Ife PsychologIA, 28 (1), 2020, 117 - 130
Copyright (c) 2020 © Ife Centre for Psychological Studies/Services, Nigeria
ISSN: 1117-1421
EFFECT OF COMMUNITY-BASED HEALTH EDUCATION ON TIMELY REFERRAL
OF HIGH RISK PREGNANCY BY TRADITIONAL BIRTH ATTENDANTS IN OYO
STATE, NIGERIA
Adebayo M. Mustapha, Nnodimele O. Atulomah & Catherine O. Agbede
Department of Public Health
Babcock University
Ilishan-Remo, Nigeria
E-mail: Mustapha_unknown@yahoo.com, nnodatulomah@hotmail.com
agbedec@babcockuni.edu.ng
Abstract
Globally, women of child bearing age are susceptible to emerging life threatening complications
and poor pregnancy outcomes with lack of early detection and timely intervention. These
complications are responsible for 75% of maternal mortality globally and the burden is
significantly high in Nigeria with 814/100,000 live births where deliveries are supervised mostly
by traditional birth attendants. This study examined the effect of community-based health
education on timely referral practices of high-risk pregnancy by TBAs in Oyo State, Nigeria. This
study employed a quasi-experimental design with one-arm intervention group and control.
Sample size of 90 participants was computed for the study (45 participants assigned to each
group). The study utilized a 58-item validated questionnaire. Data were analyzed using
descriptive and inferential statistics. Result showed that at 12th week follow up, a total of 91
referrals were made by the intervention group to referral points. Effect size (ES) at the 12 weeks
follow up and respective value at baseline was significant (16.53±0.27, 7.75±0.27, p=0.00,
ES=0.94).The study recommended regular training focused on early detection of high risk
pregnancy and timely referral for skilled care in collaboration with trained health providers
Key words: High risk Pregnancy, Traditional Birth Attendants, Referral, Health Education,
Maternal mortality
Introduction
Birth complications are unpredictable in pregnant women and they are responsible for 75% of
maternal deaths globally, claiming about 585,000 lives of women annually (WHO, 2018). There
is a wide disparity between developing countries and developed countries with 99% of these
deaths coming from developing countries and 1% from developed countries (UNICEF, 2015;
WHO, 2015) For decades, it has been known that about 80% of women while pregnant are
susceptible to life threatening complications while approximately 15% will experience
unpredicted complications during childbirth which will require timely intervention of skilled
obstetric care (Thaddeus, 1994). Every day, it is estimated that over 1,600 women experiencing
these complication cases dies at childbirth or after delivery. Furthermore, infant mortality rates
are unacceptably high with about 3.7 million deaths of newborns due to unskilled postpartum
care (WHO, 2016). Over 50% of the infant mortality rate occurs in the first 24hours life and
others occur in the first week of life. There was however, a tremendous reduction of the global
burden of maternal mortality recoded (1990 to 2015) experiencing 44% reduction after the
Millennium Development Goals era in 2015. Although the global reduction was not equal
between developing countries such as Africa and Asia compared to developed countries such as
Europe (UNICEF, 2015). Maternal mortality is 18times higher in Sub-Sahara Africa and Asia
countries than developed countries such as Scandinavian countries (Sweden, Norway, Finland,
Iceland, Denmark). Maternal mortality in Africa is more than 1000 per 100,000 live births and
Nigeria has the highest maternal mortality rate in this region, the second nation contributing to
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the burden globally after India (Asia). It is estimated that maternal mortality rate in Nigeria is
814/100,000 live births (Jane, 2012; Sageer, 2019; WHO, 2019). This is unacceptably high. High
proportions of maternal deaths (75%) are preventable, managed with timely intervention of
skilled birth attendants (Adanna, 2019; WHO, 2019). However, due to shortage of health care
personnel and poor health care seeking behavior of some pregnant women (Crowe, 2012; Osain,
2011; Yarney, 2019), over 60% of deliveries are supervised by traditional birth attendants who
are not formally trained (Adeniyi, 2015, Aschenaki,2018; Adanna, 2019). Consequently, they are
not equipped with knowledge and skills to handle pregnancy complications but these TBAs can
facilitate timely referral of pregnant women with high risk to skilled birth attendants which has
been significant to better outcome of maternal and child health.The findings of the study will be
useful to Ministry of Health and other key stakeholders such policy makers in designing a
sustainable intervention in facilitating referral between TBAs and skilled birth attendants thereby
reducing maternal mortality on the long run.
Referral is the process of coordinated movement of health care seeker to reach a high-level care
within a small window of time (Biswas, 2018).One of the core aspects of maternal health care
services is referral system, especially in the care of obstetric and new born emergencies when the
need arises like birth complications. According to World health Organization (WHO), a referral
is a “process in which a health worker at one level of health care system, having insufficient
resources (knowledge, skills, equipment and drugs) to manage a clinical condition, seeks the
assistance of a better or differently resourced facility at the same or higher level to assist in or
take over the management of the client’s case” (WHO, 2017). Referral for this study, is defined
as a process in which a traditional birth attendenats at the community level, detects early high risk
pregnancy and child birth complications while having insufficient knowledge and skills to
manage birth complications, refer the pregnant woman to skilled birth attendants at the primary
health care centre and if its beyond their limits, they also refer to the next level of health care as
they have limits to the care they can provide.i.e. Health staff at some primary health care level
can not adequately manage severe complications so they refer to the secondary level of care and
the last level of care is the tertiary level according to the health system of Nigeria.
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Methods
Research design
The intervention study was carried out between September, 2019 and February, 2020. The study
adopted a quasi-experimental design with one-arm intervention group and control. A total of 90
participants were assigned equally to intervention group and control (45 participants assigned to
each group) There was triangulation of data from qualitative to quantitative design. All responses
obtained at the focused group discussion informed the basics in designing the quantitative
instrument for data collection. The study was carried out in three phases; First phase was baseline
data collection, Second phase was implementation of the intervention and post-intervention
assessment while the last phase was 12weeks follow up of the respondents to measure changes in
the referral practice. A validated structured 58-item questionnaire with reliability coefficient of
0.8 was utilized for data collection. Quantitative data were collected through intervieweradministered questionnaires with the help of research assistants. The study was conceptualize on
PRECEDE model. The constructs of the conceptual frame such as predisposing factors,
reinforcing factors, enabling factors and referral behavior were operationalized in the instrument
used for data collection. A total of five research assistants that speak local dialects were recruited
and trained to this effect. The instrument measured respondents’ measured personal level factors,
environmental level factors and referral practices before the intervention, after the intervention
and at the 12weeks follow up of the respondents.
Recruitments and Study Protocols
In July 2019, the researcher met with the traditional birth attendants in all the local government
areas selected for the study during their monthly meeting scheduled to hold every last Monday of
the months, for some every last Wednesday/Thursday of the month. The date varies for different
local government areas in the state. The trip was made to different LGAs to recruit the
participants and obtain verbal consent approval. To participate in the study, TBA had to be a
recognized maternal health care provider in the community, no plan of relocating for the next two
years from the inception of the study and provide oral informed consent to the study. Meetings
were also held with the primary health care coordinators for each of the LGAs, the traditional
rulers in some communities in engaging them about the study. Recruitments of respondents and
research assistants were done at this stage.
Training manual was developed and modified by the researchers based on the outcome of the
baseline study. The content of the training manual was in accordance with the international
confederation of midwives essential competences for basic midwifery practice and World Health
Organization training manual for traditional birth attendants with inputs from research assistants
such as the midwives and the nurses recruited for the study. The modules of the intervention
sessions laid emphasis on specific educational objectives in identifying high risk pregnancy and
childbirth complication which should necessitate timely referral of such cases. This was to
improve TBAs’ cognitive domain and raise their perceived seriousness of high risk pregnancy
and susceptibility of pregnant women to pregnancy complications which would stimulate their
timely referral practices. Issues on pregnancy management from first trimester to third trimester
were discussed such as Nutrition, family planning, prevention of mother to child transmission of
HIV, malaria prevention, focused antenatal visits, monitoring of blood pressure, glucose level,
body weight of the pregnant woman and fetus, normal positioning of the baby in the womb and
potential signs of pregnancy complications. Videos and pictures of poor outcomes of pregnancy
complications were displayed to the participants to raise their perceptions and modify their
referral behaviors. Data were collected in four phases (Baseline, Immediate post-intervention and
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12 weeks follow-up assessment) to answer the research questions and test the hypothesis that
guided the study.
Baseline data collection
Baseline was the first phase of data collection from the participants. The baseline data served as
bases for comparison between the intervention and control. This also served as means of
detecting changes attributable to the intervention. Data were obtained from the intervention and
control groups with the use of the designed 58-item questionnaire through intervieweradministered by the research assistants recruited for the purpose. The instrument comprised of 5
sections that are control variables, independent variables and dependent variables. These
variables are; Demographic characteristics, Predisposing factors (Knowledge about pregnancy
management, perceived seriousness of pregnancy complications, perceived susceptibility to
pregnancy complications, perceived benefits of timely referral of high risk pregnancy, perceived
self-efficacy in terms of intention to initiate timely referral), Attitudinal dispositions towards
referral in terms of relationships between TBAs and skilled births attendants, Reinforcing factors,
Enabling factors and finally the Referral practices.
Immediate Post-intervention data collection
Immediately after the experimental group received the 3-weeks intervention, the same data
collection instrument used for baseline data collection was used to get responses from the
intervention and control group for the second time. The control group received just a 1-day health
talk on tuberculosis, not related to the subject matter as recommended in the principles of ethics
that the control group should also benefit from the study (SASLHA, 2011). The variables
measured are basically were the independent and dependent variables. Socio demographic data
were kept throughout the study.
End line data collection
The end line data collection was the third and the last phase of data collection. The end line data
was obtained using same data collection instrument and this was done at the 12 th week follow up.
Focus was more on the outcome variable which was the referral practices and close monitoring of
pregnant women that were referred for skilled care to prevent or manage pregnancy
complications. The referrals were counted manually through the referral slips issued to the TBAs
and confirmed at the referral points used for the study.
Sample size
Sample size of 60participants was computed for both groups using sample size determination for
intervention. However, the sample size was increased to 90participants to give room for attrition,
incompleteness and unpredicted obligation to other things by some participants. Also, according
Zamboni, (2018) having a sample size of 30 and above is statistically appropriate for each group
in an intervention study. This will minimize margin of error, gives accurate mean value and
identify outliers that could skew the data in a smaller sample size (Zamboni, 2018; Sarah, 2015).
Hence, a total of 45 participants were assigned to intervention group and same sample size of 45
assigned to control group.
Study Area
The study was carried out in Oyo State, southwest, Nigeria where 6 in 10 deliveries are assisted
by traditional birth attendants and 4 in 10 newborns do not receive postnatal care within the first
two days of childbirth, most especially in the rural areas selected for the study. The maternal
mortality rate and infant mortality rates are estimated to be 262/100,000 live births and 6.9/1,000
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live births respectively (NURHI, 2015; Olaleye, 2019). The MMR is 5times higher than the set
target of the Sustainable Development Goals (SDGs) and highly unacceptable compared to global
practices.
The capital of Oyo State is Ibadan (Yoruba: Ìbàdàn or fully Ìlú Ẹ̀ bá-Ọ̀dàn, the town at the
junction of the savannah and the forest) Ibadan is the third largest metropolitan area in Nigeria,
after Lagos and Kano. Ibadan is also the largest metropolitan geographic area. The state covers an
area of 28,454km2 with an estimated population of 5,591, 589 people (NPC, 2006). Oyo State is
one of the six geopolitical states in Southwest, Nigeria. It is bounded in the north by Kwara State,
in the east by Osun State and the South by Ogun State. Major source of income in the area
includes; trading, farming, hunting, blacksmithing, weaving, tailoring and carpentry. There are 33
local government areas in the three (3) senatorial districts of Oyo State. In Oyo South senatorial
district, there are a total of nine (9) LGAs, Oyo central senatorial district. There are a total of
Eleven (11) LGAs, while Oyo north has 13 LGAs. For this study, a total of six (6) LGAs at the
remote areas were purposively selected across the 33 LGAs for the study. The local government
areas used for the study are Egbeda, Iseyin, Lagelu, Irepo, Ogo-oluwa and Itesiwaju LGAs.
Participating communities are mostly rural areas. The predominant local dialect is Yoruba in
these areas and research assistants that speak this language were recruited to translate the data
collection instrument to the respondents. There are mainly Primary health care centers used for
referral points in these communities while the primary health care centers also get to refer
patients that the health need is beyond their limitation of practice to district hospital where
comprehensive emergency obstetric care is available.
Population of Study
The study population comprised of traditional birth attendants registered in their association and
found to be accessible in each of the local government areas that were selected through
multistage sampling technique for the study. A total of six local government areas were used for
the study with 15respondents recruited from each LGA through simple random sampling, done
during their monthly meeting. The TBAs who were registered, available for the study and
consented were eligible for the study. Traditional birth attendants who were not willing to
participate in the survey and who did not work with in any of the LGA that were selected for the
study were excluded. Also, health care providers who assist deliveries at homes were excluded
from the study.
Ethical Consideration
Prior to data collection from the respondents, a detailed proposal containing the study protocol
was submitted to Babcock University Health research Ethics (BUHREC) seeking approval for the
study. After the proposal was dully reviewed, an approval was obtained to proceed in carrying
out the study. Ethical approval was also obtained from at the various local government areas
selected for the study with collaboration with the head of Primary Health Care centers in all the
LGAs. All respondents that participated signed the consent form after they told the purpose of the
study.
Data Analysis
Data were analyzed using the computer statistical package for social sciences (SPSS) version
23.0. Descriptive and inferential statistics were done to answer the research questions and the
hypothesis that guided the study. Significant level was set at p<0.05 for all statistical analysis.
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Results
The result showed that the mean age for all respondents in the study was approximately 53.8±6.6.
The control group had a mean score of 55.7±5.4 while the experimental group had 51.8±6.4.
There were more female traditional birth attendants (90%), male (10%) than in the control group
(85%), male (15%) which validates the result of other studies that 90% of traditional birth
attendants are women most especially in Sub-Sahara Africa. Thus, why they are very caring and
give emotional support to pregnant women. Majority of the participants in both groups (70%) are
married compared to the divorced ones ((25%) while others are widowed (5%). There were more
Christians (90%) in the experimental group compared to control group with just 80% of
respondents indicated to be Christians while Muslim participants were 20%. More than half
(60%) only had primary school education attainment while Exactly half of the participants (50%)
had only primary educational attainment in the control group, while only 40% attended primary
school from the experimental group. About 35% had secondary school attainment while others
(15%) had no formal education and none of the participants had tertiary education from the
control and experimental groups. A little above average of the participants (60%) acquired their
skills through apprenticeships from other TBAs, 15% from skilled birth attendants while 25%
acquired from both the skilled birth attendants and TBAs. The mean year of experience of all
participants was computed to be 17.6±5.8 while mean number of births assisted to by the
participants yearly was 11.9±3.2. Majority of the participants (70%) engage in another job asides
assisting pregnant women to deliver while 30% had no other jobs (See Table 1)
Table 1: Demographic Characteristics of the participants in the study for intervention and control
at baseline.
Intervention Group
Control Group
N=44
N=43
VARIABLES
Frequency
Frequency
Total
N (%)
N (%)
Gender:
Male
4(10)
7(15)
Female
41(90)
38(85)
45(100)
Mean Age
Marital Status
Married
Divorced
Widowed
51.8
55.7
53.75
32(70)
9(20)
4(10)
32(70)
13(30)
0(0.0)
45(100)
Religion
Christian
Muslim
41(90)
4(10)
36(80)
9(20)
45(100)
Education attainment
Primary
Secondary
Tertiary
No Formal education
18(40)
18(40)
0(00)
9(20)
27(60)
8(30)
00(00)
4(10)
45(100)
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Form of training
Formal training
Apprenticeship TBA
Skills from SBA
Both SBA and TBA
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0(00)
23(50)
4(10)
18(40)
0(00)
32(70)
9(20)
Outcome Evaluation at 12th Week follow-up for Control and experimental groups in the
study
At the end of 12th week follow up in the study, a final assessment of the key variables was carried
out. In order to determine the magnitude of change that occurred for the variables, baseline mean
scores are compared with the corresponding mean scores recoded for the 12th week follow-up.
Evaluation of Intervention at 12th Week Follow-up
For intervention group, Level of knowledge of respondents on childbirth complications and high
risk pregnancies measured on 16points rating scale, mean score was recoded to be 10.49±0.24.
Perceived seriousness was measured on 15points rating scale and mean score at 12 th week follow
up was recoded to be 10.02±0.31. Perceived susceptibility was measured on 12points rating scale
and mean score recoded at 12th week follow up was 9.61±0.22. Perceived benefits was measured
on 15points rating scale, mean score was recoded to be 11.8±0.25. Self-efficacy also known as
intention was measured on 9points rating and mean score for respondents was recoded to be
7.40±0.25; Attitudinal disposition of respondents was measured on 12points and mean score was
recoded to be 9.83±0.23 at the 12th week follow up. (See Table 2A)
Reinforcing factors was measured on 12points rating scale and mean score for intervention group
at 12th week follow up was recoded to be 8.87±0.4. Enabling factors measured on 15points rating
scale, mean score for the intervention was recoded to be 11.33±0.18. While referral behavior
measured on 18points rating, the mean score for intervention group at 12th week follow up was
recoded to be 16.53±0.30. (See Table 2B)
Outcome Evaluation at 12th week follow up and experimental group in the study
Table 2B: Summaries of descriptive statistics for predisposing factors in timely referral of child
birth complications and high risk pregnancies for experimental group at baseline and 12 th week
follow up.
VARIABLES Maximum
Points on
Scale of
Measure
Knowledge
Perceived
Seriousness
Perceived
Susceptibility
Perceived
Benefits
Perceived
Self-Efficacy
12th Week Follow up
N=40
Base-line
N=43
𝑋 (SD)
𝑋 (SD)
*ES (95%CI)
16
4.1(0.24)
10.49(0.28)
-3.5(-0.72)
0.000
15
4.34(0.30)
10.02(0.28)
-2.44(0.77)
0.000
12
6.9(0.22)
9.61(0.23)
-1.59(-0.62)
0.000
15
9.42(0.25)
11.81(0.30)
1.41(0.56)
0.000
9
5.67(0.25)
7.40(1.20)
-1.16(-0.50)
0.000
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Attitudinal
Dispositions
12
4.85(0.29)
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9.83(0.01)
-2.82(-0.8)
0.000
*ES; effect size of the intervention between baseline and impact evaluation computed from
Cohen’s d, the corresponding 95% CI; and p-value is level of significance
Table 2B: Summaries of descriptive statistics for reinforcing, enabling factors and referral
behavior involved in timely referral of childbirth complications and high risk pregnancies among
the respondents at baseline and 12th Week follow up assessments for intervention group
VARIABLES Maximum
Baseline
12th Week Follow up
Points on
N=43
N=40
Scale of
Measure
𝑋 (SD) 𝑋 (SD)
*ES (95%CI) P-Value
Reinforcing
Factors
12
3.17(0.4)
8.87(0.255)
-2.2(0.70)
0.000
Enabling
Factors
15
3.86(0.18)
11.33(0.20)
-5.35(-0.93)
0.000
Referral
Behavior
18
7.75(0.27)
16.53(0.27)
-5.48(0.9)
0.000
*ES; effect size of the intervention between baseline and impact evaluation computed from
Cohen’s d, the corresponding 95% CI; and p-value is level of significance.
Discussion of findings
The purpose of this study was to evaluate the effect of community-based health education on
timely referral of high risk pregnancy by traditional birth attendants in Oyo State, Nigeria.
Prevention and management of childbirth complications and high risk pregnancies have been a
key strategy to reducing maternal mortality rate in rural areas where traditional birth attendants
provide assistance to more than 60% deliveries (Kayombo, 2013). Early detection of
complications and high risk pregnancies by trained traditional birth attendants in these remote
areas and timely referral of complication cases to skilled birth attendants has been highly
correlated to better maternal health outcomes with statistical evidences from studies (Chukwuma,
2019; Kitui, 2017; Pyone 2014). However, it is known that traditional birth attendants from the
baseline study (first phase of this study) and other studies, have limited knowledge and skills to
detect early, childbirth complication and poor attitudes towards referral due to some factors such
as poor collaborative relationship between TBAs and skilled birth attendants, poor enabling
environment and the perception of pregnant women about the harsh treatment from some skilled
birth attendants (Ouendjli, 2005; MacArthur, 2009; Mathur, 2011; Ndoua, 2019; Satishchandra,
2013). Evidently, all these can be modified through evidenced-based health education
intervention that will improve on TBAs knowledge and skills to identify early, childbirth
complications and high risk pregnancies, arouse their perception of these complication cases,
change their attitude to a favorable one for timely referral and ensure there is a good working
relationship between them and the skilled birth attendants thereby making them an integral part
of maternal and child health, most especially in the rural areas (Chukwuma, 2019; Reeve, 2016).
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Outcome Evaluation at 12th week follow-up
The primary aim of the study was to find out to what extent the health education intervention will
increase the referral rate of participants at the intervention group by modifying the personal-level
(Predisposing factors) and environmental-level factors (Reinforcing and Enabling factors). The
referral rate in the last one month before the intervention was implemented was at zero to all
primary health centers used as referral points for the study. Data were obtained from the matron
of each center listed for the study. After the immediate impact evaluation, all participants
(Intervention and Control groups) were followed up for monitoring and supervision and each
TBA were attached to a primary health care center for the period of 12 weeks (October 2019January 2020). The chairperson (TBA) responsible for Lagelu LGA axis was trained and used for
close monitoring of all participants in both Lagelu and Egbeda while another person was
recruited for the third LGA because of the proximity. At the end of the 12 th week follow-up,
another impact assessment was carried out known as 12 th week follow-up outcome evaluation
which is to compare the change in all variables between the baseline phase and the 12 th week
follow up. The mean difference was also significant with a slight changes occurring from the
immediate post assessment and the effect size was also large and significant at p<0.05 (p=0.000)
for all variables (Personal-level and Environmental level)
Furthermore, there were also a total number of 91 referred cases made by the trained TBAs to
referral points used in the study. A total of 60 referred cases were to ensure pregnant women
uptake tetanus toxoid & anti-malaria injection and postpartum care such as vaccination while a
total of 31 cases were recoded to be high risk pregnancy and serious complication cases that were
managed adequately by the skilled birth attendants. Data was obtained from the TBA’
chairperson recruited by the researcher for close monitoring of participants in each LGA and was
validated by the health information officer through the manual counting of referral cards designed
for the study.
Conclusion
Considering the great impact that the intervention study made on the outcome variables such as
self-efficacy to make referral, referral practices and number of referral made at the 12 th followup, it is safe to conclude that the health education intervention combined with close dialogue with
the skilled birth attendants, key stakeholders and the community leaders are all needed to
influence and enhance timely referral practices of high risk pregnancy among the participants.
Strengthening of the relationship between the traditional birth attendants and the skilled birth
attendants to foster a smooth communication and referral link is very crucial. Therefore, all null
hypotheses were rejected in the study.
Recommendation
1. The study revealed the unacceptable level of knowledge of respondents on early
identification of high risk pregnancy and pregnancy complication at baseline with poor
referral practices based on the poor attitudes towards the skilled birth attendants. Hence, the
study recommends that there should be more community based oriented training to raise the
knowledge of the respondents on the various indication of high risk pregnancy and child
birth complication
2. The study also recommends cordial relationship between all TBAs in each local government
area and the primary health care staffs to change the poor perceptions between the duos.
Consequently, a day should be fixed for a general meeting every month for review of issues
and proper dialogue to promote working relationships which will in turn promote skilled
delivery uptake.
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3.
4.
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The study should be replicated in other local government areas in Oyo State and Nigeria as a
whole as traditional birth attendants serves as safety nets to pregnant women in areas where
health care services are short-served and they also serves as drivers of pregnant women to
skilled birth attendants
Policy on integrating TBAs should be strengthened to promote the integration of TBAs into
maternal health services, especially at the rural areas in line with section 5.10 of revised
National Health Policy of Federal Republic of Nigeria 2004.
Acknowledgements
The researchers wish to acknowledge all the traditional birth attendants in Oyo State that took
part in the study, especially all the LGA chairpersons that facilitated recruitments of other
respondents. Also, the Primary Health Care Board Oyo State, (PHCB), all primary health care
coordinators for supporting the study.
Funding
The authors did not receive any funding for the study.
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