By Abiodun Jamiu
Fatima Taiwo, 55, paced towards a large space, typically serving as a waiting room, in a three-room apartment she converted to a clinic. She flipped the door open and pointed at a middle-aged pregnant woman, “follow me,” she said softly.
Fatima has been a community birth attendant for twenty-three years, assisting women during labour and birth around Olunde, a local community in Ibadan, Southwest Nigeria.
It’s mid-afternoon in September. After a brief moment, she came out and sat on a wooden stool outside the clinic she called, “Iranlowo oluwa faith home.”
“I’ve been in this profession for more than twenty years, and have helped over five hundred pregnant women deliver their babies successfully.” She said with pride. “Although there are times we face challenges, I used to refer them to the hospital whenever it is beyond me.”
Most rural communities in the country do not have access to primary healthcare centres. And the few operational ones are in the shadow of themselves, dilapidated due to lack of manpower and negligence.
Because of this, women in these communities have leaned heavily on birth attendants for years. These attendants assist in child delivery and a range of other services having little to no formal education.
A study showed much higher rates of genital sepsis, wound infection or peritonitis in women attended to by traditional birth attendants, and without proper postnatal care, these complications can put a mother’s life at risk.
This contributes in part to Nigeria’s struggle with maternal health. Statistics from the World Health Organisation (WHO) show that the country has the highest mortality rate among under-fives and is the most dangerous place for pregnant women. The country accounts for 20 percent of all deaths related to pregnancy and childbirth worldwide, despite having 2.6 per cent of the global population.
“Nigeria’s poor mother and child health indices are of great concern,” says Laz Eze, a public health physician. “The major causes of under-five and maternal mortality are very preventable and can be managed at the primary healthcare level.”
HelpMum, a Nigerian health service committed to reducing maternal and infant mortality in the country, hopes to change this. Founded in March, 2017, its novel approach involves training community birth attendants on modern safe delivery methods.
“The traditional birth attendants these women are familiar with are not properly trained. It is more than just providing information or sensitisation. There must be services and products to tackle the broken healthcare system,” Abiodun Adereni, the founder, started.
So far, it has established a presence in the six southwestern states of Oyo, Ogun, Ondo, Osun, Ekiti and Lagos, with a network of over 2000 community health workers.
“We [HelpMum] decide that training them [traditional attendants] with safety skills like treating postpartum haemorrhage and other danger signs during childbirth would go a long way in ensuring safe delivery and reducing the mortality rate in the country,” Adereni added.
Unlearning Old Practices
In 2020, Fatima met the team at HelpMum during one of its advocacy visits. They were first exposed to unlearning harmful practices like using toothpaste for the umbilical cords, tying umbilical cords with clothes and vigorously shaking the newborn after delivery.
“We’re doing it the way I was taught. But when we had our first training with the team [helpmum], we understand that we had so much to unlearn like shaking the babies or tapping them to have their first cries,” she said.
After the initial training session, they were provided with resources to support their delivery process such as birth kits which included hand gloves, chlorhexidine cream and cut clamps for the umbilical cord and further training lasting a month.
“Meeting HelpMum has provided a new perspective in the way we take care of mothers and their babies during and after deliveries, especially with the birth kits that were given to us. It made our work easier and safer than before.” Fatima added, noting that she can now treat a certain level of post-partum haemorrhage, a situation when women bleed profusely after delivery.
Odunola Ogunyale has had a delivery at Fatima’s clinic. She told Social Voices she prefers the clinic largely in part to its affordability and proximity, “it’s affordable and also closer to my place. The last time I had my delivery here, it’s not even more than twenty minutes. This is because we have everything we need contained in the birth kit that’s given to pregnant women.”
Eze adds that the training of traditional birth attendants and active community participation in primary health care “will help to prioritise the primary healthcare needs of the community including the factors leading to maternal and child deaths.”
This, according to the public health physician, would retool a health plan “and champion its implementation with the active involvement of the government authorities at the local and state levels.”
“Deployment of Midwives to primary health facilities is very important. Where they’re not available, community health extension workers can be trained to deliver this service in hard to reach communities. The referral and transportation system must also be strengthened to enable effective referral from trained TBAs to skilled providers in case of emergency.”
Deploring Low Tech
The initiative, however, hit a brick in the middle of the pandemic. The team could no longer engage the attendants physically because of the cessation of movements across the country.
“Due to the pandemic, we could no longer do physical training, therefore we had to create an E-learning platform where community birth attendants can access our training,” Adereni recalled.
With support from its partners, the startup provided mobile tablets with pre-recorded videos in Yoruba, a language predominantly spoken in southwest Nigeria, to ensure the completion of the training module.
These tablets also come with its vaccination tracker, a mobile application that stores and tracks the medical record of newborns, including contacts of mothers, “we take the pictures of the newborns and the mothers and share details with HelpMum when they come for the monthly outreach,” Adedoye Adenike, another traditional birth attendant, explained.
“The tracking system helps to automatically copulate all the immunisation schedules a child is supposed to take, including the dates they are to be given. When they complete their registration, the data is transferred to us,” Adereni says, noting that more than 50,000 women are currently registered with the startup as they make over 1,000 calls weekly to mothers, reminding them of their child immunisations schedules.
This is aimed at boosting Nigeria’s immunisation coverage which has seen child mortality decrease from 1 in 8 children dying before their fifth birthday to 1 in 10 children, according to a 2021 report on immunisation in the country.
One of the mothers is Suara Ganiyah. She has had two deliveries, assisted by a traditional birth attendant, “Giving birth at ‘Agbebi’ [traditional birth attendant] home is not only affordable, but also friendly, especially with the birth kits and constant calls we received. When I had my first delivery, I was sensitised on immunisation, and they still followed up with calls to remind and check on us. Because of that, my two kids were vaccinated.”
It has not been without hiccups for the three-year-old startup. According to Adereni, lack of resources to execute most of its programs and the literacy level of the women in rural communities, including the TBAs, have both been key impediments.
“Some of the women we work with, especially in this part of the world, are not educated. We used to send information in English before we realised that it’s not ticking the right box – sending the right messages. This is in addition to not having the available funding to scale up our activities.”
Extortion from community stakeholders has also been a challenge in a society steeped in systemic corruption, “sometimes some community leaders or area boys would want us to tip them before we do any projects or have any access, this we deal with every now and then,” Adereni adds.
Nevertheless, HelpMum’s team is determined to push through. Afolabi Hannah, a salesperson at the startup, says, “the work we do here is just a tip of the iceberg. We’re are soon expanding to other African countries because the struggles with maternal health isn’t just a Nigeria thing, it’s across the continent.”
This story was produced in partnership with Nigeria Health Watch through the Solutions Journalism Network, a nonprofit organisation dedicated to rigorous and compelling reporting about responses to social problems.