International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 8 Training of Traditional Birth Attendants and Prevention of Mother-To-Child Transmission of Human Immunodeficiency Virus in Enugu State Udenta Nkiruka C Prof Udenta Jude Department of Public Administration Enugu State University of Science and Technology, Enugu Nigeria Abstract: As much as 60% children born in Nigeria are delivered by unskilled traditional birth attendants (TBAs). Therefore, there is no denying their relevance. Be that as it may these traditional birth attendants are by modern/current standards considered incompetent as regards appropriate skills in regard to the contemporary challenges to safe and effective child-bearing. It is, therefore, imperative for TBAs and other similar cadre of healthcare providers in resource-limited settings to be knowledgeable and have the ability to deploy evidence-based practices in the prevention of diseases. There is no gainsaying the socio economic and political impact of diseases. This study examines the prevention of Mother-To-Child Transmission (PMTCT) of Human Immunodeficiency Virus, HIV, in selected communities in Enugu State. It is about the connection between the traditional birth attendants and this quest. Simply put, as a result of resource limitations, the volume of delivery by the traditional birth attendants is huge. However, the modus operandi of the Traditional Birth Attendants (TBAs) considerably expose the community to the transmission of viruses-including the HIV. This study examines the efforts of TBAs as regards the prevention of Mother-To-Child transmission in selected Local Government Areas of Enugu State, Nigeria. Findings, indicate rooms for improvement. In conclusion, We advocate the adoption of modern practices through regular training to reduce mother-to-child transmission of HIV. This in itself is no small achievement even if only for a case. Here, however, we are speaking about millions of people, this is definitely serious. Keywords: Transmission, virus, traditional birth attendant 1. INTRODUCTION According to the World Health Organization (WHO); the transmission of HIV from a HIV-positive mother to her child during pregnancy, labour, delivery or breast feeding is called mother-to-child transmission. In the absence of any intervention, transmission rate range from 15% to 45%. This rate can be reduced to below 5% with effective interventions during the period of pregnancy, labour, delivery and breast feeding. (WHO report 2015). It is a thing of collective shame and concern to see children especially the yet unborn suffer and die of preventable causes. More so, issues they know nothing about. It is much more disturbing when these deaths are usually preceeded by debilitating ailments. To make matters worse is that, all things being equal, the infected may unknowingly go on spreading death and sickness through further and further infections. This is due basically to ignorance and or lack of awareness. It may also be for fear of stigma and discrimination. However to make matters bare, let the unborn generation be saved through the help of training and re-training, awareness creation in our healthcare providers including the Traditional Birth Attendants (TBA's) on the need for the prevention of mother-to-child transmission of HIV which eventually leads to AIDS, if not controlled. It is in the consideration of huge cost of HumanImmunodeficiency Virus-(HIV)-and-AcquiredImmunodeficiency-Syndrome-(AIDS)-related deaths as well as the debilitating conditions that immunity has come to take the front burner in several fronts. One thing is clear, everybody, the Administrator, the Engineer, the Accountant, the House Wife, the Brick Layer, Town Crier, the student, school leaver and so forth, everyone is involved. This is because when you are not infected, you are affected. According to a 2015 publication on the WHO HIV/AIDS data and statistics: "The transmission of HIV from a HIV-positive mother to her child during pregnancy. labour, delivery or breast feeding is called mother-to-child transmission. In the absence of any intervention, transmission rates range from 15% to 45%. This rate can be reduced to below 5% with effective interventions during the periods of pregnancy, labour, delivery and breastfeeding" Despite all the efforts, the HIV/AIDS pandemic seems determined to keep the future of humanity in peril. The seriousness of the situation could be gleaned from the 2017 working document of the Enugu State Agency for the control of HIV and AIDS, ENSACA. From this document, (Appendix 1), we observe a rising trend of the HIV infection of pregnant mothers. In this connection, in 2014, out of 70,024 tested 1130 got confirmed as HIV-positive. That is 1.613%. In 2015, out of 107,321 tested, 1809 or 1.685% got International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 9 confirmed as HIV-positive. In 2016, out of 59,264 pregnant mothers tested, 603 (1.005%) got confirmed as HIV-positive. The reason for the apparent ebb and flow will be clearly presented as the work advances. Suffice it, however to note at this juncture, that this data is just about the formal sector(s). In this connection, most of the economy of Nigeria belong to the informal sector(s). So, this is literally, just a tip of the ice-berg. However, even this tip reveals the dreadful situation that confronts and therefore, challenges us. Although this hurts, but it is painfully true, that several communities in Enugu State have no modern hospital even, no patent medicine store. Yet in these communities, there are marriages that produce children. There is, therefore no gainsaying that within this circumstance, there is generally a resort to the TBAs. This makes the training of TABs very imperative. Therefore, this study seeks to indicate and examine, jointly and respectively, the need and effects of the training of the TABs on the reduction of HIV/AIDS-related maternaland-child mortality and morbidity, especially as it concerns mother-to-child transmission of HIV in Enugu State, Nigeria. 2. OBJECTIVES OF THE STUDY 1) To ascertain the possibility of selecting real Traditional birth attendants for training. 2) To estimate the actual number of TBAs in the selected LGA's. 3) To evaluate the level of patronage of these TBAs by the members of our various communities. 4) To underscore the economic importance of HIV. 5) To evaluate the extent of the effect of TBA training modules as regards the level of education of the TBAs. 3. RESEARCH HYPOTHESES Hi1: Selection of real traditional birth attendants for training has been a very easy task to accomplish. Hi2: The total number of traditional birth attendants can easily be estimated. Hi3: Good number of community members patronize the Traditional birth attendants Hi4: The negative economic importance of HIV/AID to the community and the nation in general is significant. Hi5: The training module of traditional birth attendants is adequate for them considering their level of education. 4. REVIEW OF RELATED LITERATURE 4 .1 Conceptual Review Gupta (2006, p.45) defines training as a process of refining and increasing the skills and abilities of an individual towards the best performance of the particular job in which the training is carried out. He argues that the process of training leads to the development of an individual so far as the enlargement of skills and abilities is concerned. Bedean (1987, p. 369) sees training as a process of developing an individual's skills knowledge and abilities so as to improve present and future performance. According to him, training leads to behavior change in a desired direction. Buckely and Caple (1990, p. 25) sees training as a planned and systematic effort to modify or develop knowledge, skills, attitudes and performance.Mabel (2012) in her own contribution on the "Disciplinary journal of contemporary research in business" in a related issue views training as acquisition of skills, knowledge and abilities to enable one function effectively in the performance of one's job. In the words of Okpata (2004) manpower development and training is perceived as a process of exposing an employee to acquire basic or additional skills and knowledge involved in efficient job performance. Again, in the words of Glueck (1990) formal training programme is an effort to provide opportunity to the worker to acquire job-related skills, attitudes and knowledge". Hogle (2008) in his own contribution explains that: training is involved when a skill or competence has to be acquired which is exercised in relation to a specific function or in accordance with the canons of some specific mode of thought or practice. It works essentially in the realm of skills when something has to be done or manipulated. "Training is also seen as a term that defines the process of utilizing a systematic and organized procedure by which non-managerial personnel learn technical knowledge and skills for a definite process" Chandan (2000).Also, training could be seen as a process of imparting into a person or group of persons the knowledge needed to effect a positive change in a gradual process in order to achieve a desired goal. So, as it concerns training of TBAs, on PMTCT this is done to achieve the goal of reduction of maternal-andchild mortality and morbidity rate. From the above definitions and conceptual exercise on training, it is a process of ensuring that skills of workers/persons are improved so as to ensure the avoidance of avoidable mistakes, to create confidence in a worker/people, to improve productivity, to improve ability and self-reliance and finally, in regard to TBA and MTCT prevention, training allows the TBAs to understand their limitations – as well as appreciate the vast opportunities. 4.2.1 Who is a TBA? According to WHO, a TBA a person (usually a woman) who assists a pregnant woman at child birth and who initially acquired her skills deliver babies by herself or working with other TBAs (WHO, 1979). TBAs are usually very close to the local community with advanced knowledge about the culture and tradition of the community. They have the confidence of the women in the community. Policy makers have realize that the close tie between TBAs and the community they serve is a great link to reach pregnant women that are not easily accessible to skill birth attendants. The TBAs are usually very influential in their area of International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 10 practice and as such cannot be easily disregarded if the UNAIDS goal of a free MTCT by the year 2015 will be achieved. 4.2.2 The need for training the TBA Safe motherhood programme found out that most of developing countries medical personnels and health facilities including patent medicine dealers for the provision of health care in rural areas are insufficient, or even not available. The option available was to use the existing resources are TBAs. Due to shortage of medical personnel, drugs, equipment, and other medical supplies the need for TBAs become imperative (Naicker et al, 2010 – Kayonbo et al, 2007, 2012). Moreover, experts on the productive health have pointed a grim picture of maternal and child health in SubSahara Africa and warned that the situation could be worse in the decade if no immediate remedial actions are taken. (Grieco & Turler, 2005). WHO estimated if nothing was done by 2015 there would be 2.5million maternal deaths, 2.5 million child death, and 49 million maternal disabilities in the Sub Sahara Region (Grieco & Turler 2005). Thus, training TBAs now is a necessity and can make a difference on infant and maternal deaths as well as morbidity of the mother after delivery in Sub-Sahara Africa and other developing countries if well implemented and systematically followed as monitoring process after training. (Mbidzenyuy, 2012). (The problem on the TBA training lies on the possibility to identify the real TBAs. Most TBAs where generally illiterate women aging 40 years and above thus making it impossible for them to understand the need for the training. TBAs are experts on their own rights, and values and accepted by the community (Cosmnisky, 1983, Swatx, 1996, Kayombo, 1997). Furthermore, most TBAs have certain traditional beliefs as to the causes of neonatal sickness and regular/sustained training will help to change their beliefs in regard to MCTC. These would constitute a meaningful outcome from the training. TBA programme should be built on the bases of transactional model which emphasis dialogue, trustworthiness, respect, transparency, willingness to learn and share knowledge through problem solving techniques (Cosmnisky 1983, Swatx, 1996, Kayombo, 1997). 4.2.3 What is HIV and what are the methods of HIV spread HIV/AIDS means human immunodeficiency virus/Acquired immunodeficiency syndrome. It is a disease of human immune system caused by the human immunodeficiency virus (HIV). It causes a dreadful illness in the absence of proper and timely intervention. It is simply the failure of the Human Immune System. It lays the sufferer bare to the direct negative impact of any virus, bacteria or microbe. 4.2.3.1 How does HIV Spread? The spread of HIV means the ways by which HIV can be transmitted from an infected person to an uninfected person. HIV can be transmitted from one person to another through two ways/modes and these are horizontal and vertical mode of transmission (Mark et al, 2006). Horizontal mode of transmission of HIV: This occurs when two separate individual are involved in the transmission of HIV. This refers to the normal known HIV transmission which are through. Unprotected sexual intercourse with an HIV infected partner. Hence, there is exchange of body fluids such as semen, virginal fluid and serum through virginal, and or oral sex. It accounts for about 80% of HIV transmission (Pilcher et al, 2001). The sexual intercourse can be heterosexual (sexual intercourse between a male and a female) or homosexual (sexual intercourse between same sex) transmission. Transfusion of HIV infected blood and or body products sharing of contaminated needles, sharps and other contaminated instruments. Here, HIV-negative person can contract HIV infection if he use the instrument contaminated with fluids from HIV-infected person. Vertical mode of transmission:This is also known as mother to child transmission of HIV. This is a situation where an infected mother transfers HIV to her child at one or more of the following stages: transplacentally in the womb during pregnancy, perinatally during the process of labour and delivery and post nataly during breast feeding (Petropoulou et al, 2006). This mode of transmission that is the vertical mode of transmission of HIV is our primary concern so long as this work is concerned hence prevention of mother to child transmission of HIV. This transmission of HIV infection could happen at one or more of the following stages (1) transplacentally in the womb during pregnancy. Perinatally during the process of labour and delivery, and postnatally during the process of feeding. (Petropoulou et al, 2006). 4.2.4 The Economic importance of mother-to-child transmission of HIV Simply put, the child is of inestimable value. Every threat to the life unborn puts the entire civilization in peril: No succession. No secure future. Therefore, no effort should be spared at protecting the unborn one, the future, whenever this is possible. 4.2.5 Forms of Training That Have Been On The Ground As Regards The TBAs  Direct observation: in this case the trainer observes the TBAs while performing a particular procedure  On-the-job training: This is a situation were trainer works with the TBAs in TBAs own area of practice and correct or direct the TBA on how to carry out a particular procedure.  Use of posters: This is a situation were the trainer uses posters to tell the TBAs how to do certain aspect of his work, e.g hand washing,  Seminars: This is a process of bringing the TBAs together in an organized area to train them by different trainers from different areas within a specified period of time.  Use of special Television programme: In this situation the trainer arrange a programme with a particular television station at a particular time, informing the TBAs about the programme etc. International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 11 5. 5 METHODOLOGY 5.2 Sources of Data The data for this paper were sourced from both primary and secondary sources. Concerning the primary data which come from the field work by the researcher, reasonable effort was made to obtain information from the appropriate individuals so as to guarantee a balanced and reliable representation of attitude/opinions. Concerning the secondary data, there is a reliable ballast of information on data from the extant literature and the works of ENSACA as well as other relevant organizations and institutions.The primary data were collected directly from the respondents through questionnaire, interviews and direct participant observation. The secondary data essentially came through the content analysis of available literature and data revolving around the issue of TBAs, HIV/AIDS and allied matters. 5.3 Population of the study This defines the universe that is covered by the study. Here, the population is Enugu State. Though Enugu State will be represented by the three Local Government Areas.According to the Enugu State Ministry of Health, 2017, Total population of Enugu State is four million five hundred and eight thousand eight hundred and sixty-two (4,508,862). On the other hand the population of Enugu East Local Government Area is Three hundred and eighty-six thousand, three hundred and twenty-four (386324). Population of Udi Local Government Area is three hundred and twenty-three thousand nine hundred and thirteen (323913). Population of Igbo-Etiti Local Government Area is two hundred and eighty-nine thousand six hundred and fortyeight (289648). Table 5.1 Local Government Population Percentage Enugu East 386324 40% Igbo-Etiti 289648 28% Udi 323913 32% Total 999,885 100% Source: Data Unit Ministry of Health, Enugu 2017 5.4 Sample Size Determination To determine the sample size, the researcher employed the Taro Yamane formula for the determination of sample from large populations. The formula states thus: n = Where – n = sample size N = Total Population e = Margin of error. Here 0.05 I = Constant For our purposes, the population, n = = = = = 399.962 = 399.8 400 Step Two: Based on the total population of the three local government and the population of the individual 3 Local Government Areas, the ratio was worked out thus; Enugu East 386324 (8.568%), Igbo-Etiti 289648 (6.424%) and Udi 323913 (7.184%). Sept Three: Conversion to simple proportions as regards the proportion of the 400 sample, 40%, 28% and 32% went for Enugu East, Igbo-Etiti and Udi Local Government Areas respectively. Thus, we have 160, 112 and 128 to Enugu East, Igbo-Etiti and Udi respectively. 5.5 Sampling Technique In pursuit of reliable data for appropriate opinion/attitude survey, the researcher had to apprehend the appropriate respondents. To do this as regards evaluation of the effect of training of the TBAs on prevention of motherto-child transmission of HIV required that we meet the appropriate respondents across the three Local Government Areas and in right proportion of 160, 112 and 128 respectively, whose opinion/attitude matter in this regard. In this respect we had: i. Women leaders ii. Pregnant mothers iii. The spouses /relatives of the pregnant women, where obtainable. iv. Non-Governmental Organizations v. People Living Positively, where obtainable vi. Government Officials vii. TBAs viii. Conventional practitioners that is Doctors, Nurses and Midwives, ix. Community opinion leaders x. Religious leaders xi. Community Based Organization (CBOs) These categories of individuals had to represent the towns and autonomous communities in these three Local Government Areas. These communities are obtainable Udenta (2007, pp. 323-335). 1. Enugu East – Umuenwene, Obinagu, Emene, Umuchigbo, Harmony, Abakpa 1, Abakpa 2, Abakpa 3, Mbulu Ujodo, Mbulu Anwuli, Ugwogo Nike, Mbano Nike, Ogbeke Nike, Akuoga Nike, Ncheatancha Nike, Amorji Nike Ibagkwe Nike, Edem Nike Amokpo Nike, Mbulu Owehe, TransEkulu. Here we have at least 21 (twenty-one) entities. 2. Igbo-Etiti – Udueme, Ejuona Aku, Akutarani Aku, Akutaraeme Aku, Oshigo Aku, Ihekweani Aku, Ihekweani Enu, Ejime Ukehi, Ezi UKehi, Agu Ukehi, Umudule Ukehi, Amugwu Ukehi, Amakofia Ukehi, Ikolo, Ochima, Ohebe Dim, Onyoho, Idoha, Ozalla, Uwani Ozalla, Uwellu, Obodoe, Umunko, Ekwegbe, Ukepi, Diogbe, Umuna. Here we have at least 27 (Twenty-seven) entities. International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 12 3. Udi – Akpakwume, Nze, Ezi Nze, Oghu, Ebe, Abor, Umuavulu Abor, Ukana, Awhum, Okpatu-Ikeghe, Okpatu Ibite, Umulumgbe, Umuoka, Egede, Affa, Amozalla Affa, Amafia Affa, Amokwu Affa, Udi, Obioma, Abia, Agbodu, Obinagu, Umuaga, Umabi, Nachi, Oji Amokwe, Enugu Amokwe, Etiti Amakwe, Uwani Amakwe, Eke, Ngwo-Asaa, Imeama Ngwo Asaa, Ameke Ngwo, Nsude, Uboji Ngwo, Amakwno Ngwo. Here, we have at least 38 entities or autonomous communities. Accordingly for the three Local Government Areas, we have 21, 27 and 38 autonomous communities respectively for Enugu East, Igbo-Etiti and Udi Local Government Areas. At this juncture, we bring forward the early matters of eleven categories of respondents and the 160, 112 and 128 sample proportions for each of the three Local Government Areas. Now, what 160 possible respondents translates into for the 21 Autonomous Communities of Enugu East is 7.62 that is, 8 approximately, 8 for every autonomous community of Enugu East. For IgboEtiti, at 112 for 27 communities it is 4.15 that is 4 possible respondents. Then for Udi Local Government, which is 128 for 38 communities it is 3.37 that approximately 3. Hence as a participant observer, the researcher is placed in a difficulty but now reserves the latitude to choose among the eleven categories based on the area of comparative advantage of the various communities since the margin of freedom is clearly defined. 6. DATA ANALYSIS For the purpose of analysis there are certain standard approaches viz, by the objectives or research questions or research hypotheses. These are however inextricably intertwined, for our limited purposes here, we adopted a synergy of the research objectives and questions as the template for the analysis. I. On the availability/presence of real traditional birth attendants:A traditional birth attendant also known as a traditional midwife, community midwife or lay midwife is a pregnancy and childbirth care provider. These group of healthcare providers provide the majority of primary maternity care in many developing countries and may function within specific communities in developed countries (World Health Orgnization 2010. Classifying health workers, Jeneva, (W.H.O). Traditional midwives provide basic health care support and advice during and after pregnancy and childbirth, based primarily on experience and knowledge acquired informally through the traditions and practices of the communities where they originated. Sibley, lynn M; et al (1996). With these we can understand the need for proper selection of traditional birth attendants. In Enugu East Local Government Area, we have 136 registered TABS scattered all over towns and village of the local government. In Igbo Etiti local government 76 registered TBAS and in Udi local government 121 registered TBAS. These 136, 76 and 121 are the registered TBAS but we know there are still unregistered ones all over in operation, they still touch lives and need to be identified and trained for the UNAIDS goal of free PMTCT to be achieved there by reducing morbidity and mortality through HIV and AID's to the bearest minimum. And this takes us to the next point. II. On the actual number of Traditional Birth Attendants:We have 136, 76 and 121 registered TBAS respectively for Enugu East, Igbo Etiti and Udi but this does not mean the actual number of TBAS in these L.G.A.. The need for the influential persons in the communities now arises, and the PG, the lgwe's, the women leaders and so effort. These group of people in the various communities will help in the identification of the TBAS then the agencies on their own part will help encourage them by providing some incentives in various forms. III. Then on the level of patronage of the TBAS:In our various communities even the Akpaka Nike community is totally urban irrespective of the suborbs, the patronage of the TBAS cannot be under-estimated. According to the Nigeria Demographic and Health survey 2008, between 2003 and 2008 only 46% of women living in the rural area received antenatal care from a skilled provider that is Doctor, Nurse/midwife, Auxiliary nurse/midwife, 28% of births were assisted by a skilled provider, and 25% of deliveries took place in a health facility. Expectant mother who cannot access these services are left to make do with "alternative" such as TBA services. Ref. "Nigeria Demographic and Health survey 2008". On the Economic importance of HIV & AIDS:HIV and AIDS affects economic growth by reducing the availability of human capital. Without proper prevention, nutrition, health care and medicine that is available in developing counties, large numbers of people are falling victims to AIDS – People living with HIV/AIDS will not only be unable to work, but will also require significant medical care. The forecast is that this will probably cause a collapse of babies and societies in countries with a significant AIDS population. In some heavily infected areas, the epidemic has left behind many orphans cared for by elderly grandparents. International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 13 IV. Increased mortality will result to reduction in skilled population which incidentally results to decreased productivity. HIV disproportionately infects and impacts on women, so those sectors employing large numbers of women examples; education, may be disproportionately economical impacted by HIV. Greener R (2002). AIDS and macroeconomic impact". V. On the issue of the level of education and the TBA training module:The training module of the TBA should be able to contain such vital information on issues such as;  How to describe and recognize all the conditions during labour and delivery which are not normal.  Explain how to manage all complications during labour and delivery.  Name some people and places where she can send women with complications.  Be able to understand the need for collaboration with the nearest health facility.  Should be able to identify and tackle the 3 delays in labour and delivery; the delay at home, the delay on the road ,and the delay in the hospital. Furthermore, sensitization does not automatically translate into awareness. This is because of differences as regards sensitivity. Some are more sensitive than others. Others require steady stimulation using required stimuli to even wake up and then little by little increase in awareness. On the other hand, awareness does not automatically translate into appropriate action. In this respect, many people in Nigeria are aware as regards certain matters – Good and Bad. Yet, they refuse or fail to take appropriate action to redeem or remedy or enhance the situation as the case may be. In Nigeria, we are all aware of the kleptocracy going on but the question is who will bell the cat? There is dictatorship, corruption, impurity and all that. We all are clearly aware of all this. On the other hand, there is fear, gullibility, docility and so forth that provide the ground for the unpalatable tendencies to grow. Hence, we have little options to the TBAs and must learn to make the most of their services. It is critical that we continue on this logic of sensitization, awareness and appropriate action. In this connection, the withdrawal of foreign partners led to a drastic drop in our PMTCT efforts. Hence we have the challenge of dependence on foreign partners for laboratory/ testing input, medicine and equipment. When we add to this, the issues of ignorance, poverty, stigma discrimination and so forth, we begin to realize the need for constructive intervention and engagement of and with the TBA's and the need for their training and retraining until things actually take a turn for the better. EFFECTS OF THE TRAINING OF TBA's ON PMTCT IN THE SELECTED COMMUNITIES FROM THE THREE LOCAL GOVERNMENT AREAS IN ENUGU STATE. The effect was salutary. Many positive mothers have given birth to healthy babies because of the training of the TBAs. This is no small matters. 1. In view of the synergy with certain Local Government Health Officials, the TABs in these communities have even exceeded the WHO projection and beyond 55% in the reduction of MTCT – this has being achieved through training and retaining of the TBA's. 2. However, since late 2015 efforts have been hampered by the withdrawal of foreign partners. 3. These have complexified other challenges. 4. Moreover, with the training and retaining of the TBAs, most public health facilities in the rural areas now use the TBAs as volunteers hence lack of staff to fill the spaces of retired staff. 5. However, the training of the TBAs cannot go without its own problems because of their level of exposure to modern health practices, making the TBAs practice at their level is now posing a threat to the skilled health practitioners. One major challenge remains that of underdevelopment and dependence. It is for this reason that the inputs for testing have dried up with the withdrawal of foreign partners. What can the TBA's do but to continue with the apriori method with all the danger that goes with it. 7. FINDINGS, RECOMMENDATIONS AND CONCLUSION 7.1 Findings 1. Selection of real traditional birth attendants from the various groups having the same features like the herbalists, the trained health workers that are practicing at home because of lack of job, retired midwifes and others, has been a very big problem to the training of the TBAs. 2. Because of this problem of selection of the real TABS it is still very difficult to estimate the actual number of TBAS in our various local government for proper guidance and monitoring. 3. Because of the readily available nature of the TBAS in our various communities, patronage of the traditional birth attendants by pregnant mothers in these communities is on the high side. So the only option to save this population from MTCT is to train the TBAS. 4. Economically, HIV is impacting negatively on the population, leaving children orphaned to be taken care of by the very old grand parents thereby International Journal of Academic Multidisciplinary Research (IJAMR) ISSN: 2000-006X Vol. 2 Issue 10, October – 2018, Pages: 8-15 www.ijeais.org/ijamr 14 putting a halt to the economic activities that should be carried out by the younger populations. 5. The TBA training module is a bit higher than the assumed level of understanding of the TBAS considering the level of education. 7.2 Recommendations i. I recommend that every traditional birth attendant should be involved in the training so as to improve their practice globally. ii. There should be at least an existing primary health care facility in every community in Enugu State so as to reduce quackery and encourage referral. iii. The TBA training module should be done arranged in such a way that every traditional birth attendant will be able to understand it. iv. Supervision of the TBA's should be made a compulsory activity by the concerned body. v. The TBA training method must be reduced to the level of understanding example: (a) Edutainment, (b) Pictural (c) Video show (d) Drama and so on. If these few recommendations are religiously carried out by the concerned bodies the TBA's will not only improve in the works but will also enrich their pocket better, hence better confidence in themselves and the global target of reduction of mother-to-child-transmission of HIV will be achieved. 7.3 Conclusion TBA's have a role in PMTCT of HIV and have demonstrated that some good practices related to PMTCT as a result of evidence and polices that are communicated to them by training and workshops; though there are significant gabs in the key practices. The PMTCT knowledge and practice gab was found to be significantly reduced by training innovative and strategic intervention which will translate research to policy, and practice are very essential to enhance participation of traditional birth attendants in the prevention of mother to child transmission of HIV. (Abiodun et al, J Ans chin Res 2015). Moreover, expanding the knowledge and skills of TBAs will make them assume more responsible roles in health care delivery. And this also can be a productive and rewarding experience both for the TBAs the other healthcare practitioners, the community members, the state, the country, and the world at large. Evaluation of studies have shown that the traditional birth attendants always carry their new acquired health improvement knowledge to their various groups and community members. Through local communication channel network the TBAs continues to disseminate their new health improvement knowledge to their colleagues and others in the community. Enhancing the knowledge and rolls of this TBAs and creating closer collaborations between them and other health practitioners offers new hope for improving the health of individuals and families through sustainable primary healthcare programmes. Moreover, in view of the pervasive nature of TBAs in Nigeria, improvement of their practices by the adoption of modem practice techniques through regular training will no doubt translate into the reduction of MTCT. This in itself is no small achievement even if only for a case. Here, however, we are speaking of millions this is definitely serious. REFERENNCE 1. Abiodun. O. Sotunsa, J., Ohu-Abiodun O. Ani, F., Agboola T., and Ogechukwu T. 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