Traditional Birth Practices and Reasons for Preference of Home Delivery Among Women in Some Rural Communities of Plateau State

Envuladu, E. A.^1*, Miner, C. A.¹, Osagie, I. A.², Lawan, U. M.³, Shambe, I. H.⁴, Jibrin, E. F.⁵, Egga, A. K.⁵ & Dbal, D. J.⁵

¹Department of Community Medicine, University of Jos, Nigeria
²Department of Community Medicine, Bingham University, Nigeria
³Department of Community Medicine, Bayero University Kano, Nigeria
⁴Department of Obstetrics and Gynecology, University of Jos, Nigeria
⁵Faculty of Medical Sciences, University of Jos, Nigeria

*Correspondence to: Dr. Envuladu Esther Awazzi, Department of Community Medicine University of Jos, Nigeria.

Copyright © 2018 Dr. Envuladu Esther Awazzi, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Nigeria records one of the highest maternal mortality rate in the world with rate as high as 560 per 100,000 live birth and as high as 145 maternal deaths daily [1]. This high maternal mortality rate has been attributed to many reasons including lack of access to functional health care system, poverty, culture and some social factors spanning from the period of pregnancy to about 42 days after termination of the pregnancy [2].

Pregnancy and child birth is considered a significant event for most African women and so heralded by practices embedded in the customs believed to enhance the wellbeing of both the mother and the baby [3]. This is not different among Nigerian women whose culturally based beliefs about pregnancy and child birth determines the acceptable food, daily activities and even access to health care [3] Though some of the practices may be beneficial, some significant others are detrimental to the outcome of the pregnancy, depriving them of essential nutrients which results in malnutrition and other health related conditions that contributes to maternal mortality.

It is difficult to imagine that Nigeria can meet up with the SDG target of global reduction of maternal mortality to 70/100,000 or the supplementary national target that no country should have an MMR greater than 140/100,000 by the year 2030, considering the persistent high rate of home delivery attended to by non-skilled personnel [4]. Women do not want to die during child birth, but the choice of home delivery which is still high in Nigeria is motivated by many factors such as economic, social, physical, cultural and institutional [5].

In delivering at home, women are mostly assisted by unqualified attendants who could be traditional birth attendants (TBAs), family members or neighbors. Although TBAs are known for their roles in assisting child deliveries especially in the rural settings and countries such as Ghana have recognized them in their health system, engaging them is questionable noting that they are not trained in dealing with complications which results in maternal death [6,7].

The high rate of home delivery and unacceptable maternal mortality rate in Plateau state and Nigeria despite effort and strategies put in place by the government to ensure skilled attendance at delivery, necessitated this study which is aimed at finding out some of the practices during pregnancy and delivery and the reasons for home delivery beyond the documented reasons.

Methodology
It was a community-based cross-sectional study conducted among 253 women who have ever given birth in Vom Community of Jos South LGA, Plateau State. Vom Community was purposively selected following a non-published history of high rate of home delivery despite the presence of a secondary health facility and several primary health care facilities in the community.

The sample size was calculated using the formula z²pq/d² where p was the prevalence of home delivery which was 40% obtained from a previous study in Jos North LGA of Plateau State [8]. Consideration was given to the fact that the population was less than 10,000 so the sample size was further calculated thus: nf = n/1 + (n/N). Where, nf = minimum sample size for population <10,000; n = minimum sample size for population >10,000 initially calculated; and N = estimated total population of pregnant women in Jos South LGA, which was approximately 600. Therefore, n f = 368/ [1 + (368/600)] = 234 and the sample size was estimated to be 257 after factoring in 10% non- response rate.

The study population comprised of women of child bearing age who have delivered and reside in the community. The houses were enumerated and houses with women in this category were identified for the household survey. A systematic sampling technique was used to select the participants using a sampling interval of 3 derived by dividing the number of women in that age group who have delivered by the estimated sample size calculated.

After obtaining consent from the eligible women, data was collected using a semi structured interviewer administered questionnaire. The data was then analysed using with Epi info version 3.5.4 statistical software.

Results
A total of 235 women responded to the questionnaire. Most were married (95.7%) and 74.8% were in monogamous unions. Almost 40% of the women had no formal education and majority (91.7%) of the respondents were Berom by tribe, which is the indigenous tribe of the study area.

Food Recommended During Pregnancy
Most of the women (84.6%) reported having traditional food and medication recommended during pregnancy of which 38.3% used herbs, 27.9% special vegetables and 19.2% some form of proteins and 1.4% carbohydrate diet.

Forbidden Food During Pregnancy
Almost half (47.8%) of the women said they are forbidden from eating certain foods during pregnancy, 52.1% were forbidden from eating meat, 8.2% said some fruits and vegetables, 26.4% mentioned being forbidden from consuming certain herbs and 13.2% had restrictions on eating sugary food.

Reasons for Restriction of Some Food During Pregnancy
The reasons given for the restriction included: to avoid having big babies (73.3%), to avoid giving birth to abnormal babies (21%) to avoid preterm labour (1.7%) and 5% said to avoid having stillbirth babies.

Birth Practices
A history of the last delivery revealed that 74.2% delivered at home, while 25.8% delivered in the health facility. Delivery by skilled attendant was 31.1%, while 68.9% was by unskilled attendants; 39.5% were delivered by a traditional birth attendant (TBA) and 30.4% was by relatives which included mother in laws and aunts.

Reasons for Home Delivery
The reasons varied, 52.2% of the women said they received special practices during delivery such as massaging, head gripping, insertion of herbs into the vagina and sitz baths. Other reasons were; they did not like the birth position in the hospital (6.4%), lack of money to pay for hospital delivery (58.8%), harsh treatment from health care providers (26.8%) and 8% gave the lack of transport money to go to the hospital as reason.

When asked the preferred birth position, 45.1% said they preferred squatting, 42.7% said lying on their backs and 12.3% said sitting down.

Post-Partum Practices
45.8% said they are made to have hot baths after delivery, 21.3% said they are made to rest and 26.9% said they are given fluid diet during that period.

Discussion

Food Restriction/Taboos During Pregnancy and the Role of Nutrition in Pregnancy
Beliefs and traditions direct the kind of food consumed during pregnancy, while some may be beneficial, others may be harmful. The concern is that some of the recommended foods may be rich in a class of nutrients but deficient in others or even harmful. The herbs that were mentioned as recommended by these women is feared to be harmful as the constituents of those herbs are not known. Fruits mentioned by a few may be beneficial. The danger of consuming herbs which could be potentially dangerous in pregnancy was also expressed in a study in Mexico [9].

Food taboos, restriction or recommended foods for pregnant women is a known practice across many nations especially in Africa [10]. This was our observations in this study which is also similar to findings from a study conducted in eastern Nigeria where some women did not eat nutritionally recommended foods such as meat, some fruits and vegetables because it was forbidden, believing it will cause either big babies or birth of abnormal babies [11,12]. The misconception towards certain foods deprives the mother and the foetus from essential nutrients placing the mother at risk of pregnancy complications such as anaemia in pregnancy, and maternal death [13-15]. Some women in Ethiopia also mentioned in a study that it is forbidden for them to consume vegetables as documented in this study [16].

Birth Practices and Reasons for Home Delivery
Nigeria has always recorded high prevalence of home delivery. A study conducted in Plateau state confirmed this finding [8, 17] The major concern about home delivery is the fact that rarely is it conducted by a skilled attendant as is the case in this study and other studies where majority of the home deliveries were conducted by TBAs and family relations [18]. Delivery by TBAs and unskilled attendants have been associated with high maternal mortality which is not unconnected with their poor knowledge on handling complications, the unhygienic environment and harmful practices such as introduction of some herbs into the vagina while conducting deliveries [18]. One wonders why despite the complications arising during home delivery, women still prefer to deliver at home. This study community is privileged to have both primary and secondary health facilities situated there but despite this, there is still a high rate of home delivery. Some of the reasons given by the women for their choice of home delivery aside the common complaint of lack of money for hospital bills and the harsh treatment by health care providers is the birth position they are forced to take in the health facilities. More than half of the women did not like the conventional lithotomy position which they are subjected to in the health facilities. Our question is; should this be the only birth position in the health facility? Is this birth position convenient for the health provider or the woman? Some have opined that this birth position is really for the convenience of the health provider and not for the women [19].

The birth position of sitting and squatting as preferred by most of the women here has been reported to have some benefit. The sitting position is said to combine the force of gravity and relaxation which helps to ease delivery while the squatting position helps in opening the pelvis and assisting the baby’s passage [20]. This could be some of the silent issues responsible for the poor turn out of women for hospital delivery that is being overlooked.

Postpartum Care
A qualitative systematic review showed that postpartum practices and rituals are common worldwide. They include practices such as rest for the mother, diet restrictions or modifications and different forms of hot baths as were seen in this study [21]. It also suggested that these practices may have implications for clinical practice in regard to postpartum care. In Nigeria, other studies found similar results on postpartum practices as the ones in this study [22,23].

Conclusion
The study revealed that women in this community have misconceptions about food consumed during pregnancy for the wrong reasons. Home delivery was found to be unacceptably high with pertinent factors influencing home delivery, one of which is the birth positions they are compelled to take in the health facilities against their desired positions in addition to financial constraints and harsh treatment from health care providers.

Recommendations
We therefore recommend targeted health education for women of reproductive age through behavioural change communication to correct the misconceptions on food taboos during pregnancy and negative birth practices among the women in communities. Furthermore, the TBAs should be educated on positive roles they can play in improving maternal health while the option of other birth positions should be explored and allowed in the health facilities to accommodate every woman as much as is compatible with safe delivery.

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