Solving delayed referrals of childbirth cases from unskilled to skilled birth attendants in Nigerian urban communities: A case study exploration of new frontiers

Problem
Delayed referrals of women from untrained traditional birth attendants (TBAs) to formally trained health personnel in primary healthcare centers and hospitals contribute to maternal and child mortality in Nigeria.

Background
Reasons for delayed referrals by TBAs could be shaped by personal beliefs and diabolical practices, which are not apparent.

Aim
Our study went beyond the usual rhetoric of health systems inefficiencies alongside economic and educational deficits as responsible for delayed referrals to underscore other unexplored nuances.

Methods
Data were collected using a case study approach via in-depth iterative interviews with service users, TBAs, and primary healthcare workers.

Findings
Four overlapping issues caused and reinforced delayed referrals: (a) TBAs in high demand and considered more experienced because they conduct more volume of childbirths (b) spiritual description of pregnancy by clients and TBAs (c) fear of diabolic tendencies of some TBAs by clients, and (d) income of TBAs rely on the duration of the childbirth process and not necessarily the outcome.

Discussion
Therefore, addressing delayed referrals caused by TBAs is beyond regular health system structural factors that are amenable to capacity building and resource-based interventions.

Conclusion
Incentives and sanctions targeting identified nuanced subjectivities, including spiritism in the practices of TBAs that have shaped relationships with pregnant mothers, should be considered by governance and health promotional interventions.