“Once the delivery is done, they have finished”: a qualitative study of perspectives on postnatal care referrals by traditional birth attendants in Ebonyi state, Nigeria

Abstract

BackgroundWhile 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers.MethodsThis study collected qualitative data using focus group discussions involving 28 female health workers, TBAs, and TBA delivery clients. The study conceptual framework drew on constructs in Fishbein and Ajzen’s theory of reasoned action onto which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. We analyzed the transcribed data thematically, and linked themes to the study conceptual framework in the discussion to explain variation in TBA referral behavior across the maternal continuum, from the antenatal to postnatal period.ResultsDifferences in TBA referral before, during, and after delivery appear to reflect the TBAs understanding of the added value of skilled care for the client and the TBA, as well as the TBA’s perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBAs in routine postnatal care referrals to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers.ConclusionsThus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. Further research is needed on the interactions between postnatal maternal complications, TBA referral behavior, and maternal perception of TBA competence.Electronic supplementary materialThe online version of this article (10.1186/s12884-017-1616-x) contains supplementary material, which is available to authorized users.

The impact of monetary incentives on referrals by traditional birth attendants for postnatal care in Nigeria

“…Among most clients, ill-health of the mother or neonate following delivery was not the primary motivation for attending early postnatal care. This finding may, however, point to a pattern of primarily referring clients that did not have complications [8]. We thus pooled all the client data to examine the probability of attending postnatal care within 48 h of delivery among maternal and neonatal clients with or without complications.…”

“…TBAs compete with skilled health workers for clients, primarily antenatally and at childbirth, and there is a reputational risk and the potential for client loss in future pregnancies if the TBA refers to skilled health workers [8]. Nonetheless, qualitative research indicates that even when Nigerian mothers do not receive postnatal care themselves, they often recognize the need for their newborns to receive early postnatal care, particularly for recommended immunizations [8]. Thus, recent programs that have offered TBAs monetary incentives have focused on referrals of mothers specifically to skilled providers, with mixed results, as described below.…”

Repositioning traditional birth attendants to provide improved maternal healthcare services in rural Ghana

“…In a recent study, Haruna, Kansanga and Galaa, found that despite the obvious need for collaboration between TBAs and community health nurses (CHNs), their relationship was largely acrimonious . These conflicts were mainly due to the differential notions of legitimacy both CHNs and TBAs held about each other's mandate to offer maternal health services and the eventual perception of encroachment on each other's roles within the rural community . While TBAs draw their legitimacy from their longstanding culturally mandated role as traditional midwives in their communities, nurses interpreted the activities of TBAs from a legal and biomedical perspective, mostly highlighting about the unlawful and harmful nature of their operations …”

“…6 These conflicts were mainly due to the differential notions of legitimacy both CHNs and TBAs held about each other's mandate to offer maternal health services and the eventual perception of encroachment on each other's roles within the rural community. 6,8,9 While TBAs draw their legitimacy from their longstanding culturally mandated role as traditional midwives in their communities, nurses interpreted the activities of TBAs from a legal and biomedical perspective, mostly highlighting about the unlawful and harmful nature of their operations. 6These prevailing role conflicts are ironic given that the Community-based Health Planning and Services (CHPS) policy which sanctioned the deployment of community health nurses to rural areas, envisaged a cordial, complementary, and collaborative relationship between CHPS operatives and all other local community stakeholders.…”

Socioeconomic Disparities of Facility-Based Childbirth in Indonesia

“…(3)(4); education factor (5)(6)(7); economic factors (8) (9), and social factors, which are related to public trust in non-health workers, such as traditional birth attendants, as birth assistants (10) (11) (12).…”