A Postcolonial Feminist Perspective on Traditional Birth Attendants and Management of Pregnancy Complications Among Indigenous Women in Rural Nigeria

Abstract

The work of Traditional Birth Attendants (TBAs) in the Global South continues to be pivotal to the operations of rural healthcare services, especially as formal healthcare services often malfunction in rural communities, as in rural Nigeria, where TBAs preponderantly conduct deliveries among Indigenous women. This study examines TBAs’ management of delivery complications in rural Nigeria among Indigenous women using a sample of TBAs and TBAs’ service users. The study adopts a qualitative methodology involving focus groups of TBAs’ service users and interviews of TBAs to determine TBAs’ effectiveness in managing obstetric complications, considering their differentiation in terms of service competence. The study apprehends the phenomenon through a postcolonial feminist theoretical lens. The results show that TBAs have differential capabilities in the management of cases and their perception and interpretation of problems determined whether physical or metaphysical strategies were employed in their work. While some TBAs competently managed the presented cases, others invited either TBA colleagues or traditional resource persons to assist in such dire moments. Even though the TBAs—victims of patriarchy and colonial subjugation—continue to be marginalized and subjugated by male-dominated colonial and neocolonial power structures, they have significantly transformed their values to create a model for rural social work that provides social and emotional support to Indigenous women in rural spaces. The study therefore identifies a social policy and social work imperative for ideas sharing between different forms of Westernized healthcare practitioners and TBAs to engender the best health outcomes for rural Indigenous women.

Keywords

Indigenous womens’ health system management of delivery complications postcolonial feminist perspective rural research traditional birth attendants’ work

One of Nigeria's poorest and most vulnerable population groups is pregnant Indigenous women in rural areas, whose access to basic life support is limited. While not exactly being synonymous with the entire rural population, Nigeria's Indigenous women are part of the Indigenous peoples that constitute the preponderance of Nigeria's rural population. Being native to the land, Nigeria's Indigenous peoples have endured oppression from both British colonizers and other non-Indigenous groups and settlers who are not only assimilated into the colonizer's world but function as present-day neocolonial extensions of the original colonizers. Nigeria's last official census figures suggested that the majority of Nigerians reside in rural areas (National Population Commission [NPC], 2010), the preponderance of them constituting 66.6% of the population are poor, with 31.3% living in the lowest wealth quartile as against 3% urban (National Bureau of Statistics, 2012; NPC & ICF International, 2014). Similarly, the maternal mortality rate was estimated to be 828/100,000 live births for rural dwellers against 351/100,000 live births among urban dwellers (Duru et al., 2014). Thus, using the services of Traditional Birth Attendants (TBAs) is nearly invariably synonymous with being an Indigenous woman living in a rural area.

Taking cognizance of rural existential burdens, it is, therefore, germane to expect that the effective maternal health care strategy in Nigeria's healthcare system must be rural-centred. In contrast, the healthcare situation in Nigerian rural communities indicates a failure of the health system to meet the needs of this vulnerable population, especially women and children as health facilities are not only concentrated in urban areas neglecting rural areas, but the few Westernized, government-backed health facilities in rural areas are malfunctional. The primary health centers, which are usually located at the local government headquarters, and the occasional private medical clinics, which are primarily run by medical personnel who are essentially employed by the government in the primary health centers, are examples of the westernized and government-backed healthcare system that has failed to function in Nigeria's rural areas, leaving rural Indigenous women to their own ways for survival (Abdulraheem et al., 2012; Anyiro, 2010). Only 2,500 out of 30,000 primary healthcare facilities in Nigeria are functional (Adaramola, 2016).

The prevailing situation at the supply end of the formal healthcare system in rural areas has created a gap in maternal healthcare delivery, hence the recourse by pregnant women in rural areas to the services of TBAs. Indeed, following the crisis created by the COVID-19 pandemic where the hardly existing rural health facilities had to be diverted to pandemic-related uses under emergency conditions, towards the exigencies of fighting the pandemic, more and more Indigenous women in the rural areas of Nigeria have come to rediscover the TBAs, whom they have embraced as a most natural alternative to Nigeria's westernized and government-backed but failed healthcare system (Okafor et al., 2022).

The TBA is a person who assists mothers during childbirth and who initially acquired her skills by delivering babies herself or through an apprenticeship with other TBAs. The TBAs use traditional medical knowledge in delivering obstetric services, and as such, they are often misclassified as unskilled birth attendants (Pfeiffer & Mwaipopo, 2013).

TBAs frequently acquire their work skills through apprenticeships or independent study among the Indigenous communities; in certain communities, having experience as a mother is a requirement for being recognized by clients as a TBA. Herbalists and other traditional healers often double as TBAs. They are ideally prepared to act as birth attendants and to provide Indigenous women with social support when they come to them for care or delivery because of their backgrounds as traditional healers and seasoned mothers. World Health Organization (2012) observes, therefore, that TBAs rely mostly on their informal experience and knowledge from the customs and traditions of the communities from which they emerged to provide basic healthcare, support, and guidance during and after pregnancy and delivery. According to the United Nations Population Fund (1996), TBA's work is centered on helping women during labor and the first few days after giving birth. Often, they offer aid with domestic responsibilities. TBAs are also known to offer additional emotional and social support in the form of compassion, love, and empathy.

Nonetheless, TBAs’ work has come under fire on multiple occasions due to their presumed handling of pregnancy-related complications resulting in maternal deaths. This has led to an unfair pathologization, marginalization, and villainization of TBAs in the birthing and birth attendance discourse. These criticisms have primarily come from academics whose research had methodological flaws, such as when TBAs or their service customers were left out of the mostly quantitative studies or combined with samples that had scant prior knowledge of TBAs’ work, or even when such academics had utilized only arm-chair conjectures to arrive at their conclusions (see for example, Inyang & Anucha, 2015; Liambila & Kuria, 2014; Miller et al., 2012; Sheikh et al., 2016; Yuan et al., 2017). Therefore, the present study is a corrective effort that uses a qualitative methodology and a postcolonial feminist theoretical lens to investigate TBAs’ work and their management of delivery complications among Indigenous women in rural Nigeria to ascertain how well TBAs work at treating obstetric problems.

Literature Review

Traditional Birth Attendants and the Management of Delivery Complications

Management of delivery complications constitutes a major challenge in maternal health care requiring a certain degree of healthcare provider's competence (Munguambe et al., 2016; Mwilike et al., 2018; Reeve et al., 2016; Sufiyan et al., 2016). It is estimated that about 15% of pregnancies will develop a potentially life-threatening complication that demands skilled care (WHO, UNFPA & UNICEF, 2017). Studies show that complications during delivery account for about eight in ten maternal deaths (Nurgi et al., 2017; Salem et al., 2018). Some of these deaths, unfortunately, are said to be avoidable if patients had access to skilled personnel (Odetola, 2015).

However, there appears to be a consensus among some scholars that only westernized and Eurocentric health providers’ approved skilled birth attendants (SBAs) can effectively manage delivery complication issues (Lawrence et al., 2015; Liambila & Kuria, 2014; Odetola, 2015; Tadese & Ali, 2014). Conversely, other practitioners like TBAs who utilize a cultural and Indigenous knowledge paradigm in delivering obstetric services (Bryne et al., 2016; Noa et al., 2017; Unyime et al., 2016) are often framed as incapable of managing complications, and as contributors to many cases of maternal deaths (Hernandez et al., 2018; Inyang & Anucha, 2015; Pfeiffer & Mwaipopo, 2013; Unyime et al., 2016).

Although the foregoing assumption appears plausible, it should also be noted that most of these postulations are outcomes of certain methodological flaws including (a) the inability to differentiate between TBAs’ based on users’ perspectives on service effects (see, for example, Hernandez et al., 2018; Pfeiffer & Mwaipopo, 2013; Reeve et al., 2016); (b) inability to undertake empirical research supporting claims on TBAs’ culpability. For instance, Inyang and Anucha (2015) utilized the arm-chair method and theorized that TBAs’ lack of Western education and certification, and their way of attending to delivery cases lead to poor health outcomes and maternal death. The validity of this assumption is subject to empirical research; (c) the tendency to incorporate non-TBA service users without an exclusive focus on mothers who used TBA services (see, for example, Mahiti et al., 2015; Oshonwoh et al., 2014; Sialubanje et al., 2015; Unyime et al., 2016). For instance, in Unyime et al.'s (2016) study, sample selection was done using an undisclosed set of inclusion criteria and eventually, non-TBA service users were recruited for the assessment of TBAs’ competence. It is doubtful how non-TBA service users would provide reliable and valid information on TBAs’ service effectiveness; (d) inability to juxtapose the views of TBAs and mothers as counterbalance or complementary vista in the quest for truth (see, for instance, Reeve et al., 2016; Vyagusa et al., 2013).

Feminism and Postcolonial Feminist Theory on Traditional Birth Attendants

The feminist theory focuses on understanding how gender inequality and oppression operate in different areas of human activity using diverse social scientific disciplinary tools (Brabeck & Brown, 1997; Chodorow, 1992). Similarly, the postcolonial theory uses diverse social scientific and humanistic disciplinary approaches to examine the relationalities which are at the bases of colonialism and neocolonialism with the sub-disciplines of postcolonialism seeking to understand the influence of colonialism and neocolonialism on feminist, anarchist, and religious practices (Raja, 2019).

However, feminism has been critical of the tendency for postcolonialist theoretical formulations to have a limited conception of power and domination especially as postcolonial studies often neglect the gender dimension of power and domination in their analyses. Postcolonial theoretical formulations are said to exclude gender in their analysis such that categories like gender are often obscured within the larger formation of colonial and postcolonial theory, which tend to construct a single category of the colonized (Tavassoli & Mirzapour, 2014).

On the other hand, feminist theorizing has been critiqued by feminists from the non-European and non-North American world for its inability to address its complicity in the imperialist domination of other parts of the world as well as its essentialising, homogenizing, and universalistic conception of the history of women (Tavassoli & Mirzapour, 2014). Feminists from the non-European and non-North American world, therefore, hope that the wider feminist movement will subsume the group of theoretical propositions under postcolonial feminism as they reach a cultural perspective beyond the European and North American world by conceding to the lived experiences of women in other parts of the world (Ali, 2007). This hope is predicated on the observation that the absence of recognition and appreciation of the peculiar experiences and thoughts of feminists from the non-European and non-North American parts of the world reinforces the sort of hegemony redolent of empire and strengthens the claim of “outweighed representation” of White scholars from the Global North since the majority of extant feminist literature concerning the Global South appears to be produced by theorists from the Global North leading to a “whitewashing of histories” (Connell, 2015).

Postcolonial feminism, therefore, challenges the essentialist and homogenizing assumption that all women's lived experiences are the same in varying locations around the world. Postcolonial feminism's aim is thus to eliminate the homogenizing terminologies employed by feminists of the Global North and to integrate all women into the theoretical space. Postcolonial feminists make efforts to do away with the idea of the Global South “other”, as a Eurocentric feminist construct which depicts the “other” as a victim of their culture and traditions (Bose, 2005).

From the postcolonial feminist theoretical perspective, the emphasis is on the double colonization of women in the non-Euro-American parts of the world especially in the post-colonies and neo-colonies via the formidable collaboration between patriarchy and colonialism leading to the issue of female visibility and related struggles in a world that is predominantly male (Holst Petersen & Rutherford, 1986; Tavassoli & Mirzapour, 2014). Postcolonial feminists critique feminists from the Global North for being prejudiced and complicit in the domination of Black women whom they ought to have supported in their struggles as they face concurrent oppression from patriarchal, racial and class structures (Carby, 1997). Thus, feminists from the Global North are criticized for presenting women from other parts of the world as monolithic thereby failing to consider the diversity in the lived experiences of women globally (Mohanty, 2003).

In Nigeria, the sinister alliance between colonialism and patriarchy that dominates women is most apparent in the healthcare service delivery industry. One of the areas this manifests is in the alternative healthcare service delivery industry of which TBAs constitute a considerable proportion of actors (Arukwe & Okwara, 2020). Colonialism and neocolonialism have progressively relegated women to objects under the “expert gaze” of colonialist and Eurocentric physicians, in the westernized and government-backed healthcare system, who treat them as objects that are bereft of agency despite women in certain communities in Africa being the chief custodians of the Indigenous knowledge systems of their ethnic groups and Indigenous nations as well as enjoying a more elevated gender status than men in some cases (Arukwe, 2010, 2014). Even in the Eurocentric medical industry in Nigeria, ironically, the double colonization of women by patriarchy and colonialism are manifested in the relationalities obtainable in the work organization as nurses who are preponderantly women, are compelled to function virtually as servants, without agency, to the male medical doctors (instead of as fellow medical professional group members with full rights within the medical industry). Indeed, the situation in the Westernized, government-backed healthcare system has become so grotesque that actions that are considered as disobedience by the male doctors often lead to physical punishment of the female nurses (Ogwuche, 2024).

TBAs have conducted the deliveries of pregnancies and managed pregnancy complications in Africa for millennia (Akansor, 2021). The colonial invasion and the subsequent cut-throat competition they faced against the colonialist hospital model (Sawadogo, 2021) brought about their subjugation and consequent relegation to the confines of the fringes of the rural areas. The rural areas incidentally continue to hold about 70% of Africa's population (Okafor & Arukwe, 2020), underscoring the continuing importance of the TBAs even in the face of the onslaught that they equally face from the neocolonial regimes in several places in Africa. Having suffered colonial domination under the colonial regimes, it seems that the TBAs today continue to be dominated by both neocolonial and patriarchal culture at the hands of their fellow Africans who are colonially-trained and, despite their privileged or “elite” positionality, allow their Black bodies to be deployed in general complicity in their own and their fellows’ domination by colonial power structures (see Arukwe, 2024). Public health scholarship has also not been able to go beyond its anti-TBA bias (see, among others, for example Hernandez et al., 2018; Inyang & Anucha, 2015; Pfeiffer & Mwaipopo, 2013; Unyime et al., 2016).

However, who is in the best position to report on the efficiency and effectiveness of the TBA other than the service users themselves side by side with the practitioners? Hence, we set out to incorporate both the mothers’ and TBAs’ perspectives into our analysis of TBA's management of pregnancy complications among Indigenous women in rural Nigeria. This was to be able to cross-check and validate information provided by the two groups. The present study, employing a qualitative methodology, therefore sought to ascertain TBAs’ effectiveness in managing obstetric complications among Indigenous women, considering the TBAs’ differentiation and how this translates into observable differences in their management capabilities.

We hope that this work would be of benefit to rural social work in Nigeria, especially feminist rural social work practice. Incidentally, while several non-governmental agencies are doing rural social work in Nigeria currently, social work itself as a social science discipline and as a profession is still at a low level of evolution. There are only a handful of academic departments in Nigeria offering courses in social work, usually as part of larger departments of sociology and anthropology or other social science disciplines. In the few examples where autonomous social work academic departments exist such as at the University of Benin, University of Nigeria, Nsukka, and the University of Calabar, such academic departments have only been recently created out of the hitherto ‘parent’ departments and in most cases lack all it takes to produce as well as support the most professional practitioners of social work.

Methods

Research Design

This study was designed as a qualitative study using interviews and focus groups.

Study Area and Sampling

The study was conducted in Arochukwu Local Government Area (LGA) in Abia State of Nigeria. Arochukwu LGA is composed of five community clusters of Indigenous clans, namely: Abam, Aro, Ihechiowa, Ututu and Isu. A community cluster in this context is a naturally occurring network of mixed aggregate of communities that identify themselves as descending from a single putative ancestor. Cluster sampling was employed as part of the mixed sampling method utilized in this study. To this end, the five community clusters of Indigenous clans that make up the Arochukwu LGA were considered the primary sampling units. Out of these five community clusters, three clusters of Indigenous clans were randomly selected. Then out of these three selected clusters of Indigenous clans, two villages each were randomly selected. From these selected six villages, our sample of participants for the study were drawn.

We had previously purposively selected the Arochukwu LGA as part of the larger rural network of communities in Nigeria, where Indigenous women mostly utilize TBAs’ services. TBAs’ services in Arochukwu LGA are as old as the collective memory of the local oral tradition could recall.

Focus Groups

We conducted a total of six (6) focus group sessions involving forty-four (44) Indigenous women of reproductive age (15–49 years) between March 2019 and May 2021 (observing some unforeseen breaks owing to the pandemic). The women were TBAs’ service users during pregnancy and delivery. Non-TBA-service users were precluded given that recipients of TBA-services were better placed to provide insiders’ views on the efficacy or otherwise of services received than non-users. The focus group was considered useful in generating insights on TBAs’ practices using real-life experiences of service users.

In each of the three community clusters, two villages were randomly selected. Participants were purposively selected considering age, number of children and willingness to participate. The mean age of participants and number of children were 29 and 3, respectively. Nevertheless, parity was considered the most determining factor in stratifying participants. Although, age was equally important in pregnancy and delivery experiences, parity was deemed strategic based on the logic that the more children a woman has, the more pregnancy and delivery experiences she gains in the course of service use. She was expected to draw from such experience in her assessment of TBAs’ effectiveness.

Consequently, we delineated participants into two cohorts consisting of mothers who had ≥3 children and those who had ≤2 children. Accordingly, the two groups constituted the two separate focus group sessions conducted in each of the three communities.

Interviews

In each of the communities where focus groups were held, we obtained, from mothers, details about TBAs including their residential addresses. After the focus groups phase of the study, we purposively selected as key informants six (6) TBAs spread across six villages. Considering that the focus group participants might operate on the limited knowledge of some TBA-practices, we considered interviews useful in generating detailed first-hand information from TBA practitioners who were better placed to clarify areas of ambiguity. We formulated a semi-structured interview guide, using the same set of questions and prompts in the focus groups’ schedule to ensure that responses were steered within defined goals. Before the interview sessions, we visited each of the TBAs to familiarize them with the study's aims and obtain permission for an interview. We further asked the TBAs that showed a willingness to be interviewed to choose convenient dates, times, and venues for the interviews as well as to sign the informed consent forms just like the Indigenous mothers in accordance with the Helsinki Declaration (see Declaration of Helsinki, 2001).

Data Analysis

We transcribed and translated into English language, data from focus groups and interviews for further analysis. Being fluent in the Igbo language we were actively involved in the exercise. Texts were coded and categorized taking cognizance of participants’ and key informants’ manifest opinions on thematic issues raised. More so, we juxtaposed the opinions of participants and key informants to either complement or contrast responses on each subject. In this regard, views and ideas that engender encompassing descriptions of and insights on thematic issues whether corroborated or contrasted were presented to establish a common consensus as well as underlying differences between TBAs. The qualitative content analysis was utilized to derive in-depth interpretation and emergent deductive meanings. Eventually, a broad classification of TBAs emerged namely: those perceived by mothers as more competent and those seen by them as less competent.

Reflexivity

Here, we address the issue of our positionality in relation to this research. To this end, we acknowledge that our perception of TBAs and how they handle complicated deliveries and pregnancies among Indigenous women in rural Nigeria may be influenced or even distorted by our identity as Westernized researchers employed in the Westernized university system (one of us indeed works in the westernized government-supported healthcare system) in Nigeria. This may also have preceded our earlier exposure to literature that vilify TBAs and their work activities.

Nonetheless, starting this research has caused us to gradually resocialize ourselves, which has resulted in an emergent dispositional shift. As a result, we have applied this exercise in knowledge generation, among other things, to emancipatory practice, where we critically reflected on how our positionalities and professional experiences influence the lens we took, and we considered how we could meaningfully use the insights from our critical reflections to effectively elevate the perspectives of the TBAs and their Indigenous women service users. Thus, while writing up this research, we have tried to give the TBAs and the Indigenous mothers who use their services a voice by using a reflexive approach and, to the greatest extent feasible, letting them speak for themselves. Our aim is to highlight the agency and roles of the TBAs and their Indigenous women clients through this co-productive endeavour, in addition to amplifying their voices. This is why we have among other things adopted a postcolonial feminist theoretical orientation.

Results

The Self-Training Methods of TBAs in the Arochukwu Local Government Area

In Africa generally, long before the continent was colonially invaded, TBAs have been performing birth deliveries and treating pregnancy-related issues for millennia. Historically in Africa and as interviews with the TBAs in Arochukwu LGA have corroborated, training to become a TBA originates from inheritance, voluntary apprenticeship, or a spiritual calling.

In terms of inheritance, mothers or other senior members of the extended family would typically train Indigenous women in Arochukwu LGA to become TBAs. Thus, acquiring the art came as effortlessly to these women as learning other household tasks. Young girls would typically assist their mothers or other elder family members who were TBAs informally when they reached adolescence, and when they demonstrated a desire, they were given the chance to learn. TBA trainees were also equipped with all the necessary abilities and information to accomplish this. These youthful TBA interns first assisted their mothers or other family members, and once they had learned enough about the trade, they would become initiates.

Similarly, TBAS in Arochukwu LGA used a long-standing apprenticeship program to train others to become TBAs. When a potential apprentice reached adolescence, her family introduced her to a TBA and the established TBA here accepted the young apprentice. After that, the apprentice lived with the TBA for as long as the master TBA thought it was necessary for her to learn everything needed to become an accomplished TBA on her own. The younger apprentice would labour and assist the elder TBA for the term of the apprenticeship, usually living with her and just infrequently visiting her own home. There is usually a ceremony where the older TBA gives the now-skilled apprentice the tools of the trade to set her up as a TBA when, after many years, she deems it necessary to let the trainee become an expert in her own.

Another situation is TBAs who believe they are called to become TBAs due to a spiritual calling. When a TBA is spiritually called, she usually realizes it after experiencing multiple dream sequences or a significant divination event. Even though she is thought to be extraordinarily intelligent, one of the telltale signals that she is being summoned (by her ancestors) to take up the role of TBA in her community is that she has always faced challenges in her previous career choices. The family would often seek the services of a diviner when these indicators were enduring. The girl or woman would be sent to one of the most reputable TBAs to start her training if the diviner's revelation indicates that the ancestors desire her to become a birth attendant and assist the community. Upon completion of the training, she will begin serving the community as a TBA. The narrative always ends with the called one becoming a TBA and giving back to the community, at which point all other endeavors she ventures into, unlike previously, seem to work out miraculously.

One more thing about the TBAs in Arochukwu LGA is that they seem to be generalists especially with regard to their economic life. Thus, they have multiple streams of income. This appears to have implications for their practices of delivery assistance. This may be the reason the TBAs typically had very flexible terms of payment and could afford to charge very little. Also, the TBAs in Arochukwu LGA efficiently practice rural social work in a context devoid of any major government-supported social work infrastructure because they were probably related to their customers and hence inclined to charge them a cheaper cost. Similarly, in situations where the TBAs were strangers to the client, they viewed their work primarily as a moral and ancestral duty to assist their fellow humans, and they would accept any payment or gesture of goodwill from their client after the service was rendered. Some TBAs who feel they have been called did not request or accept remuneration until it was made available.

Condition of Delivery Assistance

Mothers and TBAs are almost unanimous in affirming that apart from deposits collected during antenatal care, ANC, and registration, no other demand for material deposit is usually made before delivery assistance. However, payment for assistance is usually made after delivery though some TBAs would insist on complete payment before discharging the mother and her child. A participant provided further clarifications as follows:
It was only a deposit I made during ANC that she demanded. During delivery, nothing else was given to her; I only paid after delivery. Even when a woman does not have the money, her TBA would release her. She would only pay when she gets the money [focus group 5; mother 19 years, one child].
As further corroboration to the foregoing, a mother who had benefitted from TBAs’ lenient deferred payment arrangement stated that:
There was a time that I delivered with my TBA, but I did not have money to pay. So, she discharged me, but I pleaded with her to allow me to work on her farm after weaning my baby to enable her to recover her money. Sadly, after some months I lost my baby, so she asked me to forget about the payment, saying that I was already suffering a loss [focus group 2; mother 36 years, five children].

In contrast, few participants acknowledged having witnessed where TBAs insisted on monetary deposits before delivery assistance. However, they explained that such deposits were used as symbolic tokens usually placed on the ground for ritual appeasement of spirit and ancestral entities to help ward-off evil forces. According to a participant:
Some TBAs may insist on monetary deposit, not necessarily as a service charge per se but as a symbolic ritual, usually coins or paper money between N10 – N50 [ten to fifty naira], which they present in supplications to spirit entities controlling childbirth. TBAs offer such deposits to appease the unseen agents and solicit supernatural assistance from ancestral energies to help ensure safe delivery [focus group 1; mother 37 years, five children].

A TBA also commented on this view, however, stating that such practice was engaged in only when a woman who came for delivery was examined and found to be in danger of attack from spiritual age cohorts. According to her:
We can make such demands on rare occasions because every labour experience is a battleground that attracts powerful entities and forces. During such occasions, the token amount of money we demand during labour is not meant for payment. We usually place such items on the ground and make our supplications to the God of childbirth whose power we rely on to deliver babies [interview 5; TBA 51 years].

Motivation for Lenient and Humane Delivery Assistance

We probed the participants, both mothers and TBAs to understand the rationale behind the decision by TBAs to not demand financial deposits before delivery assistance. Similarly, the mothers who participated in the study, as well as the TBAs, were unanimous in asserting that the motivations for favourable and lenient treatments from the TBAs were because of the resolve to alleviate or counter the peculiar challenges and difficulties that the Indigenous women suffer on account of the locations and positions that they occupy in the power matrix relative to the privileged women like those in the urban areas. The TBAs used this treatment as a means of giving their clients material and interpersonal help. For example, one of the TBAs reported as follows:
We inherited this art from our ancestors as a gift and part of our credo is not to privilege the accumulation of wealth over human life and service to those in need. That is why we do not impose any financial conditionalities on mothers who come to us for delivery. We assist them to deliver their babies and they can come back later when they recover and get the money to come and pay and appreciate us for our service. We are only doing these for ourselves since our community does not receive any relief from the government. Our people say that those who have been rejected do not reject themselves [interview 5; TBA 51 years].

This notion was corroborated by the participating mothers as articulated in the following typical response from one of the participating mothers:
Without the TBAs I do not know what we would have done in this community, especially in this period of COVID-19. You know that our government health centers do not function and only those who have money to travel to the cities can have access to hospitals where they could deliver their babies. COVID-19 has made it even more difficult for people to afford to go to the cities for baby delivery. Since the government and the politicians have abandoned us, we cannot afford to abandon ourselves and that is why we would remain grateful that we can rely on our TBAs [focus group 2; mother 36 years, five children].

Similarly, another mother responded as follows:
After God, we must next give constant thanks and praises to the TBAs without whom most of us [women] in this community would not be among the living today. As you can see, our government does not care about our welfare in this community and the men who are the leaders of our community also do not care for us. That is why we do not even have any maternity home that is built by the community leaders for us as some community leaders in some communities that we know of have done for their women [focus group 1; mother 37 years, five children].

Delivery Complication

Many cases of delivery complications were revealed by TBAs in whose domain such cases were brought and handled, and Indigenous women who had experienced them directly or vicariously. Obstructed labour was the most frequently experienced complication among the Indigenous mothers. Others include severe bleeding, retained placenta and prolonged labour, umbilical cord prolapse, and breech presentation.

Perception and Management of Cases of Delivery Complication

The perception and management of delivery complications present an entirely new vista in the TBAs’ service delivery. While some complication cases were perceived as natural, others were seen as preternatural. In any case, the perception and interpretation of cases determined the TBAs’ corresponding actions. A given case perceived as natural by the TBAs was also managed through a physical approach involving the TBAs’ technical ability drawn from experience. On the other hand, when a complication is perceived as preternatural the TBAs usually adopt an arcane approach for their management.

While managing pregnancy cases, to provide social and emotional support, TBAs in Arochukwu LGA would first try to comprehend the kind of person they are working within each circumstance as well as the kind of emotional support that a person may require. Therefore, they would usually make an extra effort to ascertain what their clients require, establish a rapport with them as well as actively listen to them, indicating to the concerned client that they acknowledge their pains and distress and comprehend their varying behavioural response. They would also show them affection to reduce their stress and give them a sense of care, and then continue to follow up with their clients thereafter. An average TBA in Arochukwu LGA would often keep their clients in their home for a few days within which duration they provide them with a range of social and emotional assistance. In this manner, a steady stream of multiple traumatized Indigenous mothers and would-be mothers, whose cases they regularly treat, would receive appropriate palliative and healing care from the TBAs.

TBAs’ Approach When Complication was Perceived as Natural

The TBAs’ perception of delivery problems as natural ensures that only a physically demonstrable approach was adopted in the management of the cases. Given this situation, the TBAs’ depth of knowledge and practical experience gained over the course of practice was brought to bear in different scenarios. For instance, when faced with a breech presentation a TBA explained as follows to address the problem:
I have had cases of breech presentation, and in each case, the first thing I usually do was to either tie a wrapper around the woman's upper abdomen or look for a woman to hold the mother while I gently press down the abdomen. This was to prevent the baby's head from hitting its mother's heart and at the same time, increase pressure down the uterus and vulva to stimulate delivery. When that is done, I insert my hand gently into the woman's vagina, to search for the baby's shoulder; grab it and gently turn its head downward for delivery [interview 3; TBA 78 years].
Similarly, another TBA explained her technique in managing obstructed labour, emphasizing that:
Some babies have a large head size that hinders their passage through the vagina. In such situations, I would usually insert my hand into the mother's vagina, and search for the pelvic bone which takes the shape of two pin-like bony structures. These pin-like bones usually grip the baby's skull, resulting in obstructions. On getting hold of them, I gently press and bend them backwards to free their grips on the baby's head, and at the same time urge the woman to push her baby towards delivery. The only problem is that for some number of weeks after delivery the woman's physical posture and movement would be affected as she feels the pains resulting from such manipulation. However, this problem is resolved by constantly applying hot water soaked in a towel and massaging the affected part until the bone settles back into shape and the woman regains her posture. Usually, the affected woman stays for four days in my house, before she is discharged [interview 4; TBA 47 years].

On retained placenta, TBAs approached such problems using medication rather than a mechanical approach as seen in the foregoing cases. According to one TBA:
I have managed many cases of retained placenta. After delivery, if I noticed that the placenta had not fallen, I would quickly administer herbal medicine to the mother who drinks up and mostly within five minutes the placenta falls. The medication stimulates the woman's body, and she pushes out the placenta just like regular child delivery [interview 1; TBA 63 years]
On their part, mothers shared their real life and vicarious experiences during TBAs’ service utilization. Narrating their experiences, a mother who hitherto registered in a public, western-oriented, health centre but could not experience any labour sensation even at ten months stated that she was eventually taken to a TBA who diagnosed and effectively addressed her problem.

Mothers’ experience of delivery complications also highlights the differential skills of TBAs. While some TBAs competently managed presented cases, others got confused and lost their sense of direction in such situations. A mother shared the experience of her sixteen-year-old daughter who experienced obstructed labour but could not deliver with her former TBA, leading to the invitation of another TBA. According to her,
my first daughter got pregnant out of wedlock, and I had to force her out of our home to live with her male partner. She was eventually registered by the mother of her male partner with one of the TBAs in our village. On the day of delivery, she had an obstructed labour which proved exceedingly difficult for the TBA to manage. As a result of this, the TBA and my daughter's ‘mother-in-law’ abandoned my daughter in the delivery room. Luckily, I came to their house that day to check on her and was surprised to see her shut-in alone in a room. I got so scared. Immediately, a thought came to me to quickly go to Mama Okereke [another TBA in the same village] and plead with her to come to my rescue. Mama Okereke did not hesitate and upon her arrival, she asked the other TBA to give way. Within a brief period of Mama Okereke's intervention, my daughter was delivered of a baby girl, though it was a stillbirth [focus group 1; mother 49 years, four children].
Unlike the foregoing experience of obstructed labour, a mother used her personal experience of prolonged labour to provide a contrarian interpretation. She maintained that depending on the TBA involved prolonged labour could be erroneously taken as a problem when no problem was in view. Continuing, this mother observed that:
Labour experience is of two types: ‘grass-cutter’ labour and ‘hunger’ labour. The hunger type is a swift and short-lived labour experience that does not take long before delivery takes place. The grass-cutter type is prolonged and often subjects the woman to intermittent feelings of labour such that she keeps having the sensation of imminent delivery, but the child is not yet ready to embark on the delivery course. This is always traumatic for the woman. However, the TBA would always encourage the woman to wait for the appropriate delivery time. This was the experience I had during my child's delivery, but my TBA kept assuring me that my baby was not yet due for delivery. She even predicted the time for my baby's delivery, and it happened that I delivered at the exact period she gave me [focus group 6; mother 33 years, four children].

TBAs’ Approach When a Given Case was Perceived as Preternatural

Conversely, when complication cases were perceived as preternatural, TBAs’ usually sought a solution through otherworldly media. Drawing from Igbo cosmology that accommodates dualist construction of the world, TBAs see as inexorable the interconnectivity between mind, body, and spirit. Consequently, otherworldly entities are usually explored in the search for solutions to perplexing instances of delivery complications. However, only TBAs who are imbued with transcendental capabilities could validly determine when a given problem assumes a preternatural dimension. Whereas some TBAs were effective in adopting this approach in case management, others were not equally imbued. This explains why some TBAs either invited their TBA colleagues or traditional resource persons to manage difficult cases.

A mother shared the experience of her sister whose case was perceived as preternatural. She narrated as follows:
My sister had a prolonged and very strange labour experience. After spending many hours trying to deliver her baby, when eventually her real labour experience began, her eyes became dimmed and blank. While the TBA was urging her to push so that her baby would be delivered, to our surprise, my sister burst into a peal of hysterical laughter. Suddenly her eyes were closed, and her legs crossed so she could no longer push as instructed by the TBA. We all know that labour is a battlefield, so the TBA sensing otherworldly interference in my sister's unusual behaviour quickly went out, got some herbs, squeezed them, and applied the juice to her eyes. This was accompanied by two slaps to her cheek, which revived her back to consciousness and eventually she pushed her baby to delivery” [focus group 1; mother 21 years, one child].
A similar account of a strange labour experience was shared by another mother, who revealed among other things as follows:
My labour experience persisted for about three days in a TBA's home. On the third day, having tried all she could to stimulate real labour experience my TBA hurriedly went out and invited a member of the Ekpe cult [an exclusively male traditional secret society group]. The man came with the Ekpe group's symbolic masquerade staff in hand and tapped me with the staff three times in quick succession. After this, I started having a tummy ache and my real labour experience began. Some minutes afterwards, I delivered my baby [focus group 1; mother 27 years, two children].

However, in rare situations where complication was neither attributed to preternatural nor natural phenomena, a mother stated that her TBA opted for a verbal appeal specifically addressed to the unborn baby. According to her:
During my prolonged labour experience, my TBA informed me that she could not identify anything within my reproductive system that could warrant such prolonged labour as everything appeared to be in order. However, she observed that it is mostly female babies that could exhibit such a trait of delaying their journey from the womb. With this proclamation, she began to directly appeal to my unborn baby in flattering and palliative tones. Eventually, when the baby was delivered it was a female child as earlier predicted by my TBA [focus group 3; mother 32 years, three children].

Discussion

What the TBAs in Arochukwu Local Government Area, rural Nigeria, have managed to achieve among other things is to take back their agency and resist double colonization by enacting the delivery of rural health social work services to the Indigenous women who constitute the poor and most vulnerable members of the population, albeit by the same segment of the population—sort of social work for the poor and vulnerable by the poor and vulnerable. There is the recurrent local saying among the TBAs and the Indigenous mothers that “those who have been rejected cannot afford to reject themselves”, which at the same time sounded like a rallying cry. As victims of colonial subjugation and patriarchy, the TBAs, whose thousands of years of art and craft were devastated by colonial violence also continue to deal with the everyday invisibilization, inferiorization, and domination by the male-dominated neocolonial power structures at the local and national levels that do not show any inclinations for accommodating the needs of the perennially marginalized TBAs or their Indigenous women clients. This finding is consistent with the contentions made by postcolonial feminist scholars including Carby (1997), Mohanty (2003), Tavassoli, and Mirzapour (2014).

The effectiveness of the Arochukwu LGA TBAs’ in managing obstetric complications among Indigenous women was also evaluated in this study, considering the TBAs’ differential competence. The findings show that the TBAs had differential capabilities in the management of cases and that the perception and interpretation of problems determined whether they employed the physical or metaphysical strategy. While the current finding aligns with the finding of Miller et al. (2012) that significant difference exists among TBAs based on competence and skills; it however refutes the idea of classifying all TBAs as a homogeneous group in terms of knowledge and expertise, as evident in some extant literature (see, for example, Eshiet et al., 2016; Yuan et al., 2017). More so, it is important to note that TBAs’ dual approach to the management of pregnancy-related problems has been reported in Akpomuvie (2014), Aziato and Omenyo (2018), Dako-Gyeke et al. (2013), and Mboho et al. (2012).

Given this dualist lens, when a given problem is perceived as physical, TBAs adopt a physically demonstrable strategy involving either medication or technical abilities drawn from operational experience. For instance, when faced with problems like retained placenta and severe bleeding, medications were administered in the treatment of cases; hence mothers and TBAs perceived them as less problematic. Indeed, a TBA was reported to have applied such a medication on a patient who registered in the westernized health centre but could not deliver even at ten months of pregnancy due to the umbilical cord prolapse that westernized nurses could not diagnose. Although a similar finding was made by Chukwuma et al. (2017) to the effect that some TBAs usually managed delivery cases that were beyond the capability of personnel in westernized, European-styled health centres, our findings also highlight TBAs’ medicinal efficacy as reported in Ohaja et al. (2019).

However, problems such as obstructed labour and breech presentation that could not be managed using regular medication were seen as problematic. Hence, detailed, and practical steps were usually taken for addressing them. Our finding on this count negates the finding of Unyime et al. (2016) that TBAs were neither able to recognize cases of complications when encountered nor managed the same. It is thus questionable how health providers who managed 78.1% of childbirth as reported by the scholars, could not have encountered, recognized, and managed complications of pregnancy.

In cumulative terms, therefore, it could be inferred that TBAs were effective in managing a wide range of presented cases using the medicinal approach, practical skills, and esoteric media (which may depend on the placebo effect and other effects) relative to the presented problem. However, the effective management of cases was not generalized as some TBAs were found to be more competent than others. The foregoing result provides a contrast to earlier findings (see, for example, Bryne et al., 2016; Eshiet et al., 2016; Marchant, 2013; Reeve et al., 2016; Yuan et al., 2017) that all TBAs are incompetent in the management of delivery complications; as well as Saravanan et al. (2011), Sibley et al. (2012), Mahiti et al. (2015), and Satishchandra et al. (2013) who attributed the TBAs’ differences and competence to westernized training. The exception was however found in Oshonwoh et al. (2014) who found differences in TBAs’ skills and management of birth complications.

Similarly, having trained themselves over millennia from generation to generation to be disciplined and abide by the highest values of humanity, TBAs among Indigenous women in Arochukwu LGA are known to often choose service to their community and safely delivering their clients’ babies over material gratification. In the same vein, Arochukwu LGA TBAs are renowned for making the most of their limited resources in order to provide a variety of social and emotional support to their clients who are mostly Indigenous women. The Arochukwu LGA TBAs provide a splendid example for rural social work due to their highly developed emotional, social, and mental attitudes.

Social work and rural social work in Nigeria would evolve at a much more meaningful rate if the attitude of the TBAs, as well as their Indigenous women clients, were properly understood and re-appropriated for the purpose of engendering a broad-based rural health security programme relating, among other things, to the managing of pregnancies and pregnancy complications. TBAs and their Indigenous women clients in Arochukwu in rural Nigeria are reclaiming their agency to re-assert their pre-colonial gender status and pedestal, where they as custodians of the deeper Indigenous knowledge systems were either of higher status than men or were of equal status to men (see Arukwe, 2010, 2014). Hence, all the stakeholders of rural social work in Nigeria, both professional and academic, need to copy from the books of the TBAs and their Indigenous women clients to accelerate the evolution of social work, especially for the poor and vulnerable majority populations in the rural areas. Similarly, a postcolonial feminist orientation and conceptual disposition would be apt to provide suitable insights towards supporting the practice of social work professionally when the subject matter relates to the doubly colonized women in Nigeria, especially in the Nigerian rural spaces such as the TBAs and the Indigenous women.

Conclusion

From our analysis of the data, we conclude that Indigenous mothers’ perception of TBAs’ differentiation in various aspects of antenatal care services rendered include: some TBAs possess more knowledge of practice than others, and TBAs use a dual approach in the management of complications (adopting physical and metaphysical approaches in the management of cases). Users evaluated TBAs effectiveness. Indigenous women described TBAs as humane and lenient in offering them delivery assistance. These findings are consistent with postcolonial feminist a postcolonial feminist theory, even though these survivors of colonial subjugation and patriarchy were most likely not hitherto exposed to postcolonial feminist ideology.

This study has demonstrated among other things that TBAs in Arochukwu LGA can sufficiently manage cases of delivery complications, though differences exist in TBAs’ practical competence. While we recognize that no health system is completely effective and secure in all cases, it must be emphasized that denying credit to the practical competence of some TBAs in the absence of Westernized training does injustice to Indigenous mothers whose experiences of delivery complications were effectively managed by some TBAs without exposure to westernized medical orientation. Moreover, if all TBAs were solely responsible for most maternal deaths owing to the poor management of complications as alleged by some arm-chair scholars, few mothers would have continued utilizing their services, given the fear of death; and, TBAs would naturally have fallen into disuse over time in these rural regions. Yet studies show that TBA patronage is not only on the increase but in some cases, mothers who registered in Westernized, government-supported hospitals ended up delivering their babies with TBAs. Herein lies the imperative of differentiating TBA practitioners and disaggregating their service effects.

Above all, TBAs in Arochukwu LGA are grounded in human values and place a higher priority on serving their community and ensuring the safe birth of babies than on monetary gain. Because of their highly developed values, they have established an exemplary model for rural social work by offering social and emotional support to Indigenous women in Arochukwu LGA.

Drawing from the knowledge gained through this study, we recommend the inauguration of forums for ideas-sharing between different forms of formal healthcare practitioners including those involved with rural social work and TBAs. However, inclusion criteria for TBAs should be evidence-based, where opinions of TBAs’ service users would be sought beforehand, to determine which of the TBAs existing in each community is more competent and knowledgeable than others to merit inclusion. Such forums would provide an alternative to the practice of so-called TBA training in westernized contexts, and would provide a platform for the interchange of ideas on approaches adopted by TBAs and westernized, government-supported medical practitioners on given maternal health problems.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nnanna Onuoha Arukwe

Author Biographies

Nnanna Onuoha Arukwe was educated at the University of Nigeria, Nsukka and the Graduate Institute of Development Studies at the National Chengchi University in Taipei City, Taiwan. He is currently a visiting scholar. Additionally, at the University of Nigeria, Nsukka, he teaches as a senior faculty member of the Department of Sociology and Anthropology, Faculty of the Social Sciences. His academic background includes anthropology, but he is primarily a sociologist.

Chukwudi Samuel Chime was educated at the University of Nigeria, Nsukka. At the moment he teaches as a senior faculty member of the Department of Human Anatomy, Faculty of Medicine, University of Nigeria, Nsukka. His academic background includes social and clinical pharmacy as well as medicine and surgery.

Francis Okoronkwo Okwara was educated at the University of Nigeria, Nsukka. He is currently a graduate researcher at the University of Nigeria, Nsukka's Department of Sociology and Anthropology. His academic background includes anthropology though he is primarily a sociologist.

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