Policy Advocacy for Traditional Births Attendants Registration/Regulation/Supportive Supervision in Africa

According to the World Health Organization (WHO), current estimates of maternal mortality ratios are at more than 1000 per 100,000 live births in most African countries. Despite the existence of modern health facilities in Nigeria, over 58% of deliveries take place at home whereas only 37% take place in hospitals.

The outcome of pregnancies and their sequelae are purely left to providence in many rural communities. The place of delivery is one of the determinants of maternal and child morbidity and mortality. And with the shortage of skilled birth attendants, particularly those who are also unevenly distributed geographically, Traditional Birth Attendants (TBAs) tend to fill in the gap.

Who are TBAs?

WHO in 1992 defined TBA as a person who assists the mother during childbirth and who initially acquired their skills by delivering babies themselves or through an apprenticeship to other TBAs. According to Kruske and Barclay, approximately half of all births in developing countries are attended by Traditional Births Attendants (TBAs). 

This is the light of current evidence that over 58% of the deliveries take place at home with Traditional Birth Attendants (TBA) giving various reasons ranging from the unavailability of staffs, high costs of services, bad attitudes of health workers and lack of transportation to far distances of health facilities, according to Nigeria Demographic and Health Survey (NDHS 2013).

Global Maternal and Neonatal Mortality Outlook

According to Trends in Maternal Mortality: 1990 to 2015, a joint publication by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, maternal mortality ratios (MMR) declined by 44% over the past 25 years, to an estimated 216 maternal deaths per 100,00 live births in 2015 globally. The annual number of maternal deaths also reduced by 43% from about 532,000 in 1990 to an estimated 303,000 in 2015.

The developed nations have made a landmark achievement in the reduction of Maternal Mortality, on the other hand, the developing regions accounted for approximately 99% (302,000) of the global maternal deaths in 2015 with Sub-Saharan Africa alone accounting for roughly 66% (201,000), quoting figures from Nigeria Demographic and Health Survey (NDHS) 2013. Similarly, national statistics for MMR are 576 per 100,000 live births and the Neonatal Mortality rate (NMR) is 37 per 1,000 live births. This has however worsened to 38 per 1,000 live births in 2018.

Nigeria accounts for 14% of global maternal death

Nigeria presently accounts for the second-highest global burden of maternal deaths in the world and one of the top 5 of child deaths. Despite only contributing to 2% of the world population, Nigeria actually accounts for about 14% of maternal deaths. Many such deaths have been attributed to deliveries taking place at TBAs.

The majority of pregnant women, especially in remote settings are still found of patronizing traditional birth attendants (TBAs) who neither have the skills nor the equipment to treat life-threatening pregnancy complications.

In order to meet up with the Sustainable Development Goal 3 which advocates for reduction in the maternal mortality ratio to be fewer than 70 deaths per 100,000 live births by 2030, it’s of utmost necessity to provide a supervisory framework and establish regulatory body to ensure effective collaboration with the informal health sector as this can result into a great opportunity for improved and better maternal health outcomes in the community considering the spread, accessibility and cultural acceptability of TBAs.

Why TBAs must be regulated

As noted in the preceding paragraph, TBAs provides an opportunity for improved and better maternal health outcomes in the community considering their spread, accessibility, and cultural acceptability.

Also, sociocultural values, as well as tradition, imbue TBAs power and authority to manage pregnancies and assist in child deliveries despite their lack of requisite skills and equipment to treat life-threatening complications.

However, due to the prevailing conditions of failing health system which is characterized by the mass exodus of qualified personnel, unavailability of drugs, poor and decaying health infrastructures and understaffing of healthcare centers, among others, TBAs still remain the lifeline for many women in the country and in Africa.

In view of foregoing, there is a dire need to come up with definite policies to regulate TBAs activities in many African countries, develop a tool for their supportive supervision, monitoring, and evaluation from knowledge and insights gained from the globally recognized and United Nations awarded Ondo state Abiye Safe Motherhood Initiative which reduced maternal mortality by 84.9% from 745 per 100,000 live births in 2009 to 112 per 100,000 live births in 2016, with a baseline survey which showed that less than 16% of registered antenatal patients are delivered by Skilled Birth Attendants (SBAs) (Ondo State Abiye Bulletin).

As long as unregistered, unsupervised and unregulated TBAs/Faith-Based Birth Attendants (FBBAs) continue to practice and there is a continued shortage of skilled midwives and doctors to provide the necessary care, maternal morbidity and mortality will not reduce.


It is, therefore, necessary that TBAs are repeatedly trained and retrained, encouraged, supervised, regulated and enabled to play a role in improving maternal health in Africa pending when the health system is repositioned to attain skilled care in pregnancy and labor for all women.

Government at all levels should stop the activities of TBAs/FBBAs who are not registered or refused to be registered when the regulatory board/agency is put in place and also who do not undergo training or refused to be retrained to reduce obstetric complications.

Dr. Marius O. Adeniyi, MD, MSc Physician & Public Health Manager mariusvictory@gmail.com  +2348137601417+2348074294379

Dr. Marius O. Adeniyi

Dr. Marius O. Adeniyi

Dr. Marius O. Adeniyi, MD, MSc, is a seasoned Physician & Public Health Manager, with a special interest in maternal and child health policy. Dr. Adeniyi is also a leadership expert who has written several articles on various aspects of leadership.