by attending antenatal will be passed on to their children as they were all birthed at home through the risky and life threatening traditional birth attendants methods.
A state government document explaining the concept of Agbebiye initiative claims that among those referred by traditional birth attendants, there was no single maternal death with 99% neonatal survival – and facility utilisation increased by 20.4% in the primary health care facilities and there was a reduction in the facility utilization of the apex tertiary hospital.
Whether the Abiye programme can be sustained, as fiscal allocations to states continue to decline is a question that time will answer.
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