Guidelines traditional birth journal joachim_chijide

GOVERNMENT OF
CROSS RIVER STATE
N O V E MB E R 2016
GUIDELINES FOR THE
COORDINATION, MONITORING
AND SUPPORTIVE SUPERVISION OF
TRADITIONAL BIRTH
AND FAITH-BASED
BIRTH ATTENDANTS
IN CROSS RIVER STATE

Foreword 3
Acknowledgment 4
Acronyms 5
List of contributors 7
Background 9
Requirements for registration and licensure
to practice as a TBA/FBBA
13
Scope and standards of practice for TBAs/FBBAs 17
Code of conduct 22
Penalties and rewards 24
Coordination, monitoring and
supportive supervision of TBAs/FBBAs
29
Data Management 33
TABLE OF CONTENTS

It is our belief that the challenges of
achieving universal health coverage
can be overcome if the primary
healthcare system is able to deliver
on its mandate of providing efficient
and affordable healthcare to the
people of Cross River State
irrespective of their location.
Some of the interventions we have
undertaken to address these
challenges are the establishment of
the Cross River Primary Healthcare
Development Agency, providing
support for the operationalization of
PHCUOR (Primary Healthcare Under
One Roof) and the implementation
of one functional PHC per ward.
Over the years the inefficiency of the
primary healthcare system has led to
the emergence of alternative care-
givers who are attempting to fill the
gaps. This phenomenon is probably
most evident in the area of maternal
health, where TBASs/FBBAs have
become a preferred alternative to
pregnant women in the rural areas of
Cross River and other states of the
federation.
Mindful of the traditional and
religious beliefs that act as enablers
for the patronage of these care-
givers, a systematic and evidence-
based approach is required to
protect their clients. It is expected
that these guidelines will serve as a
minimum standard to streamline the
operations of the TBAs/FBBAs
practicing in the state, thus ensuring
that our pregnant women and
newborns are not at risk.
I therefore recommend the effective
use of these guidelines by all
stakeholders to set Cross River on the
path of reduction of maternal and
reduction of neonatal mortality and
morbidity; and ultimately the
attainment of the SDGs.
FOREWORD
The commitment to provide an enabling environment for universal
access to primary healthcare services that caters to the needs of every
Cross Riverian is a significant policy thrust of my administration.
Senator (Prof) Ben Ayade
Executive Governor,
Cross River State
03
GUIDELINES FOR THE COORDINATION,
MONITORING AND SUPPORTIVE SUPERVISION OF
TRADITIONAL BIRTH AND FAITH-BASED BIRTH
ATTENDANTS IN CROSS RIVER STATE

I would like to express my profound
gratitude to His Excellency, Senator
(Professor) Ben Ayade for creating
an enabling environment for
expedient health sector reforms, the
signing of the “AYADE CARE” State
Health Insurance Scheme into law;
the establishment of the Cross River
S t a t e P r i m a r y H e a l t h c a r e
D e v e l o p m e n t A g e n c y a n d
improving access to universal
healthcare for all Cross Riverians.
I acknowledge the support and
leadership of Her Excellency Dr.
Linda Ayade throughout the
development of these guidelines. In
fulﬁlment of her role as a Maternal
Health Ambassador, the outcome of
this document is a demonstration of
her commitment to ensure that no
woman has to die while bringing a
life into the world.
On behalf of the Cross River State
Primary Health Care Development
Agency, I would also like to
appreciate the United Nation
Population Fund (UNFPA) who
provided technical suppor t
t h ro u g h o u t t h e p ro c e s s of
developing this guideline. I
acknowledge the signiﬁcant
contributions of the Honourable
Commissioner for Health Dr.
Asibong, the Cross River SMoH, staff
of the CRSPHCDA, the TBAs/FBBAs,
donor agencies and indeed
appreciate all stakeholders for their
support.
ACKNOWLEDGEMENT
The guidelines for the coordination, monitoring and supportive
supervision of traditional birth and faith-based birth attendants
provides a framework for setting regulatory standards on the scope of
practice, code of conduct of TBAs/FBBAs and the effective monitoring
of these standards.
Dr. Betta Edu
Director General,
Cross River State
Primary Healthcare
Development Agency
04

AIDS Acquired Immune Deﬁciency Syndrome
ANC Ante –Natal Clinic
CBO Community Based Organization
CHEW Community Health Extension Worker
CRSPHCDA Cross River State Primary Health Care Development Agency
DHIS District Health Information System
DPRS Director Planning Research and Statistics
DQA Data Quality Assurance
FBBA Faith Based Birth Attendants
HCT HIV Counselling and Testing
HIV Human Immunodeﬁciency Virus
LGA Local Government Area
M&E Monitoring and Evaluation
MMR Maternal Mortality Ratio
MNCH Maternal New-born and Child Health
NDHS Nigeria Demographic and Health Survey
PMTCT Prevention of Mother to Child Transmission
PHC Primary Health Care
ACRONYMS
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ACRONYMS
RH Reproductive Health
SMoH State Ministry of Health
SDGs Sustainable Development Goals
TBA Traditional Birth Attendant
TT Tetanus Toxoid
UNICEF United Nations Children Fund
UNFPA United Nations Population Fund
VHC Village Health Committee
WDC Ward Development Committee
WFP Ward Focal Person
WHO World Health Organization
06

07
chapter ONE

On a global scale, maternal mortality ratios (MMR) fell by
nearly 44% over the past 25 years, to an estimated 216
maternal deaths per 100,000 live births in 2015. The
annual number of maternal deaths also decreased by
43% from approximately 532,000 in 1990 to an estimated
303,000 in 2015 . In 2015, the approximate global lifetime
risk of a maternal death fell considerably from 1 in 73 to 1
in 180 . However, further interrogation of these figures,
reveal that the rates of progress towards the attainment
of better indicators have not necessarily been the same
across the regions of the world. Whilst the developed
nations have made significant progress in reduction of
MMR, the developing regions accounted for
approximately 99% (302,000) of the global maternal
deaths in 2015. Sub-Saharan Africa alone accounting for
roughly 66% (201,000), followed by Southern Asia
(66,000).
At the country level, Nigeria and India were estimated to
account for over one third of all maternal deaths
worldwide in 2015, with an approximate 58,000 maternal
deaths (19%) and 45,000 maternal deaths (15%),
respectively. Given that Nigeria accounts for
approximately only 2% of the world’s population, these
figures are unacceptably high. According to the 2013
NDHS the national average for key maternal health
indicators for Nigeria were as follows: Health facility
deliveries (35.8%), Deliveries at home (63.1%), Skilled
birth attendance (38.1%), estimated Maternal Mortality
Ratio (576)
At the state level, Cross River State has not necessarily
fared much better than the federation in terms of its
maternal health indicators. Some of the key MNCH
indicators for the state are as follows: Health facility
deliveries (40.4%), Deliveries at home (59.1%), Skilled
birth attendance (41.3), estimated Maternal Mortality
Ratio (545) .
Also noteworthy are the statistics that in spite of the fact
that 72.6% of women received ANC services in Cross River
State, yet only 40.4% of women delivered in a health
faciliy. This trend indicates that alternatives to health
facility deliveries are being utilized by women across
1.1 Situation Analysis
Trends in Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division
Trends in Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division
Nigeria Demographic & Health Survey 2013
Nigeria Demographic & Health Survey 2013
1
2
3
4
08
On a global scale,
Maternal Mortality
Ratios fell by nearly 44%
over the past 25 years, to
an estimated 216 maternal
deaths per 100,000 live
births in 2015.
1.0 BACKGROUND

the state. A significant alternative to health facility
delivery and care utilized by women in the rural areas are
the Traditional Birth Attendants and Faith-Based Birth
Attendants.
A Traditional Birth Attendant may be defined “as a person
who assists the mother during childbirth and who initially
acquired her skills by delivering babies herself or through
an apprenticeship to other TBAs”. A Faith-Based Birth
Attendant on the other hand provides the same services
as a TBA, may have acquired skills in the same manner as
a TBA, may indeed double as a TBA but with the
significant element that she/he is generally
acknowledged by community members to possess
spiritual powers that enhance his/her capacity to assist
mothers during child birth. Though both the TBA and
FBBA are often not formally trained, they are respected
members of the community and their status is further
enhanced by prevalent cultural and religious beliefs that
are steadfast and are at the very fabric of societal life in
the rural areas.
The lack of training of both entities may significantly put
their clients at risk of maternal morbidity and mortality as
well as neonatal mortality and morbidity, especially in
cases when the pregnancies are already high-risk such as
multiple pregnancies, primigravidas, multigravidas,
previous Caesarian Section scars, etc.
In order to reduce the risks of mortalities and morbidities,
it is imperative that measures are put in place to
streamline the operations and standardize the practice
and the conduct of TBAs/FBBAs. The development and
the implementation of guidelines for the coordination,
monitoring and supportive supervision of TBAs/FBBAs
would be helpful in achieving this goal.
09

The primary purpose of the articulation of these
guidelines is to provide guidance to all stakeholders on
the standards of practice of TBAs and FBBAs in Cross River
State, the roles and responsibilities of state and non-state
actors in ensuring compliance with these standards
through effective coordination, monitoring and
supportive supervision of TBAs/FBBAs. The ultimate goal
is to reduce maternal mortality ratios, neonatal mortality
rates, maternal and neonatal morbidity rates in line with
national targets and the SDGs. Furthermore, the
guidelines will:
Ÿ Serve as a reference document defining the
requirements for recognition and/or registration and
licensure as a TBA/FBBA
Ÿ Articulate the criteria for the registration and licensure
to practice as a TBA/FBBA
Ÿ Clearly define the scope of practice and code of
conduct of a TBA/FBBA in Cross River State
Ÿ Articulate penalties for noncompliance to regulatory
standards of practice for TBAs/FBBAs
Ÿ Articulate rewards for exemplary compliance to
regulatory standards of practice for TBAs/FBBAs
Ÿ Define the roles and responsibilities for the
coordination, monitoring and supportive upervision
of TBAs/FBBAs
Ÿ Recommend tools required for the operationalization
of effective coordination, monitoring and supportive
supervision of TBAs/FBBAs
1.2 Purpose of the Guidelines
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11
chapter TWO

Ÿ Must be literate and possess secondary school
education certificate (e.g. SSCE,WAEC, NECO)
Ÿ Should be within the age range of 30 – 65 years (In
exceptional cases, the SPHCDA may grant a waiver on
a yearly basis to a TBA/FBBA above 65yrs who is able
to pass a competency-based eligibility test)
Ÿ Must be in good standing with the Local and State
Chapters of the TBA/FBBA association and the LGA
health authorities
Ÿ Must have practiced as a birth attendant for at least 2
years
Ÿ Must have undertaken training on danger signs of
pregnancy and referral of high-risk
Ÿ pregnancies
Ÿ Must have a practice site which fulfills the criteria set
by the standards of practice in Cross River (Please
refer to section 3.2.1).
2.1 Eligibility Criteria
2.2 Licensure/ Registration Procedures
TBA/FBBA shall provide the following to the CRSPHCDA :
Ÿ A filled registration form (Please refer to section 2.2.1)
Ÿ A letter of good standing endorsed by the TBA/FBBA
community police, health facility head and the PHC
Coordinator
Ÿ Certificate of attendance of at least one refresher
course within period of licensure
Ÿ A predetermined administrative fee of no more than
N1,000 for the production of the license
Ÿ The license shall be provided to the TBA/FBBA by the
CRSPHCDA
Ÿ The CRSPHCDA shall provide the TBA/FBBA with a
license that shall be valid for a period of no more than
2 years
2.0 REQUIREMENTS FOR REGISTRATION
AND LICENSURE TO PRACTICE AS A
TBA/FBBA
12
This section outlines the criteria for the recognition
of an individual as a practicing TBA/FBBA.
The essence of this section is to provide information on
the eligibility criteria, the required qualifications and
attributes of the TBA/FBBA, as well as the requirements
for maintaining registration/licensure
in Cross River State.

2.2.1 Draft Registration Form
CROSS RIVER STATE PRIMARY HEALTH CARE DEVELOPMENT AGENCY
REGISTRATION FROM FOR TBA/FBBA
To register as a TBA/FBBA, the following requirements are necessary:
I. Has at least two referees with reputable standing in the society that must either be a pastor,
landlord, village head or WDC chairman.
II. Two recent passport photographs of the applicant.
Fill the information below in block letters:
Date: Form No
1. Name:
(Surname First name middle name)
2. Date of birth. Day Month Year
3. Age:
4. Pace of birth:
5. Sex:
6. Permanent Address:
7. Site Address:
8. Phone No.
9. Signature:
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DECLARATION
I declare that all the information given by me are true
and correct and I am willing to adhere by the code of conduct and ethics of a skilled TBA/FBBA in
CRS.
Date: Signature: Phone No.
RECOMMENDATION
I hereby recommend for registration, training and licensing of
Name:
Ward:
LGA:
Phone No.
Signature:
Ofﬁce use only (CRSPHCDA)
Received by:
Date:
Signature:
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15
chapter THREE

Ÿ For the purposes of these guidelines, a skilled
TBA/FBBA is one that has undergone a competency-
based training exercise which includes at least
content on identiﬁcation of high-risk pregnancies,
identiﬁcation of danger signs and referral of cases. It is
noteworthy that only skilled TBAs/FBBAs are eligible
for licensure.
Ÿ This section outlines the standards and scope of
practice expected of a licensed TBA/FBBA in Cross
River State. It also provides a basis for determining the
violation of these standards and scope and can
therefore be used as a benchmark for the evidence-
based application of the penalty and rewards system.
Ÿ Refer all pregnant women for ante-natal care at the
nearby health facility
Ÿ Provide supplementary care to women during
pregnancy, deliveries and after birth.
Ÿ Refer all women who have labored for more than six
(6) hours to the nearest health center.
Ÿ Must refer all HIV positive mothers for eMTCT services
at health facility
Ÿ Maintain up-to-date data of at least all those who
attended ANC, number of deliveries, referrals and
deaths.
Ÿ Maintain proper hygiene of delivery room and
immediate environment
Ÿ Must attend the TBA/FBBA’s meetings on a regular
basis.
Ÿ Must have a link with the nearest health facility and
must maintain excellent networking with the facility
head in terms of data reporting, referrals and other
support system.
Ÿ Must subscribe to a transport system that will move
clients from their TBA homes to nearest health facility.
Ÿ Attend TBA refresher courses organized by
CRSPHCDA at least twice in a year.
3.1 Scope of Practice
3.1.1 The Expected Roles of skilled TBAs/FBBAs:
3.0 SCOPE AND STANDARDS OF
PRACTICE FOR TBAS/FBBAS
16

The following are high-risk interventions that a TBA/FBBA
is not expected to undertake in Cross River state.
Undertaking any of the following significantly goes
beyond the scope and standards of practice and
significantly puts the client or her baby at risk. Therefore
the following shall attract penalties:
1. Managing a woman who is with her first pregnancy
(primigravida).
2. Managing a woman who has had up to or more than
four deliveries (multigravida and grand multigravida).
3. Managing a woman with multiple pregnancies (i.e.
twins, triplets, etc.)
4. Managing a woman who has a previous caesarian
section or any abdominal scar.
5. Managing a woman who has a previous history of
bleeding during pregnancy (whether ante-partum,
intra-partum or post-partum).
6. Managing a woman who has a history of high blood
pressure or fits during a previous or current
pregnancy.
7. Managing a woman who is pregnant after a
history of repeated abortions or still births
(precious baby).
8. Managing a HIV positive client during pregnancy or
in labour.
9. Managing a woman with abnormal presentation e.g.
breech or transverse lie.
10 Managing a woman in labour with bare hands.
11. Administering herbs to a pregnant woman
during antenatal care or labour
12. Administering IV drugs, fluids or blood transfusion at
the practice site.
13.Depriving a woman of her right to take decision on
where to deliver.
14.Coercing a woman to deliver in a TBA/FBBA facility by
threatening her with false prophecies of negative
outcomes of pregnancy or other means.
15. Sharing client’s information with others in the
community.
16. Falsification of data
17. Absenteeism from monthly review meetings
3.1.2 Limitations of Skilled TBAs/FBBAs:
The purpose of this section is to highlight the
minimum standards of practice which shall be
the benchmark for ensuring that the highest
quality of care possible is achieved within
theresources available. These standards shall provide the
basis for the monitoring, supportive supervision,
comparability and regulation of services rendered by
TBAs/FBBAs. The minimum standards for TBA/FBBA sites
will serve as a document to inform and guide persons
responsible for ensuring services delivered by TBAs are
3.2 Standards of Practice:
17

• Referrals : TBAs/FBBAs must adhere to referral
procedures and conditions especially for new clients
and complicated pregnancies
• Equipment and kits: Every TBA should have a
standard delivery kit which include the following:
Mackintosh, 2drapes, kidney dish, scissors, 2 artery
forceps, one cord scissors, and cord ligatures, one
packet of razor blade, small suction pump, surgical
gloves, aprons, protective footwear (i.e. rain
boots/crocs) and Consumables : Methylated spirit,
Cotton wool and gauze
• There should be a sterilizing point/unit (a pot and
stove for boiling instruments may be considered as
the minimum requirement)
Records and Charts such as the following should be
available :
Ÿ Patient records
Ÿ Referral cards
Ÿ Tally cards for deliveries and other services provided
safe and meet service delivery standards. It is also
intended to help achieve uniformity in practice and if
adhered to will ultimately contribute to the improvement
the Maternal Newborn and Child Health indices in Cross
River State.
This document defines a set of minimum standards in the
following areas:
Ÿ Physical site requirements (Infrastructure)
Ÿ Service Provision
Ÿ Human Resources (staffing)
Ÿ 2 rooms strictly for practice, with not less than 2 beds
protected with padding and covered with mackintosh.
Ÿ A waiting area.
Ÿ Mosquito nets
Ÿ Water containers with 200- 500 liters of water.
Ÿ Means of proper waste management (including at
least a separate pit for disposal of placenta and
medical waste).
Ÿ Must have the items (jik, izal, dettol, plastic buckets
with lids and utility gloves) for sterilizing their
equipment. -
Ÿ Resuscitation table with an easy to clean top
(Formica/Mackintosh)
Ÿ At least one roofed pit toilet with cemented floor, a
concrete slab/raised seat. The toilet must be well
ventilated and TBA/FBBA must have disinfectants for
washing the toilet at least 3 times a day.
Ÿ Must have a sign-post that is easily identifiable by
community members, health facility head and PHCC.
3.2.1 Physical Site Requirements.
3.2.2 Service Delivery
18

19
• Where a TBA/FBBA has below 10 deliveries/clients to
attend to in a month, there should be a least one
identifiable person in each TBA/FBBA site who serves
as a support staff.
• Where client volume is more than 10-20 in a month,
there should be at least a pool of 2-3 identified
support staff that the TBA/FBBA can draw from.
3.2.3 Human Resource (Staffing)

20
chapter FOUR

In addition to the standards and scope of practice of
TBAs/FBBAs, the following code of conduct shall govern
the comportment of TBAs/FBBAs and shall set them apart
to conduct their legitimate business in a dignified
manner that commands the confidence of their clients
and the communities in which they serve. The following
shall be applicable as codes of conduct to TBAs/ FBBAs:
1. TBAs/FBBAs are to provide services in a safe an ethical
manner
2. TBAs/FBBAs diagnosed with infectious medical
conditions that can be passed on to clients must
practice in a manner that does not put clients at risk
3. TBAs/FBBAs must not practice while suffering from a
physical or mental impairment, disability, condition or
disorder that detrimentally affects their capacity to
provide care to clients
4. TBAs/FBBAs must not practice under the influence of
alcohol or unlawful drugs
5. TBAs/FBBAs must adopt standard precautions for the
control of infections in his/her practice
6. TBAs/FBBAs must not exploit their clients
either by prescribing treatments that are not
required, making false claims or receiving
inducements to initiate a required referral to
a health facility.
7. TBAs/FBBAs must keep appropriate (accurate, legible
and contemporaneous) records of their clients
8. TBAs/FBBAs must display at their practice
sites this code of conduct and relevant
information on how to make complaints with
regards to their services to the appropriate
authorities
9. TBAs/FBBAs must not engage in sexual or
improper personal relationships with their
clients
4.0 CODE OF CONDUCT
21

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22
chapter FIVE

5.1 Penalties for Erring TBAs/FBBAs
Penalties shall be determined by the CRSPHCDA and
shall be preceded by a hearing with at least the the
following in attendance: the offender, the TBA/FBBA
chairperson, the community police, the PHCC and the
CSPHCDA
Written communication shall be provided on the
outcome of the hearing shall be provided to the offender
with copies to the facility head, community police, A file
copy of this communication shall be kept in the custody
of the relevant CRSPHCDA desk officer.
Ÿ Offences no 1-11 stated in section 3.2 above are very
serious and often life threatening. When violated, the
TBA/FBBA offender must be considered a high risk
attendant. The penalty therefore will be the closure of
practicing site and revocation of the practicing
license.
Ÿ Offences No. 12-15 (refer to section 3.2) will attract
suspension from practice for not less than six (6)
months.
5.2 Rewards for TBAs/FBBAs
At the discretion of the CRSPHCDA and key stakeholders
a TBA/FBBA who diligently provides services according to
the standards of practice and code of conduct,
demonstrates exceptional competence in both the
delivery of services and efficient referral of cases shall be
eligible for a reward.
The reward shall be determined following a consultation
with the TBA/FBBA to determine the most suitable
reward. The rewards may be along the lines of
recognition of service, support towards the maintenance
of TBA/FBBA licensure and support for alternative
livelihood options. Specific rewards may be along the
following lines but not limited to:
1. A letter of commendation
2. Upgrade of TBA/FBBA practice site (e.g.
M i n o r r e n o v a t i o n w o r k s , p r o v i s i o n o f
e q u i p m e n t , p ro v i s i o n of c o n s u m a b l e s ,
incentives for clients such as mama kits etc.)
3. O p p o r t u n i t i e s t o s e r v e a s a To T f o r
TBA/FBBA capacity building interventions
4. A seed grant for alternative livelihood
options
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5.0 PENALTIES AND REWARDS

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5.3 Management Tools for penalty and rewards system
5.3.1 Draft Letter of Commendation
FORMAT FOR REWARDING TBAs/FBAs IN THE STATE
LETTER OF COMMENDATION
Mr. /Mrs , a
TBA/FBBA in Community in LGA has been
found to be of exemplary conduct keeping all the rules and regulations governing TBAs/FBBAs
practice in Cross River State.
She/he has been speciﬁcally noted to have excelled in the areas of
She/he is hereby recognized as a good TBA/FBBA and is designated a TBA/FBA ambassador for
LGA for the year
We wish you more years of meritorious service to humanity. Congratulations!
Signature/Date:
LGA TBA/FBBA coordinator

5.32.2 Draft Penalty Form
FORMAT FOR PENALIZING EARING TBAs/FBBAs IN THE STATE
OFFENCE(S)/PENALTY FORM FOR TBA/FBBA
Mr. /Mrs. , a TBA/FBBA was found to have committed the
following offences(s). (Please tick the appropriate offence(s):
1. Conducting delivery on a primigravida
2. Conducting delivery on a multigravida.
3. Conductind delivery of a multiple birth pregnancy (i.e. twins, triplets, etc.)
4. Conducting delivery on a HIV positive client.
5. Conducting delivery on a woman with previous caesarian section or abdominal operation scar.
6. Conducting delivery on a woman with abnormal presentation e.g. breech or transverse lie.
7. Keeping a woman in active labour for more than 6 hours without referral.
8. Administering IV ﬂuids, IV drugs or blood transfusion.
9. Administer herbs or other harmful substances to client or her baby (during pregnancy or after
birth).
10. Attempting to turn or rotate a baby who presented with a hand, buttocks or transverse lie.
11. Disclosing client information or health records to members of the community.
12. Depriving a client of her right of deciding on where to deliver.
13. Non-renewal of bi-annual practicing license for up to three (3) years.
14. Managing a woman who has a previous history of bleeding during pregnancy (whether ante-
partum, intra-partum or post-partum).
15. Managing a woman who has a history of high blood pressure or ﬁts during a previous or
current pregnancy.
16. Managing a woman who is pregnant after a history of repeated abortions or still births
He/she is therefore penalized as follows:
(State the penalty)
Signature/date:
Name and designation:
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5.32.3 Draft attestation Form
ATTESTATION FORM
I Mr./Mrs./Miss , the PHCC of
LGA hereby attest to the following:
That Mr./Mrs./Miss a TBA/FBBA practicing at
Village in LGA has met
the following minimum eligibility requirement for registration:
a. Has an acceptable practicing site.
b. Is between 30-65 years.
c. Has been practicing for at least 2 years as a skilled birth attendant.
Name/signature of testator:
Referees:
Name: Name:
Address: Address:
Relationship: Relationship:
Signature: Signature:
TBA/FBBA PRACTICING LICENSE
License No
Name: I met the criteria for becoming a TBA/FBA and has
thus been licensed to practice.
This license is valid till
Director General, CRSPHCDA
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27
chapter SIX

The Cross River State Primary Health Care Agency
(CRSPHCDA) will be the convener and provide oversight for
the state-wide coordination, monitoring and supportive
supervision of the activities of TBAs/FBBAs in Cross River
state. It shall perform these functions in collaboration with
all relevant stakeholders; including state and non-state
actors at the state, local government area and
community/ward levels. To effectively fulﬁl this mandate,
the following roles and responsibilities will be undertaken
by key actors at the various levels of coordination:
Ÿ Standardize the minimum requirements for
practicing as a TBA/FBBA in Cross River State
Ÿ Maintain an up-to-date registry of recognized and/or
registered and licensed TBAs/FBBAs in Cross River
State
Ÿ Coordinate strategic partnerships with stakeholders
on the operations of TBAs/FBBAs in Cross River State
Ÿ In collaboration with state and non-state actors
provide oversight for the monitoring and supportive
supervision of the operations of TBAs/FBBAs in Cross
River State
Ÿ Convene stakeholder consultations on the
coordination monitoring and support supervision of
the operations of TBAs/FBBAs
Ÿ Periodically review as may be required, the guidelines
for coordination, monitoring and support
supervision of the operations of TBAs/FBBAs in Cross
River State
Ÿ Validate the content and standards of capacity-
building interventions for TBAs/FBBAs
Ÿ Conduct capacity building interventions of
TBAs/FBBAs as may be required.
Ÿ Coordinate the conduct of periodic assessments of
TBA homes and/or FBBA mission homes to ascertain
the functionality in line with recommended standards
Ÿ Facilitate the enactment of relevant legislations and
the enforcement of applicable legislations guiding
the operations of TBAs/FBBAs
6.1 Coordination, Monitoring and Supportive Supervision
at the state level (coordinated by the CRSPHCDA, with
supervision from SMOH)
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6.0 COORDINATION, MONITORING
AND SUPPORTIVE SUPERVISION OF
THE ACTIVITIES OF TBAS/FBBAs

Ÿ Ensure the implementation of the performance-
based penalty and rewards systems for TBAs/FBBAs
Ÿ Establish, facilitate and monitor community-based
monitoring systems (i.e. community police) of
TBAs/FBBAs
Ÿ Monitor referrals between TBAs/FBBAs and health
facilities according to the recommended standards of
practice for TBAs/FBBAs
6.2 Coordination, Monitoring and Supportive
Supervision at the LGA (Coordinated by the
PHC Coordinator)
Ÿ Maintain an up-to-date registry of recognized and/or
registered and licensed TBAs/FBBAs in the LGA
Ÿ Validate list of eligible TBAs/FBBAs in the LGA; as may
be required for capacity-building interventions
Ÿ Provide evidence of good standing to TBAs/FBBAs in
the LGA; as may be required for licensure
undertake monitoring and supportive supervision of
the operations of TBAs/FBBAs in the LGA
Ÿ Conduct periodic assessments of TBA homes and/or
FBBA mission homes to ascertain their functionality in
line with recommended standards
Ÿ Facilitate the enforcement of applicable legislations
guiding the operations of TBAs/FBBAs
Ÿ Recommend eligible TBAs/FBBAs to the SPHCDA for
the receipt of performance-based rewards
Ÿ Make recommendations to the SPHCDA on the
penalties for TBAs/FBBAs who have violated the
standards of practice and/or code of conduct
Ÿ Facilitate the conduct of and monitor community-
based monitoring systems (i.e. community police) of
TBAs/FBBAs
Ÿ Monitor referrals between TBAs/FBBAs and health
facilities according to the standards of practice for
TBAs/FBBAs
Ÿ Report all Data to the SMOH
24
29

Ÿ Provide referral services to TBA/FBBA practice sites
Ÿ Endorse letter of good standing of eligible
TBAs/FBBAs in the LGA; as may be required for
licensure
the operations of TBAs/FBBAs in the ward
Ÿ Recommend eligible TBAs/FBBAs in the ward to the
PHCC for the receipt of performance-based rewards
Ÿ Make recommendations to the PHCC on penalties for
TBAs/FBBAs in the ward who have violated the
standards of practice and/or code of conduct
Ÿ Liaise with community police in the conduct of
community based monitoring systems (i.e.
community police) of TBAs/FBBAs
at the Health Facility (Coordinated by the PHC in-
charge or designate)
Ÿ Facilitate referral services from TBA/FBBA practice
sites to the health facility
Ÿ Monitor functionality of the established referral
system (i.e. compliance of clients with referral to the
health facility and responsiveness of the health facility
to referred clients)
Ÿ Endorse letter of good standing of eligible
TBAs/FBBAs in the LGA; as may be required for
licensure
the operations of TBAs/FBBAs in the ward
at the community (Coordinated by the Community
Police & Ward Health Committee Focal Persons or
designate)
24
30

24
31
chapter SEVEN

The following individuals and persons will be responsible
for data collection at the various levels:
Ÿ TBAs/FBBAs
Ÿ In-charge of Health facilities in the community
Ÿ Ward focal persons
Ÿ LGA RH focal person
Ÿ LGA M&E focal person
Ÿ State RH officer
Ÿ State M&E officer
Ÿ State HMIS officer
Ÿ SPHCDA M&E Officer
Ÿ SMOH PRS Unit
7.2 Data variables
Data collected and collated from the TBAs/FBBAs should
include but not be limited to the following:
• Number clients registered with TBAs/FBBAs
• Number first visits
• Number of re-visits
This section of the guidelines highlights the key
elements of data management processes required for
effective implementation of the coordination and
monitoring and supervision of TBAs/FBBAs in Cross River.
Data shall be collected on a monthly basis and its
collation, analysis, quality assurance shall be a priority
intervention to ensure that a sufficient body of evidence
is available for decision making with regards to the
coordination, monitoring and supportive
supervision of TBAs/FBBAs.
7.1 Data Collection Responsibilities
24
32
7.0 DATA MANAGEMENT

• Referrals for : registration at ANC Clinic, Oedema, HCT, Tetanus Toxoid, Multiple pregnancies, Anemia
• Pregnancy Outcomes - Live births, still births, abortions, maternal deaths and deformity at birth
• TBA/FBBA Activities - Home visits, Village Development Committee/TBAs meetings attended
• New born data - Referrals for immunization referrals for treatment and referrals for birth registration
7.3 Data Analysis, Data Quality Assurance and Validation
Responsibilities
Ÿ The State M&E ofﬁcers (SMoH and SPHCDA) shall take the lead on data analysis, data quality and assurance, under
the supervision of the respective Directors of Planning Research and Statistics (DPRS) and they shall be supported by
assigned teams.
7.4 Data Flow Chart
SMoH DPRS receives the data collected and inputs it into the State database
SPHCDA M & E/RH Focal Persons then collates and submits to the DG
SPHCDA and SMoH DPRS
M & E/RH focal persons (LGA) collates the data collected from the TBA/FBBACoordinator and submits
to the State M & E/RH Focal personsat the SPHCDAduring the State monthly review meetings
Ward focal person (TBA/FBBA Coordinator) collects data from the TBAs directly during monthly
meeting collates same and submits to the Health worker/TBA coordinator/RH Focal Person (LGA)
TBA/FBBA.
24
33

Annexure 1: DQA Checklist
Name of Reporting Entities Date of DQA
Reporting Period: {monthly}
LGA:
Selected Community: Ward
Summary Sheet
Sub Category Scored Follow up actions
recommendation
Resources/
support
needed
Responsible
person
Expected
completion
data
Part A:
TBA/FBBA
Date on-site
veriﬁcation
Data
Availability
Data
Consistency
Data validaty
Timeliness of
Reporting
Part B:
System
Assessment
Data recording
function and
capabilities
Data
collection
and reporting
forms and
tools
24
34

Data
Management
process
Part C:
Beneﬁciary &
TBA/FBBA
check
Beneﬁciary
check
TBA/FBBA
Check
Part D: Health
Facility Check
Sub Category Scored Follow up actions
recommendation
Resources/
support
needed
Responsible
person
Expected
completion
data
24
35

Annexure 2: Detailed Checklist
Section 1: Data collection process quality check tool
Part A:
Yes No Comments
A1
A2
A3
Yes No comments
A4
Does the
TBA/FBBA record
names and mark
tally cards in
person?
A5 Does the TBA /FBBA
document names
and mark tally
Total for part A Maximum score=26
Does the TBA/FBBA
have a tally card? For
the current period
under review?
Does the TBA/FBBA
have a register for
recording names of
clients?
Are identification
details of the client
sufficient to trace
client?
TBA/FBBA Data On-Site
Verification
Data collection Process
verification
Directly on the source
register/tally card?
24
36

Section 2: Beneficiary client and TBA/FBBA Level Data Quality
checklist
Beneficiary checklist Yes No Comments
C1
Are you able to
access a beneficiary
of the selected
TBA /FBBA?
C2
Did the beneficiary
confirm being
referred by the
TBA /FBBA for ANC,
HCT & TT?
C3 Did you meet, or
find at least one
randomly selected
beneficiary who has
given birth, confirm
being referred for
immunization by the
TBA
C4
Did the pregnant
woman in C2 above
confirm that she
received the service
she was referred for?
C5
Did the pregnant
woman C3 above
confirm that she
received the service
she was referred for?
Part C: Beneficiary and TBA Volunteer Checklist
24
37

C6
Are two randomly
selected community
members aware of
the TBA/FBBA activities?
(sample two women
to know)
C7
Is the TBA/FBBA
attending the meetings
for TBAs /FBBAs
(conﬁrm from the TBA
/FBBA leader/member
of the VHDC)
C8
Does the TBA /FBBA
have registration
documents at any
level?
D1 Does the HF know
the TBA /FBBA ?
D2
Is the HF aware of
the activities of the
TBA /FBBA in the
community
D3
Does the HF receive
referred clients from
theTBA /FBBA ?
24
38
Total for part C Maximum score =16
Section 3: Health facility Level DQA
Part D: Health Facility
check
Yes No Comments
TBA /FBBA Checklist Yes No Comments

D4 discrepancies
between
records
captured
in the
TBA /FBBA tally card
and the records in the
ANC/PMTCT/Delivery
/HCT/Immunization
register?
D5
Is there a follow up
on PMTCT care for
mothers and continuum
24
39
Are there
care for infant?
Total Maximum score =12
Section 3: Health facility Level DQA
Part D: Health Facility
check
Yes No Comments

Annexure 3: TBA Data Verification checklist
S/N Data reported Number
reported
Number
verified
Comments
Referrals for first ANC/HCT
Referrals with Anaemia
Referrals for Oedema
Referrals for HIV tests
Referrals for Tetanus
Toxoid
Referrals for immunization
Number of first visits
Number of re-visits
Total numberof clients
registered with TBA
Number of live births
Number of still births
Number of abortions
Number of maternal deaths
Number of home visits paid
Number of VDC/TBA
/FBBA meetings attended
TBA Data verification checklist
24
40

Annex 4: TRADITIONAL BIRTH ATTENDANT/FAITH BASED BIRTH
ATTENDANT MONTHLY SUMMARY FORM
Section A: IDENTIFICATION
1 Total no. of new pregnant women
seen
2 Total no. of revisits by pregnant
women seen
3 Total no. of
Deliveries
Male Female
4 Total no. of
live births
Male Female
5 No. of Still
births
Male Female
Month: Year:
24
41
Facility Name:
Address/Phone Number:
Ward:
LGA: State:
Ward:
Month: Year:

6 No of pregnancy - related deaths
among women seen
7 No of deaths in babies aged 0 – 28
days
8 No of abortions
9 No of pregnant women referred for
HIV testing
10 No of pregnant women referred for
Tetanus
Toxoid
11 Total no. of suspected cases of
anemia
12 Total no. of two – way referrals for
complications
Compiled by Veriﬁed by
Designation Designation
Signature Signature
Date Date
24
42

Annexure 5: CHECK LIST FOR MONITORING OF TBA/FBBA PRACTICE
SITE
S/N Minimum Basic
Facilities
Yes No What is the Status
of these facilities
Remarks
Satisfac
tory
Poor
1a
The site has at least
three rooms for the
following purposes:
a. Consulting room
b. Bathroom/toilet
c. Labor room
1b
Beddings
a. At least 2 beds with
a padded mattress
& Mackintosh
b. Resuscitation table
c. Mosquito nets
2 The site has the
following
a. Cross ventilation
b. Illumination/light
source
c. Source of water
24
43
supply

d. An arrangement
for waste disposal
(including medical
waste)
e. An arrangement
for upkeep an
security of
premises
3 Other services
3a Referrals and records.
i. Referral records for
ﬁrst pregnancies
and complicated
cases
ii. Referral records
for HCT.
iii. Records of births
on a monthly basis
iv. Records of
mortalities (maternal
and neonatal)
monthly basison a
44
3b i. Standard delivery kit
ii. Sterilizing equipment/unit
iii. Equipment storage
unit/locker
Equipment & Kits

Kori Habib
Iffat Zehra
Ema Uruetse
Ikwo Bassey Duke
Comfort Monday
Margaret Pius
Egbodor Victoria
Beatrice Ekuma
Yemsi Femi - Pius
Ephraim Chukwu
Elder Dr Bassey Ikpeme
Rajesh Kapse
Jonathan Ugbai
Dr. Linda Ayade
Dr Inyang Asibong
Dr Betta Edu
Dr Onabieni Ana
Dr Iwara Iwara
Mr Rekpene Patrick
Sally Enyim
Felicia Eyaba
Chaba Jay
Obere Bernadette
Umana Elizabeth
Aleje Edmund
Florence Esari
Affiong Eborty
Felicitas Boko
Julius Idoko
Mr Keneth Ehouzou
Dr Yakubu Aliyu
Dr Joachim Chijide
Ishioma Ntaka
Dr Idowu Araoyinbo
Dr Musa Elisha
UNFPA
UNFPA
UNFPA
TBA Association
TBA Association
TBA Association
TBA Association
TBA Association
Pathfinder International
UNICEF
EU-SIGN
Tulsi Chanrai Foundation
Cross River Watch
OWOG/ MDF
SMOH
CRSPHCDA
CRSPHCDA
CRSPHCDA
SMOH
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
CRSPHCDA
NPHCDA
UNFPA
UNFPA
UNFPA
UNFPA
UNFPA
UNFPA
Media Associate
Gender Advisor
Programme Associate
TBA President
TBA
TBA
TBA
TBA
SPM
Jeffrey Adamade Mediatrix Development
Foundation
Executive Director
Consultant
Director
Correspondent
Wife of Governor/President
MDF
Commissioner
Director General
Director PHC
Director RBM Program
Director PRS
Deputy Director
Deputy Director
CCPHO
ACNO
M&E Officer
CNS
Assistant Director
DG Office Assistant
ZTO
Programme Coordinator
RH Specialist
RH Programme Officer
Data Assistant
ASRH/HIV Analyst
Fistula Analyst
STA
SIO
LIST OF CONTRIBUTORS
NAME ORGANZATION DESIGNATION
45

UN Building,
Plot 617/618
Diplomatic Drive,
Central Business District,
Abuja, FCT.
Delivering a world where every
pregnancy is wanted, every childbirth
is safe and every young person’s
potential is fulﬁlled.
0905 3779 641
UNFPANIGERIA
Facebook.com/NigeriaUNFPA
Nigeria.unfpa.org
@crossriverstate
Facebook.com/crossriverstate
www.crossriverstate.gov.ng
GOVERNMENT OF
CROSS RIVER STATE

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