In Ilorin, the capital of Kwara state, it is common sight in various homes to find the presence of Traditional Birth Attendants (TBAs).

Despite availability of both government and private orthodox health centers, Weekly Trust findings in Ilorin revealed that most pregnant women prefer to put to bed in the hands of traditional birth attendants.

Instead of clean and hygienic environment, most of the traditional birth centers operate in filthy environment in which babies are given birth to. The delivery rooms are most times, air tight, littered with personal belongings of the birth attendants and the likes.

The entrance to most of the centers had cages with pigeons inside, which the birth attendants said were used for sacrifices during emergencies.

The TBAs are usually the local women (and occasionally men), without any formal medical or midwifery training, who, Weekly Trust learnt that the deliveries take place mostly either in the homes of the expectant mothers, or that of the TBAs.

Under current World Health Organisation (WHO) guidelines, TBAs are not meant to attend to baby deliveries. The WHO insists that such function is the exclusive preserve of 'Skilled Birth Attendants' (SBAs), nurse-midwives and doctors.

However, the preponderance of TBAs and their continued patronage is reportedly compelled by several reasons.

Weekly Trust further gathered that sometimes, and in some very rural parts of Nigeria, some of these TBA-attended deliveries take place at a health facility. More so, if the TBA has had some working relationship as a maid, cleaner with that specific health facility, and the midwife/doctor is not available to take responsibility for the delivery.

Investigations further revealed that lack of awareness is a major setback for the fight against child and mother mortalities in Nigeria especially in the north. In Ilorin, it was noticed that most people who patronize TBAs are either not aware of a better alternative, or not convinced that the alternative is truly a better one. In some rural communities, health facilities are inaccessible or non-existent, thereby compelling those trapped in this fate to opt for TBAs.

Monsurat Abdul, a mother of two who patronises the traditional birth attendants since her first pregnancy says "ever since I was a little girl, I have always known the traditional birth attendants. My parents and sisters and even friends patronise them whenever they want to give birth. In my family, we hardly have any expectant mother who is about to deliver to go to the hospital".

"So, why should I be the first to go to a hospital to give birth? I will continue to follow the tradition of my parents. The traditional birth attendants have not disappointed any of us, for that, I will particularly continue to patronise them," she said cheerfully.

Thus, it was learnt that community recognition and support for traditional birth centers has boosted its popularity. The TBAs are usually groomed in villages, and are sometimes recognized in families where the skills are passed from a grandmother through mother to daughter.

They have also built a strong trust in the people to the extent that when prenatal deaths occur; members of the community accept it as an unavoidable act of God.

"We cannot cheat our creator. He gives and He takes. We cannot deny that there are instances where we have lost babies and even mothers, but it cannot be compared to what is experienced in hospitals these days," Shehu Mutiu a father of three said. Shehu said all his children were given birth to in the local birth centers.

Furthermore, investigations also revealed that poverty has also influenced the push for traditional birth centers. Unlike the TBAs whose services are cheaper, as well as piecemeal payments, the delivery services in hospitals require strict payments, most times.

"The money we spend in the birth centers is less than what we will spend in any hospital. We are promptly attended to and no time wasting over getting tested and waiting for results before treatment is given. If we spend less and get faster services, then why would we want to waste time going to hospitals where time wasting and more money will be spent?" Mr. Adedayo Adewusi a husband asked.

Proximity of the TBAs continues to make them relevant in child delivery in communities. Because expectant mothers are required to be moved to health facilities most times at a cost, community dwellers usually see it as cost saving to have a TBA at home or their centers if they are nearer their homes.

A mother said "our TBAs are nice and treat us with respect, especially during labour. They don't verbally or physically abuse us, like the nurses in the hospitals do. They are not expensive and we can always pay them later."

An NYSC member resident in Ilorin, Ms. Ayilara Hamza said "you find out that majority of the mothers in the communities prefer the TBAs as they always have great confidence in them, because they live in the same community. They relate with the traditional birth attendants daily and have more confidence in them than in doctors that they have no common link with. Sometimes, it may be the distance to get to the hospital in good time.

"It is sometimes difficult to try to convince these women to see reason why they should patronise hospitals, but when they argue that they do not have the resources to convey them and even to register for the services of the hospital, what can we do? I would suggest that clinics or hospitals be built around the locals in most of the villages. That way the excuse of proximity can be eliminated," Ayilara said.

But regrettably too, superstition is synonymous with the traditional birth centers. Most of them rely solely on divine revelation for guidance in managing deliveries in their care. Traditional birth attendants on the other hand believe they are relevant in the hospitality business in the communities. Most of them argued that they handle more complicated cases than the hospitals and that the hospitals are mere mortals and do not consult with the relevant gods during difficult situation.

A traditional birth attendant, Pa Abbey who has been in the business for 12 years explains that "people do what they want to do and what they believe in. You can't force them otherwise. They have lived all their lives knowing how powerful and efficient these traditional birth centers have been. Most of the difficult cases are not always ordinary and that is where we come in."

"Most times, before we attend to deliveries we try to consult the gods to know if the delivery is going to be safe or not. Not every delivery is ordinary and so we must be prepared. This is something the modern hospitals cannot give to their patients. "We believe that the services we provide are from a god-given power. People will not like to waste time at hospitals doing tests; they'd rather come to us. Most of the cases are not what the hospitals can handle, so they have to come to us. When we have difficult cases we offer sacrifices with pigeons to appease the gods and if we are lucky the delivery will be safe, that is if the patients come to us on time" another traditional birth attendant said.

Some traditional birth attendants, who have undergone training in hospitals, say they work in partnership with hospitals.

"We sometimes refer very stubborn cases to hospitals, but the hospitals also sometimes refer cases to us as well. We do not see them as rivals but rather as people we should work hand in hand with" says Madam Aisha Ahmed.

In the past, several institutions and organisations have researched and interacted with the traditional birth attendants. The consensus opinion is that they should be educated and trained on the dangers of child and maternal mortalities.

Most of them came to the conclusion that educational programmes and trainings for the TBAs and better integration into the health care system is necessary to lower the high risk of child and maternal mortality. The Wellbeing Foundation whose interests are focused on child and maternal mortality recently stressed the need for traditional birth centers to be integrated into the health system through advocacy. The foundation noted that there is no need to ban them in the society, since they already have heavy presence and support from the locals.

It added that banning the TBAs would now only push them further away from visible areas which could be very dangerous for potential mothers.

"If the fight against high rate of child and mother mortality is to be won, there is need for the traditional birth attendants to be trained on hygiene: what is to be done, when to do it and how important the health of a pregnant woman is. And if there's any complication; the patient must immediately be referred to the hospital," the foundation advised.

However, an Abuja-based medical practitioner Dr Mohammed Abdullahi said pregnant women must not take their health and those of their unborn babies for granted.

He said the skilled attendance at all births is considered to be the single most critical intervention for ensuring safe motherhood, because it hastens the timely delivery of emergency obstetric and newborn care when life-threatening complications arise.

Dr Abdullahi added that according the United Nations Population Fund "Skilled attendance denotes not only the presence of midwives and others with midwifery skills (MOMS) but also the enabling environment (see figure below) they need in order able to perform capably. It also implies access to a more comprehensive level of obstetric care in case of complications requiring surgery or blood transfusions."