Despite all efforts to reduce maternal mortality rate during the Millennium Development Goals (MDGs) initiative, maternal mortality remains unacceptably high. In Nigeria, the maternal mortality rate is 800-1,000 per 100,000 live births, making Nigeria accounts for about 10% of the global estimate for maternal mortality. One of the reasons MDGs initiative failed to achieve the set target was because it focused mainly on clinical measures and other important drivers of maternal health care were ignored. For instance, some of the vital roles of traditional birth attendants (TBAs) were ignored.Although, TBAs practices are not in consistence with best practices but they are safety nets in areas where maternal health care services are short served.  They were isolated from the strategies in implementing the MDGs.In Africa, Over 58% of deliveries are delivered outside hospitals in the rural areas which traditional birth attendants have higher patronage and according to WHO, global goal is that over 70% of deliveries should be assisted by skilled birth attendants so as to manage complication cases. Lifetime risk of women to die as a direct result of complication during pregnancy and delivery is estimated to be at 1:16mothers compared to 1 in 8,700 in North America or Europe.Therefore, the main objective of the study was to determine factors that ensure emergency obstetric referrals and referral intentions among traditional birth attendants in Lagelu local government, Oyo State, Nigeria
The study was a cross-section design in which a focus group and validated questionnaire was used to collect information from 52 consenting female traditional birth attendants in lagelu local government. Ethical clearance was obtained from Babcock University Health Research Ethics Committee (BUHREC) to conduct the study. Data collected was analysed using frequency distribution, summaries and descriptive statistics was done. 
The result in this study showed that the mean age of the participants was 49 years with majority (75%) attaining primary education only. All the participants (100%) are women. Majority (95%) are also married with 90% of them being Christians. Years of experience of all participantsare from 2-25years. High patronage by pregnant women was recorded with each of traditional birth attendants attending to deliveries in a range of 1-25 births annually. Attitude of most of the respondents was unfavorable with mean score of 7.6 on a rating scale of 27points.Subjective norms were above average with 62.52% with mean score of 13.13 on a rating scale of 21 points. Referral intentions were positive for majority(95%) There was a significant relationship between attitude and perceived behavior with p-value less than 0.05. (P < 0.05)
The study concluded that traditional birth attendants have a strong influence on the utilization of emergency obstetric care by pregnant women and a good strategy in reducing the alarming high maternal mortality would be to use the qualities of traditional birth attendants to improve bilateral respect between pregnant women and the hospital staff. The traditional birth attendants should be involved in planning, implementation and monitoring of any intervention training directed to them to enhance their skills in referrals. Partnership between the tbas and the biomedical staffs should also be strengthening. 

1.1 Background to the Study
Pregnancy complication is unpredictable even when it occurs and a major cause of maternal mortality in developing countries where majority of the pregnant women are assisted by Traditional birth attendants during deliveries. (TBAs)(Julia Hussein, 2012) Three quarters of maternal death occurring in developing countries are caused by direct obstetric cases such as postpartum hemorrhage, postpartum sepsis, Eclampsia, obstructed labor and complications of unsafe abortion.(WHO, 2004) A global goal is to ensure that before 2015, 80% of deliveries should be assisted by skilled birth attendants but over 50% of deliveries are assisted by TBAs in developing countries.(Statistics, 2015) Although, the positive impacts of TBAs can’t be neglected but their attitudes, belief and perceived behavior towards obstetric care is needed to be determined since they can’t handle complications in pregnant women and this contribute mostly to maternal mortality. Pregnancy complications cause 75% of maternal death in developing countries which are categorized as direct causes while indirect causes have 25%.(Imogie, 2013)TBAs can’t predict nor handle complications in pregnant women but they can facilitate a smooth referral to skilled birth attendants where emergency obstetric care can be performed. TBAs have been identified to be the backbone of maternal health care for pregnant women in Africa.(Foundation, 2010) A global goal in improving maternal health is that 80% of deliveries should be assisted by skilled birth attendants. However, over 50% pregnant women patronize TBAs in a developing country which thus, increases over the years.
According to United Nations, A traditional birth attendant (TBA) is a pregnancy and child care provider. They assist pregnant women during deliveries and acquired skills by delivering babies herself or through apprenticeship to other TBAs. They attend to majority of deliveries in the rural areas of middle and low-income countries. They are highly respected in Africa communities. They provide essential social support to women during childbirth with little or no financial reward. Their clients trust them more than the skilled birth attendants and share secrets with them because community women perceive them as part of the community and this fosters a very good relationship between the TBAs and the community members.The TBAs have been the natural helpers at therural areas where the official health care services are not accessible or short served.  They bridge the gaps in supporting women with deliveries. Some received formal education but choose not to register with official health system. One of the criteria for being accepted as a TBA in some communities is having experience as a mother.As seen in Mexico, TBAs attend to approximately 45% of deliveries.(Olufunke M. Ebuehi, 2012) The health system of Ghana also allows TBAs to attend to routine deliveries while complications cases are referred to skilled birth attendants due to the partnership that exist between the official health care and TBAs and this has a significant impacts in reducing maternal mortality in Ghana.
In SierraLeone, it is estimated that TBAs conduct approximately 70% of deliveries so any intervention set to reduce maternal mortality, it is very important to involve the TBAs because they are key to maternal health globally. Although, training of the TBAs is important to achieving the said goal because studies conducted in Edo state, in Nigeria to assess the services provided by TBAs revealed that management of complication, umbilical cord, infection prevention method are poor.(Okojie, 2014)  Another research carried out in Tanzania on TBAs perceive utilization of hospital, Findings reveal that they found it important to refer in complication cases that they can’t handle but they are poorly linked with official health system so the study concluded that there is need to enhance communication between the TBAs and official health especially in terms of prompt referral.(Gladys Mahiti, 2014)
These are the responses obtained from few women that are within the age of childbearing who were interviewed on comparison of the TBAs and the skilled birth attendants at the official health system.In terms of availability of Official Health Centers VS TBAs, Staffs who work in the health centers usually close at 4pm, Lawal Ibrahim said. In some places, they close earlier, he added. It’s a lot easier to access the TBAs because they are in the community. In terms of Attitude VS Attitude, Attitude of TBAs compared to the attitude of nurses,this is a significant factor in the choices available to an expectant mother when she goes for her delivery. Recounting her experiences Larai Patrick said; when I went to have my first child, the pain was unbearable. The nurse kept slapping my thighs and raining abuses on me. Even after the labour pains ended, I was still writing in pains from the slaps and her very unkind words.

Culture and Religion; Zaria Al-Amina, a mother of four delivered of all her children by a highly revered near seventy year old TBA. She explains her upbringing has taught her that it is a taboo for a male to touch a woman who is not his wife or sister and since delivery involves a lot of body contact, she would prefer to employ the services of TBAs. Contending with complications; it was a relief to realize that both the women and the TBAs know that they should go to hospitals when there are complications. But with Zero antenatal sessions during pregnancy, how do the women know a potential complicated pregnancy? According to Adamu’’ When we massage, we can tell if the baby is well positioned or not or if there is any other problem with the pregnancy. She however admits that her diagnoses haven’t always been correct but fortunately rescue came and there have been no recorded mortalities so far.
Although, they can’t replace the skilled health attendants but with the access and good relationship they have in the communities, they can use their close ties in the various communities to bridge the gap between the community members and the skilled birth attendants so as to improve maternal care, such as an effective referral system. Referral system is a connecting linkage between the TBAs and the skilled birth attendants that enables smooth working relationship between them. Referral system is very essential in improving maternal health outcomes. Its importance is recognized, but the policy priorities for achieving it in Nigeria are not consistently or coherently explored in the various state. Although, it works in Ondo State where the StateGovernment in partnership with MDGs and other agencies came up with Abiye’ initiative to reduce the alarming high maternal mortality rate in the state.The Ondo state government, in partnership with ministry of health, community development in the LGA authority addressed and eliminates maternal mortality issues and there was drastic reduction in 2years. The three delays; Delay in seeking health care services, Delay in reaching the health care due to bad roads and Delay in receiving timely emergency care from the health professionals was addressed. Referral was addressed by enhancing the community health extension workers ways to ensure that pregnant women utilize the provided health facilities by the state government.   

1.2 Statement of the Problem
In Africa, 1 in 16 pregnant women is at risk of complications during pregnancy delivery compared to 1 in 8,700 in North America or Europe. (L Keri, 210)Despite all efforts to reduce maternal mortality rate during the MDG initiative, maternal mortality remains unacceptably high. In Nigeria, the maternal mortality rate is 800-1,000 per 100,000 live births (WHO 2014) making Nigeria accounts for about 10% of the global estimate for maternal mortality.(L Keri, 210) Maternal mortality of Oyo state is 262/100,000 live birth with Lagelu LGA one of the LGAs contributing to the burden.
 According to WHO, global goal is that over 70% of deliveries should be assisted by skilled birth attendants but in Nigeria, Over 58% of deliveries are assisted by TBAs.(Oshonwoh Ferdinand E., 2014)Pregnancy complications accounts for more than half of maternal mortality rate in Nigeria where TBAs provide assistance in most deliveries. These TBAs are not trained to detect nor handle complication. E.g. Transverse fetal position,bleeding and obstructed labor. Only the trained health provider can handle such cases and various studies conducted in western and Eastern part of Nigeria showed little or no referral linkages between the TBAs and official health system.(Olufunke M. Ebuehi, 2012) This study will unveil the determinant of responsive emergency obstetric referral among TBAs. This will be of benefit to enhance and modify their attitudes and behavior towards referral. A typical example is found in Ondo state, where the state ministry of health in partnership with TBAs and some NGOs showed how training of skilled birth attendant to modify their attitudes and behavior and in combination with good co-operation with TBAs in reducing maternal mortality in the state. They named this movement as “Abiye initiative”.In another study carried out in Malawi, it was deduced that referral system had save more poor pregnancy outcomes when referred to skilled birth attendants in hospital in the case of complications like Hemorrhage.(M. K. Mattews, 2020) Most maternal death can be prevented if pregnant women receive timely care during emergency cases.

1.3 Objective of the Study
The main objective of the study is todetermine factors responsive foremergency obstetric referrals and referral intentions among traditional birth attendants in Lagelu LGA, Nigeria. The specific objectives are:
1.      determine the beliefs and attitude towards responsive emergency obstetricreferrals among the respondents;
2.      determine perceived behavioral control (Self-Efficacy) in terms of confidence of the respondents in referring their clients when the need arise;
3.      determine the subjective norms among the respondents towards responsive emergency referrals;
4.      identify the nature of referral linkage between traditional birth attendants and the professional birth attendants;
5.      make recommendation for the need to integrate TBAs into emergency obstetric referral system and
6.      assess the utilization of referral system by the respondents

1.4 Research Questions
This study has raised a number of research questions that guided the direction of the study and these include;
1.      What is the attitude of the respondents towards referral of complication cases to official health care?
2.       What motivates the respondents to refer their clients when complication arises?
3.      What is the level of self-efficacy in terms of confidence to make decision among the respondents?
4.      What is the working relationship between the TBAs and official health care in terms of skilled birth attendants and hospital staffs?

1.5 Hypotheses
Four research hypothesis were set in solving the identified problem
H1 There will be a significant relationship between attitudes of the respondents and their referral
H2 There will be a significant relationship between subjective norms and the respondents’
referral intentions behavior.
H3 There will be a significant relationship between perceived behavioral control (Self-Efficacy)
and their attitudes towards emergency obstetric referrals.

1.6 Justification for the Study

Most research studies on benefits of referral system in reduction of maternal mortality in developing countries doesn’t lay emphasis on traditional birth attendants as key drivers of an effective referral system where emergency obstetric care is available.(Diana Gil-Gonzalez, 2006)(Andrea B Pembe, 2013) A study in Malaysia showed how increased availability and training of skilled birth attendants combined with increased smooth communication with TBAs were significant components of a successful intervention.(Pathmanathan, 2012) Also, there has been no conceptual frame work in grounding these studies(Snehan Patel, 2016)It would therefore, be of benefit to find the determinant of responsive emergency obstetric referral and outcomes among TBAs using the theory of planned behavior to find out their attitudes and belief towards referral thereby providing a baseline for behavioral modification.Also, this research would recommend policy formulation that would improve maternal health at all levels.

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