The study’s first objective was to present the characteristics of the clients of the alternative healthcare providers as captured in the study. Table 1 shows information about each participant and their identifiers, while Table 2 shows participants’ characteristics presented in both frequency and percentage format. The majority of clients (60%) were aged between 25 and 34, while 7.5% were aged between 20 and 24, 20% were aged between 35 and 44, and 10% were aged 45 and over. Only one client refused to give her age. The majority of clients (57.5%) had secondary level education, 2.5% had junior secondary level education, 37.5% had tertiary level education, and 2.5% had postgraduate level education. The majority of clients (85%) were Christians, while 15% were Muslims. The majority of clients were Yorubas (90%), 2.5% were Urhobo and Bini respectively, and 5% were Ibibio. The majority of clients were married (95%), while only 2 reported being single. Three-fifths of clients had 1 or 2 children, 27.5% had three or more children, whole 12.5% were currently pregnant with their first child. The clients were equally distributed between Lagos and Ekiti States.
From these findings, it can be observed the alternative healthcare providers’ clients, in addition to being urban dwellers, are also educated to a reasonable extent, largely Christian, and also predominantly Yoruba, though this may be accounted for by the South-West location of the study. Majority of the clients were also above 25 and married, and the majority had given birth to children previously. These findings show that the clients who choose to use alternative healthcare providers are women who are familiar with the pregnancy process, educated, exposed, and make an informed choice to make use of these health providers.
The second objective of the study addressed the motivations for women making use of traditional and faith-based birth attendants. Under this theme, ten subthemes were identified as listed below.
Subthemes
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Permission to come with companions
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Client’s perception of facility
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Complaint about hospitals
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Cost of services in facility
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Facility waiting time
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How client heard about service provider
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Factors that influenced client’s decision to use the facility
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Place of delivery and previous use of TBA or FBBA
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If client has used the same facility previously
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If client would refer provider to someone else
Permission for clients to come with companions
From the responses below, participants said they are permitted to come with their companions of choice for their antenatal visits. However, while some facilities allowed companions to come in during consultation and labour, other facilities only allowed companions in the reception area and not into the private consultation with the client.
“Yes, you can bring your friends for prayers but not into the consultation room” (E2, 28, Christian, secondary, Ekiti).
“We come with our friends so we can be chatting. Most times, the Doctor asks if you want your friend to come in with you or you want it to be private. That is, if you want to convince your friend to come, the Doctor will allow your friend to enter” (OM6, 46, Christian, secondary, Lagos).
“Yes. My husband was with me during my first and second delivery” (T5, 27, Christian, secondary, Ekiti).
“My husband can come with me. He comes for prayers” (TM6, 32, Christian, secondary, Lagos).
“No, they don’t allow visitors during consultation and even during the time of delivery” (T8, 36, Christian, tertiary, Ekiti).
The importance of being permitted to come with companions of choice is that the additional emotional support they provide can put expectant mothers at ease, and provide support and help with errands and related activities during antenatal visits, as well as during delivery. A good example of this is the participant who reported that she was able to bring a friend who she could talk to during her visit to the facility to while away time.
Client’s perception of facility
Participants generally reported satisfaction with the attitudes of the providers and their assistants, with several comparing their attitudes with the healthcare workers in hospitals. They highlighted factors like timely attention, and the friendliness and warmth of staff at the facilities as reasons for this satisfaction.
“I am incredibly satisfied with the quality of services they offer. The owner of this health facility goes above and beyond to care for us, treating us with the same level of dedication and attention as she would take care of her own children” (T3, 32, Christian, secondary, Ekiti).
“The place is okay and they attend to people quickly. They will not waste your time” (OM1, 24, Muslim, tertiary, Lagos).
“The benefit is that she is a life-saver, and patient compared to the hospital. She will patiently wait for you while in labour compared to the hospitals” (OM4, 33, Christian, tertiary, Lagos).
“They play with us and are very jovial. They don’t segregate anyone. They don’t segregate; they brought everyone together. Everyone is the same to them; they play with us” (TM4, 29, Christian, secondary, Lagos).
“I am satisfied with the approach at this facility. In comparison to hospitals, where nurses sometimes display a negative attitude towards expecting mothers, the staff here consistently treat us with kindness and compassion. Their approach is always filled with love and understanding” (T1, 26, Christian, tertiary, Ekiti).
Here, participants report the relaxed atmosphere at these facilities, in comparison to their experiences at modern health facilities, showing they appreciate the human touch to providing maternal healthcare that these alternative healthcare providers display. Participants had reports of care, compassion, patience and dedication from the service providers.
Complaints about hospitals
Study participants had some complaints about modern hospitals, with top of the list of complaints being the attitudes of health workers. A participant also expressed her dislike for medicines and injections as part of her reasons for disliking the hospitals.
“The prayers and experience at this center differ greatly from that at the hospital. While at the hospital, we often find ourselves neglected by the nurses, who may only attend to us after numerous complaints. However, at this center, our needs are addressed immediately. I usually receive prompt attention here” (E5, 31, Christian, tertiary, Ekiti).
“One of the things I don’t like about these hospitals is their injections, shouting, all their tablets, naturally, I am not a tablet person. If you give me, I will just keep it in my house, the day you will come, I will just give it back to you” (OM7, 43, Christian, postgraduate, Lagos).
“In comparison to hospitals, where nurses sometimes display a negative attitude towards expecting mothers, the staff here consistently treat us with kindness and compassion” (T1, 26, Christian, tertiary, Ekiti).
“Hmm, though in my first pregnancy I registered in hospital, I went there twice and I didn’t like their services. I didn’t register there I just said I should just go and check what they are doing so I didn’t like that place there. Coming here with the way they attended to me, I felt at home” (TM10, 41, Christian, secondary, Lagos).
Similar to the previous section, some participants expressed their grievances with the overly clinical approach taken to service delivery in hospitals. For the faith-based birth attendants, there was appreciation for the spiritual side to their service delivery, with participants reporting that the prayer sessions provided a sort of assurance to them.
Cost of services in facility
Participants generally reported that the services of the alternative healthcare providers were affordable. Though they were required to pay out of pocket for these services as these providers are usually not registered on either public or private health insurance schemes, they were able to afford the services. From the costs quoted by participants, these charges are reasonable and can be afforded by even low-income earners.
“The registration card is three thousand naira (about £2), delivery payment depends on the situation surrounding the delivery” (E4, 29, Christian, secondary, Ekiti).
“We don’t pay for everything but whenever they want to give us drugs, we pay 700 naira (about 40p), 5000 naira (about £3) for registration and 30,000 naira (about £20) for delivery” (OM1, 24, Muslim, tertiary, Lagos).
“On Mondays, we pay 500 naira (about 25p) with the concoction (aseje). Then there are some treatments that they give, herbs in powder form, they charge it together and will be deducting little by little as they give you the medication….for delivery it depends but it is not too much. You know things change year by year and different amount for each year. Like now, they are charging 20,000 naira” (about £15) (OM6, 46, Christian, secondary, Lagos).
“We pay 500 naira (about 25p) every week” (TM2, 29, Christian, tertiary, Lagos).
“They collected 4000 naira (about £2.50) for herbs, and 5000 naira (about £3) for delivery deposit” (T10, 25, Christian, secondary, Ekiti).
“I paid, but their charges are so affordable. When I gave birth to my first child, I paid 15,000 naira (about £9)” (T3, 32, Christian, secondary, Ekiti).
The general reports of affordability of services may likely serve as an attraction for clients of these facilities, given the prevailing economic conditions of the country. However, public healthcare is subsidized by the governments in both Lagos and Ekiti States, so women’s choice of the alternative healthcare providers despite similar costs in the health facilities may show that affordability is most likely not the major attraction for use of TBAs and FBBAs.
Facility waiting time
Participants reported that the waiting times at the facilities is short, and that providers don’t waste their time. One of the providers also concurred with the participants, saying that her facility tries to ensure that the clients are promptly attended to so they can go back home and rest.
“No, I do not have to wait long. They attend to us as early as possible” (E3, 29, Christian, tertiary, Ekiti).
“I don’t stay long except I want to gist and play with them and also disturb them. They don’t delay us. When there are lots of people, they already have a way of dealing with the situation; they will be attending to us as we come…. no wasting of time. It is only if the person they are attending to is lodging complaints. And if you have an emergency, they will leave that person to quickly attend to you” (OM10, 42, Christian, tertiary, Lagos).
“They attend to us on time” (TM8, 45, Christian, secondary, Lagos).
“We don’t stay long at all. The maximum time we spend here is two hours” (T7, 38, Christian, tertiary, Ekiti).
A short waiting time is more desirable for pregnant women, and may contribute to the clients’ overall perception that the service delivery is better than what obtains in modern health facilities.
How client heard about service provider
Most participants reported being referred to the provider by someone close to them, such as a family member, neighbour or church member, and a good number reported being referred by a former client of the facility. This highlights the importance of word-of-mouth advertising, and the role of satisfied former clients in bringing clients to the providers.
“My elder sister who gave birth to all of her five children recommended this place to me” (E8, 36, Christian, tertiary, Ekiti).
“My friend introduced this place to me. I explained my predicament to my friend (how I had been losing my babies) and she directed me to this place” (OM10, 42, Christian, tertiary, Lagos).
“My husband located this place for me. I lost the baby from my 1 st pregnancy so someone called my husband that there is one Yoruba woman that takes care of pregnancy very well caring for both the lives of the mother and the baby…..I delivered my 3 babies here” (OM5, 38, Christian, tertiary, Lagos).
“My relative was once here and she told me about the place” (TM7, 44, Christian, junior secondary, Lagos).
“I was referred to this place by my neighbor, who had previously given birth to her child here” (T3, 32, Christian, secondary, Ekiti).
“I heard about this place through my Mum” (T5, 27, Christian, secondary, Ekiti).
Participants reported being referred to the alternative healthcare providers by people who had either previously used the facility or otherwise had knowledge about the facility. Interestingly, two participants reported that they were referred after losing their babies from previous pregnancies, and had become repeat clients of these facilities.
Factors that influenced client to use the facility
Participants gave various reasons for their preference for alternative healthcare providers. Some women gave their motivation for use as the prayers they undertake at the faith-based maternity facilities. Others mentioned the type of care received and the fact that the providers are usually gentle and not harsh with them. Some stated their preference for herbal medicine over orthodox, and one participant said she prefers the alternative providers because they don’t present Caesarean sections as an option. Another participant said she prefers the alternative providers as she does not want to be attended to or delivered of her baby by a male doctor.
“The prayers and experience at this center differ greatly from that at the hospital. While at the hospital, we often find ourselves neglected by the nurses, who may only attend to us after numerous complaints. However, at this center, our needs are promptly addressed immediately. Moreover, I consistently receive timely attention here as well” (E5, 31, Christian, tertiary, Ekiti).
“At this midwifery center, unlike the government hospital where cesarean sections are routinely performed, they do not always suggest that option since women here typically give birth naturally and conveniently. Additionally, this midwifery center also offers prayer services as part of their services” (E10, 28, Christian, secondary).
“A lot of things motivated me ma. When I got here, I thought things will be the same as usual but as I started using this place, I saw great changes, they listen to my complaints and attend to me very well. They answer me whenever I call them” (OM10, 42, Christian, tertiary, Lagos).
“I prefer traditional, number 1, you will not have any complications in terms of breech baby, CS, or shortage of blood. Then, normally, there is always treatment for malaria. That is the main issue in pregnancy. That is why I prefer using TBA. With what I got there, most especially General hospital, before you can be attended to there, you can even collapse. Before you can collect the card, you will walk from one reception to pavement but here it is immediately. Even if you don’t have cash, they are always there to treat you immediately” (OM6, 46, Christian, secondary, Lagos).
“I have always liked herbal medicine from the beginning and they are combining it with modern medicine. I like it” (TM4, 29, Christian, secondary, Lagos).
“They attend to us well, they are not hostile. And even after delivery, they don’t charge much. Some hospital nurses will be asking for tips…but not here. But if you like, you can give them something based on the way they attend to you. I am very comfortable. All their activities are embedded in prayer. Before they start any work, they will pray and God is really working through them” (TM9, 27, Christian, secondary, Lagos).
“What I love here is the prayers but also most importantly the fact that it’s a woman that will perform the delivery for me, unlike in the hospital. I don’t like been delivered by a male doctor”(T5, 27, Christian, secondary, Ekiti).
“I have the opportunity to engage in personal consultations with mummy, the owner of this center, while in a hospital, such access is unavailable. In the hospital setting, patients are typically attended to collectively, whereas in this facility, we are seen on an individual basis, one after another” (E6 32, Christian, tertiary, Ekiti).
“One of the most significant advantages is the prayer support offered at this place. Unfortunately, I do not have access to that benefit at the hospital” (E9, 45, Christian, secondary, Ekiti).
“The benefit is that the alagbo (herbal medicine practitioner) will make some concoctions for you to eat and you will also have some herbal bath so that when you give birth, nothing will be wrong with the child such as jaundice, problem with the fontanelle. And they will take perfect care of the child” (TM5, 35, Muslim, secondary, Lagos).
The varied reasons for preferring alternative healthcare providers show that their services offer something that modern healthcare facilities do not, and that is mainly the human angle and the fact that the clients feel that the providers listen to their concerns and have their best interests at heart.
Place of delivery and previous use of TBA or FBBA
Some of the participants reported where they delivered their previous pregnancies. Most of the clients reported that they gave birth to their babies in previous pregnancies at either TBA or FBBA’s facilities, rather than in the hospital. This may likely mean that these facilities are their preferred places of delivery, rather than hospitals, if they have no complications during the delivery process.
“I was delivered of my baby here at the TBA” (OM6, 46, Christian, secondary, Lagos).
“I delivered my baby here not in the hospital where I was going… both my 1 st and 2nd child were given birth to here” (TM1, 45, Muslim, tertiary, Lagos).
“Yes, I deliver my babies here” (TM7, 43, Christian, postgraduate, Lagos).
“I gave birth to one of my babies in a place like this at Ifaki” (E1, 29, Christian, secondary, Ekiti).
“Yes, I delivered my first baby here too. And I am planning on having my second child here too” (E4, 29, Christian, secondary, Ekiti).
“I was making use of a place like this when I was in Ilorin…I used the Church (mission house) for my 1 st and 2nd babies” (OM7, 43, Christian, postgraduate, Lagos).
“I delivered all my children at the herbal medicine place. I have never been to the hospital before” (TM5, 35, Muslim, secondary, Lagos).
These responses show that the participants chose to use alternative healthcare providers for the entire pregnancy and delivery process, often only going to deliver their babies in a modern facility only when there were emergencies. This may show a high level of trust in the skill of the alternative healthcare providers by their clients.
If client has used the same facility previously
Some participants revealed that they were repeat clients at the facilities, with some having multiple previous deliveries at the same facility.
“I delivered my first baby here and plan to deliver my second baby here too” (E7, 25, Christian, secondary, Ekiti).
“I have been using this place for a very long time…..yes,you are surprised. I had issue with my 1 st pregnancy when I met her. I met her very late and since then I have been using here and she has being encouraging me not to give up” (OM3, 27, Christian, secondary, Lagos).
“I have been using here during the pregnancies and I delivered here twice too” (TM10, 41, Christian, secondary, Lagos).
“Yes, I gave birth to my first and second children here” (T6, 27, Christian, secondary, Ekiti).
Similar to their preference for TBAs and FBBAs over modern maternal healthcare facilities, these responses may show that participants possess a high level of confidence in these service providers, and believe that they will have the best pregnancy outcomes if they patronise them.
If client would refer provider to someone else
Participants generally reported satisfaction with the services and care they were given at the alternative healthcare providers, with a good number of clients reporting that they were willing to, or had already referred other women in their social network as clients to these providers.
“Very well. I have referred many people” (E1, 29, Christian, secondary, Ekiti).
“I have recommended it already for those that are yet to get pregnant, already pregnant and also to those that have given birth” (OM10, 42, Christian, tertiary, Lagos).
“I referred my younger brother’s wife to this place and she has given birth” (TM4, 29, Christian, secondary, Lagos).
“I tell people that I make hair for to come here and they told me that they are really trying here. I have brought countless of people here” (TM8, 45, Christian, secondary, Lagos).
“Yes, I have even brought like four persons and they delivered successfully” (T4, 30, Muslim, secondary, Ekiti).
These responses show that satisfied clients are willing to advertise the services of these providers, and recruit future clients, which has contributed in no small measure to the continued patronage of these providers by both returning and new clients.