Blackwell Publishing LtdOxford, UKINRInternational Nursing Review0020-8132© 2006 The Authors, International Nursing Review (2006)200653••••Original ArticleKnowledge and

attitudes of Nigerian birth attendants about AIDSE. B. Bassey et al.

Original Article

Knowledge of, and attitudes to, acquired

immune deficiency syndrome (AIDS) among
traditional birth attendants (TBAs) in rural
communities in Cross River State, Nigeria
E. B. Bassey1 PhD, C. O. Elemuwa2 MSc & K. C. Anukam3,4 PhD, MHPM
1 Co-ordinator, National Programme on Immunization, Cross Rivers State, Department of Medical Laboratory Services, General
Hospital Wuse, Federal Capital Territory, Garki-Abuja, 2 Assisant Director, National Programme on Immunization, Abuja,
3 Biomedical Research Scientist, Department of Pharmaceutical Microbiology, University of Benin, 4 Lecturer, Department of
Basic Sciences (Microbiology), Faculty of Basic & Applied Sciences, Benson Idahosa University, Benin City, Edo State, Nigeria

BASSEY E.B., ELEMUWA C.O. & ANUKAM K.C. (2007) Knowledge of, and attitudes to, acquired immune
deficiency syndrome (AIDS) among traditional birth attendants (TBAs) in rural communities in Cross River State,
Nigeria. International Nursing Review 54, 354–358

Aim: To survey knowledge of, and attitudes to, HIV/AIDS held by traditional birth attendants (TBAs) in rural
communities in Cross River State, Nigeria.
Background: As the HIV/AIDS epidemic continues to spread, undermining development, reversing health gains
and exacerbating poverty, TBAs in rural communities in Cross River State, Nigeria are still less informed about this
dreadful disease.
Methods: A survey consisting of structured questionnaires was used with 140 randomly selected TBAs to assess
their knowledge of HIV/AIDS, source of information on HIV and protective practices.
Findings: Results revealed that 62 (44.3%) of the TBAs had no formal education. Forty-four (31.4%) had primary
education, while 19 (13.6%) had secondary education. On knowledge of HIV and sources of information, 49
(35.0%) of respondents reported knowing what HIV means. While 26.4% indicated that they received information
about HIV from the government health centres, 23.6% had no information about the disease. There was a great
disparity between male (73.7%) and female (28.9%) respondents on knowledge about HIV. On the use of
protective safety procedures during delivery, 61 (43.6%) used sterilized blades, while 10.7% admitted wearing
protective clothes and gloves. Only three (2.1%) of the respondents said that they were aware of the HIV status of
their clients prior to delivery.
Conclusions: This survey has demonstrated that few TBAs in the communities studied in Cross River State are
informed about HIV/AIDS, and this has revealed the urgency of starting a programme specifically designed for
TBAs in rural communities towards a massive educational campaign on HIV/AIDS.

Keywords: Attitude, HIV, Knowledge, Midwifery, Nigeria, Nursing, Rural Communities, Traditional Birth
Attendants

Background
Correspondence address: Dr Kingsley Anukam, Department of Basic Sciences
Over 60% of pregnant women in Nigeria deliver at home, usually
(Microbiology), Faculty of Basic & Applied Sciences, Benson Idahosa University, attended by untrained traditional birth attendants (TBAs), and
P.M.B. 1100, Benin City, Edo State, Nigeria; Tel: 234-803-7268610; there is a consequent high incidence of pregnancy-related mor-
E-mail: anukamkc@yahoo.com.
bidity and mortality.

© 2007 The Authors. Journal compilation © 2007 International Council of Nurses 354

Original Article
Knowledge and attitudes of Nigerian birth attendants about AIDS
In many developing countries, TBAs have received training in
order to promote safer birth practices, including clean delivery
and avoidance of harmful practices that might lead to the spread
of HIV/AIDS.
In Nigeria, however, there are no data on the knowledge of, and
attitudes to, HIV/AIDS held by TBAs, and there is no known
project executed by any non-government organization (NGO) or
government agency towards educating the TBAs on the dangers of
their own occupation as regards HIV acquisition posed by their
clients.
Introduction
Traditional birth attendants are part of the delivery process
throughout the developing world, assisting in the births of a sub-
stantial proportion of the world’s newborns. In many countries
where skilled professional attendants are lacking, TBAs who are
self-taught or informally trained provide antenatal care to preg-
nant women in most rural areas. In developing countries, many
women are assisted in delivery by TBAs or by relatives; many also
deliver alone unassisted. Only 53.0% of women in developing
countries have the assistance of skilled health personnel (midwife
or doctor) and only 40% give birth in hospitals or health centres
(WHO 2004).
In Nigeria over 60% of pregnant women deliver at home, usu-
ally attended by untrained TBAs, and there is a consequent high
incidence of pregnancy-related illness and death (Awusabo-Asars
& Marfo 1997). In addition to providing emotional and house-
hold support to the woman and her family, the TBAs may also
provide health education, including nutrition and prevention of
sexually transmitted diseases, and advice on breastfeeding and
family planning. The TBAs therefore meet a vital community
need by supporting women throughout pregnancy, childbirth
and the post-partum period.
Healthcare workers (excluding TBAs) have been targets of
studies concerning information on the spread of infectious dis-
eases, since the outbreak of HIV/AIDS. Such studies have tended
to concentrate on exposure to risk at work, knowledge and atti-
tude about some diseases (Adelekan et al. 1995). Healthcare
workers have been studied because they are essential in the pre-
vention and management of diseases, as their perception of expo-
sure to risk can influence the management of HIV/AIDS patients.
The emergence of HIV/AIDS in the last two decades has placed
healthcare workers at risk of infection because of the nature of
their occupation, which exposes them to infection while on rou-
tine duty either through accident, through negligence or through
inadequate protection (Anna et al. 1990).
Epidemiological studies have confirmed an association
between occupational exposure and infection with HIV
(Walraven & Weeks 1999). In Rwanda, a survey of occupational
© 2007 The Authors. Journal compilation © 2007 International Council of Nurses
355
blood contact and HIV infection among TBAs revealed that 1.8%
were HIV-1 positive (Habimana et al. 1994). In Mexico, of 12 151
adult HIV/AIDS cases reported by 1993, 335 (2.9%) were health
workers and two cases were directly linked to occupational trans-
mission (Garcia et al. 1994).
Globally, more than one million women infected with HIV are
estimated to deliver their babies without the help of professional
healthcare workers (Piper 1997). Historically, traditional birth
skills have been passed on from mother to daughter for genera-
tions, and the tendency to adhere to the traditional practices is
high, thereby neglecting and undermining improvement of their
skills, and involving the risk of using instruments or procedures
that may aid in the transmission of HIV/AIDS among their clients.
In many developing countries, TBAs have received training in
order to promote safer birth practices, including clean delivery
and avoidance of harmful practices that might lead to the spread
of HIV/AIDS (De Vaate et al. 2002), but the same cannot be said
of Cross River State, in Nigeria. TBAs deliver the vast majority of
babies in the developing world usually in the home setting. These
TBAs are of great importance in the HIV/AIDS pandemic; they
are an important link in the health education chain and in the
dissemination of information about HIV. In Nigeria, there is no
known project executed by any NGO or government agency
towards educating the TBAs on the dangers of their own occupa-
tion as regards HIV acquisition posed by their clients, and the
possibility of HIV/AIDS voluntary counselling and testing.
This study was designed to collect qualitative data on the
knowledge and attitude of TBAs about HIV in rural communities
in Cross Rive State, Nigeria. It was also meant to provide a general
view on issues that are crucial to the reduction in the rate of trans-
mission of HIV among TBAs in rural communities.
Methods
Study focus
The focus of this study was to collect qualitative and quantitative
data on the knowledge and attitudes of TBAs regarding HIV infec-
tion in rural Cross River State. It was meant to provide a general
view about some of the issues that could be addressed to enhance
awareness of HIV/AIDS. Three instruments were developed for
the survey: structured questionnaire, in-depth interview and
group discussion guides. The questionnaire was developed for all
identified respondents and covered knowledge, attitude and per-
ception on HIV/AIDS. The in-depth interview and focus group
discussions (FGDs) were tailored to cover similar areas. Qualita-
tive data collection technique was considered appropriate. The
FGDs were organized to obtain additional information from
respondents as well as to use the responses to validate some of the
results from the questionnaire and in-depth interview.
356 E. B. Bassey et al.

The locality Results

Cross River State is in south-eastern Nigeria, the largest tourist From the 18 community sites that targeted a maximum of ten par-
centre in the country. It has an estimated population of 2 846 497, ticipants in each site, a total of 140 TBAs responded to the survey
with an annual growth rate of 2.98% (National Population Com- and in the nine FGDs, each with a minimum of 15 participants,
mission 1991). The state has about five major cities and large coincidentally, a total of 140 TBAs were present.
forest areas covering over 400 000 square kilometres with a large Table 1 shows the demographic characteristics of all the 140
rural population. The state has the highest prevalence of HIV/ TBAs, in relation to age, sex, ethnic background and educational
AIDS in Nigeria. The national HIV sero-prevalence sentinel sur- status. For this analysis, 121 (86.4%) of respondents are women,
vey conducted in 2003 showed that 12.0% of the population is only 19 (13.6%) are men. In the data obtained, respondents aged
infected with HIV. HIV/AIDS cases are recognized in rural com- 41–50 years were more than half the total number of respondents,
munities in the state (Federal Ministry of Health 2003). The study whereas those aged 20–30 years were only 10% of the total parti-
sites were randomly selected from 18 communities in five clans cipants. Only 24 (17.1%) of the respondents are in the age group
spread across three local government areas of Cross River State, 50 years and above. In terms of educational status, 62 (44.3%) do
located in the Niger Delta area of the country. not know how to read and write (illiterate), while 63 (45.0%) had
formal education. There was a significant difference in the knowl-
edge of HIV between male and female TBAs (5.5% vs. 94.5%
The sample and data collection
X = 5.12, P = 0.01). Of the respondents (Table 2), 48 (34.2%)
This prospective study on 140 TBAs used a convenient-sampling
indicated that they had received information about HIV from
method to select the respondents with a structured questionnaire
government hospitals/health centres, while 34 (24.3%) received
between January and March 2004.
information from the churches and village heads. Only 12 (8.6%)
Study participants were recruited after informed consent was
reported having received information about HIV from a fellow
obtained. The survey was conducted in 18 focal sites; the sample
TBA and/or traditional healers. Most worrying was that 33
in each of the 18 sites was drawn from rural resource-poor set-
(23.6%) have never received any information about HIV.
tings. In each of the 18 sites, a maximum of ten respondents was
targeted on a convenience basis. Community health workers
administered face-to-face interviews and helped fill in the struc-
tured questionnaires for the illiterate participants. A total of nine
Table 1 Demographic characteristics of traditional birth attendant
FGDs were held, each accommodating a minimum of 15 respon- (n = 140)
dents. All participants were chosen with the assistance of com-
munity health workers who were familiar with the demographic
Characteristics No. %
characteristics of the area. Moderators (local community health
workers) made it clear to respondents that the intention was to
Sex
discuss knowledge and attitude towards the provision of services. Male 19 13.6
The proceedings of the FGDs were properly documented; proce- Female 121 86.4
dures for conducting the FGDs, introductory remarks and Age (years)
guidelines as well as detailed instructions were identical for all 20–30 14 10.0
the nine centres to ensure the quality and comparability of the 31–40 28 20.0
data. Data obtained from respondents included age, sex, level of 41–50 74 52.9
50+ 24 17.1
education, and knowledge of HIV/AIDS and safety practices
Ethinicity
employed. Abinni 8 5.7
Agbo 35 25.0
Agoi 8 5.7
Statistical analysis
Assiga 26 18.6
For statistical analysis we used SPSS 11.5 for Windows. Differences Yakurr 63 45.0
between groups were evaluated by two-way chi-square and Educational status
Fisher’s exact test for categorical variables. Spearman’s rank corre- Illiterate* 62 44.3
lation analysis was used to investigate the relation between non- Formal education 63 45.0
parametric variables. Values were specified as probability values Unknown 15 10.7
(P) with 95.0% confidence intervals (CI). The P-value of <0.05
was taken as significant. *Defined here as those who are not able to read and write.

© 2007 The Authors. Journal compilation © 2007 International Council of Nurses

Knowledge and attitudes of Nigerian birth attendants about AIDS 357

Table 2 Knowledge about HIV/AIDS and sources of information on AIDS Table 4 Attitude on wearing of protective clothing/hand-gloves
(n = 140)

Response No. %
Variables No. %
Yes 15 10.7
Knowledge about HIV/AIDS No 66 47.1
Yes Not necessary 54 38.6
Male 14 10.0 No answer 5 3.6
Female 35 25.0 Total 140 100
No
Male 5 3.6
Female 86 61.0 Table 5 Attitude on importance of knowing HIV status of client before
Source of information taking delivery
Government hospital/health centres 48 34.2
Private hospitals/dispensaries 13 9.3 Response No. %
Traditional birth attendants/healers 12 8.6
Churches/village heads 34 24.3
Yes 3 2.1
No information 33 23.6
No 97 69.3
Not necessary 38 27.1
No answer 2 1.4
Table 3 Attitude on sterilization of cord-cutting blade
Total 140 100

Response No.
Yes 86
No 19
Not necessary 21
No answer 14
Total 140
On adherence to protective practices (Tables 3–5), only 15
(10.7%) admitted to wearing protective gloves during delivery
and only three (2.1%) reported that they were aware of the HIV
status of their clients. Surprisingly, in view of the previous
responses, 86 (61%) stated that they use sterilized blades for cut-
ting the umbilical cord.
Discussion
A large proportion of the population in a number of developing
countries still rely on traditional birth practitioners, including
TBAs, to satisfy their primary healthcare needs. The World Health
Organization estimates that TBAs assist in over 95.0% of all rural
births and 70.0% of urban births in developing countries (Songok
et al. 2003). HIV/AIDS is an increasing problem especially in
Africa in terms of disease burden and macroeconomic effects on
the development of the continent, besides the human cost. HIV/
AIDS is already having profound effects on Africa’s economic
development; HIV/AIDS reduces labour supply, productivity
and exports, and increases imports. The pandemic has already
reduced average national economic growth rates by 4.0% every
year across Africa (De Vaate et al. 2002; Songok et al. 2003).
%
Our study showed that 121 (86.4%) of the 140 TBAs are women
61 and 19 (13.6%) are men. The involvement of more women than
13.6 men as TBAs may be attributed to several factors such as cultural
15.4 practices; in some communities, male midwives are not allowed to
10
conduct deliveries (Isenalumbe 1990). The highest number of
100
respondents, 74 (52.9%), are in the age group 41–50 years, and the
lack of younger individuals among respondents clearly points to
their recruitment into other household activities at a certain age
(Songok et al. 2003). The respondents involved in this survey have
an educational level which is below the national average. Nineteen
TBAs (13.6%) had secondary education, the highest educational
level attained by the respondents, and 62 (44.3%) had no formal
education at all. This observed trend is of concern, as the relative
low educational level is a crucial finding. Highly illiterate respon-
dents cannot be easily involved in the dissemination of HIV/AIDS
information, i.e. how HIV can be transmitted and how to explain
effective strategies to prevent such transmission, identify pregnant
women in their communities and facilities available for antenatal
and maternity care, make sure that pregnant women and their
partners are routinely offered HIV counselling and testing,
reinforcing health programmes, including the importance of
improved nutrition during pregnancy (Robinson 1999). In Gam-
bia, where most TBAs are illiterate, this is a major constraint in
training them to provide high-quality care because of their use of
traditional practices or their inadequate knowledge (Maja 2001).
The data in this present study indicate that government health
centres (26.4%) and churches (19.3%) were the major sources of
information of the respondents on HIV/AIDS.

© 2007 The Authors. Journal compilation © 2007 International Council of Nurses

358 E. B. Bassey et al.
These figures are at variance with the 32.8% and 11.8%
obtained from similar studies in Tanga region of Tanzania at gov-
ernment health centres and churches, respectively (Babette et al.
1999). The impact of school-based information and the extent to
which peers and parents have become sources of information have
a very significant role to play in HIV/AIDS information dissemi-
nation (Garcia et al. 1994). Other sources of information on HIV/
AIDS include parents, siblings, friends and religious institutions.
These sources could be strengthened while supervising the con-
tents and accuracy of the information disseminated. In our study,
49 (35.0%) of the respondents have knowledge of HIV/AIDS, but
the majority, 91 (65.0%), of the respondents have no knowledge
of the disease. This high number of respondents who have no
knowledge of HIV/AIDS will play a significant role in the spread
of the disease and precludes rational preventive measures. This
finding was further confirmed by the attitude of respondents
towards knowing the HIV status of their clients, as only three
(2.1%) of respondents seek to know the HIV status of their clients
before conducting the delivery. Only 10.7% wear protective cloth-
ing and 61% sterilize cord-cutting blades. This observed trend
might be attributed to the following factors: TBAs do not have suf-
ficient literacy or general knowledge; they work without supervi-
sion and back-up support; and lastly there is lack of HIV-testing
centres within their domains.
The demand for TBAs is high because they share cultural and
health beliefs with the women and have strong ties with the com-
munities they serve. They speak the local languages, allow tradi-
tional birthing practices and often have the trust and respect of the
community. Although providing a highly skilled medical delivery
in poor communities remains a long-term goal, an immediate
solution is to identify, support and train TBAs practising in local
communities. Models applicable to resource-poor settings, devel-
oped as part of rural healthcare delivery programmes and empha-
sizing prevention of the transmission of HIV may be adopted.
Conclusion
This is probably the first documented survey showing the educa-
tional level attained by TBAs in Nigeria, with 44.3% having no
formal education, while 65.0% of the respondents have no knowl-
edge of HIV/AIDS. Only 2.1% of respondents seek to know the
HIV status of their clients before taking delivery.
The study showed that the TBAs surveyed work without super-
vision or back-up support, and there is lack of HIV-testing centres
within their domains. The need for support and training of TBAs
practising in rural communities in Cross River State, Nigeria
should be brought to the attention of the government and con-
cerned NGOs.
© 2007 The Authors. Journal compilation © 2007 International Council of Nurses
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