Obstetrics, Childbirth and Child Health
What traditional birth attendants do and what the outcome evidence shows, the real demographic explanation for the Yoruba twinning rate and what it is not, infant care practice, and an honest division between what helps, what is neutral and what kills.
Nigeria dey among countries wey get di highest number of women wey dey die for childbirth (maternal mortality) for di whole world, and na traditional birth attendants, no be skilled health workers, dey attend to plenty births for Yoruba land, especially for rural areas. Dis combination na im make dis topic be di most important one for dis section: people wey dey die from wetin dey happen or wetin fail to happen for dis area plenty pass all di other areas put together.
Di evidence wey dey here support one particular conclusion wey hard to swallow. Traditional birth attendants dey manage delivery wey no get wahala well enough, but dem no fit handle complications wey dey cause maternal death, and di main tin wey dey make difference no be their technique, but whether dem dey refer and how quick dem take refer. Programmes wey don improve outcomes do am by changing how referral dey work, no be by changing wetin dey happen during delivery.
Di traditional birth attendant
Agbẹ̀bí na di Yoruba word, from gbà, wey mean to collect or catch, plus bí, wey mean to born pikin: di pesin wey dey receive di pikin. Di origin of di word explain di work well well.
Di work include to dey press belle and adjust how di baby position for inside belle from outside, to manage position during labour, delivery, to cut umbilical cord and take care of new baby, herbal medicine wey dem dey give during pregnancy and labour, and ritual plus social aspects of birth wey include customs wey dey lead go naming ceremony. Most of di attendants na women, and many times na older women wey people respect for di community, and normally na through apprenticeship dem take learn am, often inside family, and sometimes dem dey claim say na call or dream make dem start di work.
Their social position dey matter for why dis practice still dey continue. Di attendant dey stay near people, dem know am, im dey available for night, dem fit pay am small-small or pay with tins wey no be money, im dey speak di language well well, and im no dey make woman travel far or allow strangers attend to am. When you compare am with hospital wey dey far, dey cost, and wey staff fit no dey friendly, dis choice make sense.
Wetin di evidence about outcome show
Di policy position for past and how e change. Between 1970 and 1990, World Health Organization promote and fund training for traditional birth attendants as strategy to reduce maternal and newborn death . Dem later drop dat policy come face skilled birth attendance, because di trials no show di reduction in death wey dem expect. Di current summary of di evidence na say support for TBA training dey limited but e show promise to reduce maternal death , wey be say e no reach di level of enthusiasm for 1970s, but e strong pass how dem totally reject am for di 2000s.
Knowledge better pass practice. One study of traditional birth attendants for Osun State look into wetin dem know and wetin dem dey do concerning postpartum haemorrhage, wey be di main direct cause of maternal death. Most attendants sabi di causes and warning signs of postpartum haemorrhage, but di way dem dey prevent am no reach and di way dem dey manage am poor . Dat gap between wetin dem know and wetin dem dey do na di common finding for dis research, and na wetin training programmes need to close.
Integration fit change di numbers. Di most useful Nigerian example na di Agbebiye programme for Ondo State, wey be Yoruba state, wey carry traditional birth attendants join di formal maternal health system instead of trying to push dem commot. Di published evaluation report say 5,606 traditional birth attendants join di programme, 14,124 referrals happen out of 142,206 facility deliveries, wey give referral rate of 9.9 percent, and 61.8 percent increase for facility births from 33,077 for 2013 reach 53,531 for 2016 . Na seven maternal deaths dem link to Agbebiye-registered attendants out of 260 facility deaths across di state during implementation, wey be 2.7 percent .
Read dat tin carefully, because di important number no be di referral rate. Na di increase for facility births. Di clear achievement of di programme na say e move tens of thousands of deliveries go inside health facility by making di traditional attendant a way to enter di system instead of an alternative to am. Dat one na different theory of change from just training attendants to deliver better, and based on di evidence, na im dey work.
Attendants fit perform specific clinical functions if dem get support. One three-arm cluster randomised controlled trial for southwest Nigeria test training plus case-manager support for traditional birth attendants to link pregnant women wey get HIV to care . Dis na specific small work, but e show di general principle: attendant wey dey inside system wey get support fit do defined task wey dey reduce harm.
Wetin dey help, wetin dey neutral, wetin dey cause harm
Di honest division, as e dey direct.
Wetin dey help. Pesin wey sabi work and wey people trust to dey present for delivery, wey dey reduce di number of deliveries wey nobody dey attend to. Care wey continue throughout pregnancy. To identify danger signs if dem don train di attendant to know dem. Referral, if proper referral route dey work. Freedom to choose position during labour, wey evidence for obstetrics generally support pass to make woman lie flat on her back. Immediate skin-to-skin contact and quick breastfeeding, wey be traditional practice and also current WHO recommendations.
Wetin dey neutral. Most of di ritual and social practices around childbirth, wey no dey cause any medical harm and dey do real social work, including naming ceremony customs and how family take acknowledge di new baby.
Wetin dey cause harm. Four categories, and na dem dey kill pesin.
Delay to refer. Di main cause of maternal death for dis setting no be say dem do wrong tin during birth, but say dem do di right tin late for somewhere else. Obstructed labour, haemorrhage, eclampsia and sepsis all get short window of time. Attendant wey continue to manage am by herself, or wey refer pesin go facility wey dey hours away without transport, na di direct reason why plenty Nigerian mothers dey die during childbirth.
Agbo wey dem dey prepare for pregnancy and labour. Na this part of the practice dem never really investigate pass, and reason dey to worry. Medicine wey dem dey give to make labour fast dey work like uterotonic medicine to contract womb, and uncontrolled uterotonic when labour block fit tear the womb (uterine rupture). Research don show say some local African malaria plants wey people dey use well well fit cause miscarriage for pregnant mice, and dem clear say this one get serious effect on the mama and baby health . These plants get strong chemical action for body; see file 03.
Practices wey no clean or sterilise. To cut baby cord with things wey dem no sterilise and to rub different substances for the cord stump dey cause neonatal tetanus and cord infection (omphalitis). Na something wey science understand well and wey dem fit prevent totally.
To turn baby from outside (Manipulation). To use hand press belle from outside make baby position change (external manipulation for malpresentation), when no scan or proper monitoring dey, fit make placenta pull comot from womb and fit tear womb.
How twin birth rate high reach and the real explanation
Yoruba people get the highest twin birth rate wey dem don ever record among any group of humans for world, and this na one of the few places wey popular talk about wetin make Yoruba people special na direct truth. Dem also dey explain am wrongly almost every time.
The figures. The studies wey Nylander do for late 1960s and early 1970s record say twin births reach 45 to 53 for every 1,000 deliveries for southwestern Nigeria . When e compare mothers from different ethnic groups wey deliver for two Ibadan hospitals, e record 45, 45, 31, and 21 twin births for every 1,000 deliveries for mothers wey come from Western, Eastern, Mid-Western, and Northern Nigeria respectively . Later analysis of hospital data from 1995 go reach 2004 across four southwestern towns record 46.5 per 1,000 for Ilesa, 46.2 for Ile-Ife, 38.5 for Ogbomoso, and 22.1 for Ado-Ekiti; the total average na 40.2 per 1,000, wey the authors talk say dey among the highest rates wey dem don record for the whole world . Igbo-Ora for Oyo State na the town wey people dey mention pass, with 45 per 1,000, wey be about one twin birth inside every 22 deliveries . The Yoruba rate pass four times the rate wey dey among people of European descent .
The real explanation, inside three parts.
Na dizygotic, no be monozygotic. Na this one be the single most important fact, and na wetin everyday stories dey always leave out. The analysis wey Nylander do on placenta and zygosity show say all the extra twins na dizygotic, while monozygotic rate, wey dem dey check with sex, placenta, blood group, and other genetic markers, no really different among the ethnic groups wey dem compare . Monozygotic twinning dey almost constant, around 3 to 4 per 1,000 for every human population; but dizygotic twinning dey vary well well. So the question no really be "why Yoruba women dey born twin pass," but the more specific question be say "why Yoruba women dey release pass one egg per cycle more frequently."
The biological reason na hyperovulation, and na hormone dey cause am. Nylander report say the average level of follicle-stimulating hormone (FSH) high well well for western Nigerian women wey don born two sets of twins pass the ones wey born one set . High FSH dey make many follicles develop, e dey lead to multiple ovulation, and that one dey lead to dizygotic twins. Dem understand how the body system take dey do am; wetin dey make the FSH different na wetin dem never settle.
Mama age and the number of pikin wey she don born dey add to am, but e no explain am finish. Dizygotic twinning dey increase as mama age dey climb everywhere for world, and e dey reach peak when the woman dey late thirties. The southwestern Nigerian data show say the highest twin births dey happen among women between 25 and 29 years, and the lowest dey among 45 to 49 group ; this one no follow the normal pattern wey world know, and e show say age pattern no be the main driver.
The talk about food (dietary hypothesis), as e really be. The explanation wey people dey repeat pass na say yam or cassava get phytoestrogens wey dey stimulate the ovaries. Science never prove this one.
Wetin research record: the community people for Igbo-Ora by themselves dey call ìlasa pass (soup wey dem use okra leaf cook with local water), together with àmàlà wey dem make from cassava, as the food wey fit dey cause am; the qualitative study see say the community dey point hand to ìlasa pass yam, wey be the story wey dey spread go international level . Nylander suggest for 1978 say things wey dey inside food fit dey increase FSH, but this talk remain idea wey nobody don prove . The conclusion of the 2020 study be say, even though many ideas dey, no research don fit pinpoint the exact thing wey dey cause am, and neighbouring communities dey chop the same food but their twin birth rate low pass; this one dey point say environmental or epigenetic factors fit dey involved wey need proper investigation .
So the honest truth na: the high number of twins na real thing, na dizygotic twins, e dey happen through high FSH and hyperovulation, e get family connection, and nobody don identify the specific environmental or food trigger even after fifty years of research. Anybody wey tell you say na yam dey cause am dey take ordinary hypothesis do like say na proven finding.
Why the rate matter clinically. Twin pregnancy dey carry high risk of death for baby around delivery time (perinatal mortality), and the work wey Nylander do still contribute to the study of perinatal mortality in multiple gestation . Population wey twin birth rate pass 40 per 1,000 and wey people mostly dey deliver outside hospital get serious obstetric wahala, because twin delivery na the exact kind delivery wey need trained medical hand because of bad baby position, complications with the second twin, and heavy bleeding after delivery.
Ìbejì. The deep Yoruba traditions about twins, the ère ìbejì carvings, and the customs for twin wey die, dey well explained for 06-orisa/16-ibeji and 07-arts/04-ibeji. The connection wey make sense to point out here follow the correct cause-and-effect direction: the deep cultural customs wey build around twins na reaction to how twins plenty reach, plus the high rate of death wey dem dey get in history. Society wey one inside twenty-two births dey produce twins, and wey twins dey die often, na society wey must build strong cultural institutions around twins.
Care for baby and small pikin
Breastfeeding dey tey and almost everybody dey do am, dem dey start early, and dis one dey give direct protection.
To carry pikin for back with wrapper dey provide continuous contact, e dey balance body temperature and e dey allow responsive feeding. No evidence dey say e dey cause harm, and good reason dey to believe say e dey bring benefit.
Ọmọ tuntun practice. Di newborn period dey include to bath baby, massage and stretch di baby limbs, wey people dey do well well and wey dis compiler no find any outcome evidence for, whether good or bad. To manipulate baby body with force get theoretical risk; dem never evaluate di practice.
Substances wey dem dey put for cord na documented cause of infection for newborn babies, as stated above.
Herbal preparations wey dem dey give infants dey common, dem dey give am for conditions including ibà, fever, and convulsion, and e dey give special concern because dose for infant no get room for mistake and because di contamination problems for commercial herbal trade wey dem document for file 12 dey apply in full force to patient wey weigh two kilogram.
Ilà, facial marks. Di cutting wey olola dey do, wey dem treat for 07-arts/09-body-arts. As medical matter, na question of clean instrument and tetanus, and di practice don drop well well.
Wetin follow
Di direction wey evidence dey support no be to stop traditional birth attendants kpatakpata, which no be wetin fit happen for medium term and wetin WHO own change of mind on di matter show. Na di Ondo model: register attendants, connect dem to facilities, pay dem for referral, and treat di attendant as di entry point to di system instead of to see dem as rival . Di measurable result of dat approach na 61.8 percent rise for facility deliveries over three years , and to move birth enter facility na di intervention wey get di strongest evidence behind am for global maternal health.
Di herbal preparations wey dem dey give for pregnancy remain di biggest risk wey dem never examine for Yoruba medicine, and na di one wey dis compiler go choose as research priority if dem ask. Dem dey give am to millions of people wey dey body state wey delicate pass, and almost nothing dey known about dem.