TWEET CONFERENCE TRANSCRIPT: Providing FGM-related services in partnership with TBAs in Nigeria – 29.08.2019
Since the adoption of the Primary Health Care (PHC) approach in Nigeria in 1979, Government has recognized the need for integrating traditional birth attendants (TBAs) into the PHC system and had consequently initiated TBAs training programmes.
In spite of the high patronage of traditional birth attendants, many of their practices during childbirth have been found to adversely affect the health of mothers.
Recent World Health Organization recommendations recognize the important role Traditional Birth Attendants (TBAs) can play in supporting the health of women.
FGM stands for ‘’Female Genital Mutilation”. FGM refers to any procedure that involves “partial or total removal of the external female genitalia, or any other injury to the female genital organs for non-medical reasons.”
The World Health Organization (@WHO), classifies FGM into four broad types, based on the anatomical extent of the procedure: …
Type I (Clitoridectomy): This refers to the partial or total removal of the clitoris and/or the prepuce (the fold of skin covering the clitoris). This is also referred to as ‘Sunna’.
Type II (Excision): Removal (in part or whole) of the clitoris and labia minora. The labia majora may or may not be removed.
Type III (Infibulation): Here, the vaginal orifice is narrowed, and a covering seal created by cutting and repositioning the labia minora and/or the labia majora. The clitoris may also be removed. It is sometimes referred to as ‘Pharaonic’.
Type IV (Unclassified): Any other harmful procedure performed on the female genitalia for non-medical purposes, for example: pricking, piercing and incision of the clitoris and/or labia, stretching and/or cutting of the vagina (‘gishiri’), scraping of tissue surrounding the vaginal opening (‘angurya’) and cauterization. It also includes the introduction of corrosive substances into the vagina to cause bleeding or to tighten or narrow the vagina.
The practice of FGM is common in Africa, the Middle East and Asia. But it can also happen to any woman or girl from any background regardless of age, race, nationality, social class, financial status or sexuality.
FGM is widely recognized as a harmful practice and a violation of the human rights of girls and women. It reflects deep-rooted discrimination against girls and women, profoundly entrenched in social, economic and political structures.
While de facto violent, the practice is perpetrated without a primary intention of violence. It is considered to be a necessary step to enable girls to become women and to be socially accepted, together with the rest of the family.
FGM functions as a self-enforcing social convention or social norm. Families and individuals uphold the practice because they believe that their group or society expects them to do so and they expect that they will suffer social sanctions if they do not.
In most FGM practicing communities, TBAs are counted among those who performs FGM because of the important role they play in the health system at community level.
A TBA is defined as a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship to other TBAs (WHO, 2004).
TBAs are integral members of their communities and provide an important window to local customs, traditions, and perceptions regarding childbirth and new-born care (Kamal, 1998; Leedam, 1985). The presences of relatives at birth were to witness child delivery and make proper decision when problem arises (Kayombo, 1997, 1999).
Trained TBAs in Nigeria can have positive impact on reducing new cases of FGM if programmes targeting them is well implemented with systematic follow-up after training. This could be done through joint meeting between health workers and TBAs as feed and learning experience from problem encountered in process of providing child delivery services.
TBAs can help to break socio-cultural barriers on intervention on reproductive health programmes such as Female Genital Mutilation.
Traditionally, the role of TBAs on reproductive health starts immediately after a woman becomes pregnant. These TBAs are consulted for any health problems occurring among pregnant women until during the first to second week after delivery (Swantz, 1966; Cosminsky, 1983; Kayombo, 1997).
TBAs have rich knowledge of herbal plants which are used for managing pregnancy and child delivery (Swantz, 1966; Cosminsky, 1983; Kayombo, 1997).
Further, TBAs educate pregnant women on appropriate diet to take, pregnancy-related taboos and on how to take care of infants after birth (Swantz, 1966; Cosminsky, 1983; Kayombo, 1997). Most TBAs are known to have some knowledge of risk signs during pregnancy (Swantz, 1966; Cosminsky, 1983; Kayombo, 1997).
Some of the taboos in the past may be today interpreted as negative aspects on health of mother.
For instance, in some communities of Tanzania, pregnant women were not allowed to eat nutritious food like eggs for fear that the foetus would be too big and become a problem at child delivery (Eresund & Tesha, 1979).
In addition, performing sexual intercourse when breastfeeding is believed to cause unexplained fevers to the child and the mother would become pregnant when child is still breastfeeding (Kayombo, 1997).
It was a shame for woman to become pregnant when child was still breastfeeding (Kayombo, 1997, 1999). This also acted as family planning mechanism coined in cultural value regarding child delivery taboos and reproductive health in general.
Besides counselling pregnant women, TBAs either act as consultant to child delivery where relatives are involved or actively involved in assisting child delivery (Swantz, 1966; Cosminsky, 1983; Kayombo, 1997).
In the management of pregnancy and child delivery, TBAs frequently examine the vagina often using bare hands and apply herbal medicines to the vulva or vagina to ensure health of the growing foetus and safe delivery.
However, some of these practices might cause genital infections including 3 pelvic sepsis (Fauven, 1993) which is one of the major causes of infertility, menstrual disorders and ectopic pregnancies (Fauven, 1993).
Moreover, TBA are also responsible for management of family planning, getting opposite sex for a woman who was giving births of one sex, managing some temporally impotence and infertility using traditional remedies (Cosminsky, 1983; Kayombo, 1997).
Some of TBAs are also involved in girls’ initiation to adulthood in some ethnic groups (Swantz, 1966; Kayombo 1992).
It is here where girls are taught on how to behave as women/ married women; and their expected roles in their respective family and community.
In some ethnic groups initiation might involve female circumcision or infibulations and scarification as part of social–cultural practices to be regarded as woman in that community (Kayombo, 1992).
Above all TBAs are involved either actively or as consultants in child deliveries. The number of deliveries assisted by TBAs varies per country and per TBA (Mbiydzenyuy, 2012).
However projects targeting TBAs should not be of hit and run; but gradually familiarize with the target group, build trust, transparency, and tolerance, willing to learn and creating a better relationship with them.
Specifying roles for TBAs acknowledges their cultural and social acceptability and the important role that they play in supporting the health of Girls and women and linking women, families and communities to the formal health system.
TBAs could be trained to encourage and accompany women to attend antenatal and postnatal care and have skilled care during birth, providing companionship to women during and after childbirth, as well as broader roles that they can play in community-level health education and community mobilization strategies to reduce new cases of FGM.
Strategies to increase partnerships with TBAs include developing collaborative relationships through opportunities for reciprocal sharing of traditional and professional knowledge between TBAs and SBAs, emphasising such collaboration in in-service midwifery training , as well as including TBAs in community level networks and as links in referral chains for complications as a result of FGM.
In conclusion, FGM is a socio-cultural event, and thus in order to bring effective intervention TBAs who have been involved in child deliveries for years are taken on board and be partners on reproductive health.
It has to be remembered that TBAs have essential components on reproductive health knowledge and skills including local customs, traditions, and perceptions regarding childbirth and new-born care (WHO, 1987; Islam, 2007).
TBAs are therefore, key actors in ending FGM and other harmful practices that affects the health of women .
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