Ousman A. Marong and Anibe Idajili (Guest writers)

When women go into labour in Mendy Kunda, a rural community in The Gambia’s North Bank Region, getting to a hospital can depend on how quickly help can be found. For Rose Mendy, a resident of the community, that support has come from people in her own community, including the traditional birth attendant (TBA) who has helped women navigate the uncertain hours before they reach a health facility.

Rose knows how quickly a delivery can change. She gave birth to her first child unexpectedly at home, but when she became pregnant again, she recognised the signs early and was taken to Essau District Hospital, where she delivered safely. “The TBA in our village is always there to help whenever a pregnant woman is about to give birth,” she said.

Her current pregnancy, however, has brought unfamiliar illnesses and painful stomach aches at night, making access to timely care even more important. Although Rose’s husband often uses his car to transport pregnant women to the hospital, getting a vehicle can be challenging when he is away at work. In such moments, community-based support, including TBAs who can recognise danger signs, provide basic assistance and help connect women to formal health services, can make the difference between waiting and getting care.

For generations, childbirth in many rural communities across West Africa has carried significant risks, partly due to weak and inadequate healthcare systems. Fortunately, in communities such as Mendy Kunda, in The Gambia and Jigawa State, in Nigeria’s Northwest, public-private partnerships, community-led interventions, and innovative policy reforms are integrating TBAs into the formal healthcare system, subsidising emergency transportation, and strengthening grassroots health networks; these communities are helping to reshape the story of maternal health and improve outcomes for mothers and newborns.

A regional crisis meets local solutions

Studies show that 75% of Gambian women cite insufficient time for travel and 29% blame transport difficulties as the major reasons they avoid health‑facility births. Although 83% want a medical professional present, more than 70% end up with a TBA, even though only 27% plan a home delivery.

Nigeria highlights a similar paradox as found in two studies conducted in Southeastern Nigeria and Nasarawa State. Most pregnant women attend antenatal care (ANC) and intend to use a hospital, but end up delivering at home or with a TBA. 82.2% of pregnant women surveyed chose and planned for a hospital delivery, but 59% of them deliver at home or outside a health facility.

Rather than demonising the use of TBAs, local health systems are increasingly recognising their role and integrating them into formal healthcare structures. Through training, retraining, and the provision of essential equipment, TBAs are being supported to carry out safer pregnancies and childbirth while strengthening links between communities and formal health facilities.

Veronic Mendy, a local TBA in Mendy Kunda, noted that past challenges involved women hiding labour pains to deliver at home without medical help. “To tackle this issue, we now make it a priority to accompany pregnant women to the hospital promptly. While there, medical staff teach us what to do in case of an unexpected home birth.”

A similar evolution is happening in Nigeria. Hafsat Shehu, a trained TBA assigned to the Madobi Primary Health Care (PHC) Centre in Jigawa, shared that, “Before the training, no matter how far away the pregnant women are, I travel on motorcycles to deliver babies at home.”

Today, Hafsat acts as a community bridge. Instead of attempting risky home deliveries, she screens women, urges them to visit PHCs for routine antenatal care, and immediately initiates referrals if obstructed labour occurs.

To solve the transportation barrier, Jigawa State introduced the Jigawa State Maternal and Neonatal Emergency Transport Scheme. When a woman goes into labour, her husband contacts a local community health ambassador, known locally as Jakada Lafiya, who maintains a direct directory of vetted local drivers.

The driver transports the patient to the nearest PHC at an agreed fee, which is subsidised and directly reimbursed by the state. Recently, according to Dr Shehu Sambo, the Executive Secretary of the Jigawa State Primary Health Care Development Agency (JSPHCDA), Governor Malam Umar Namadi doubled the drivers’ per-trip stipend from ₦5,000 to₦10,000 to ensure drivers remain motivated.

In The Gambia, Samuel Chaw, the Village Development Committee (VDC) Chair, emphasises similar local progress. “We’ve appointed women leaders as TBAs, and they do an incredible job regularly checking in on expectant mothers,” Samuel noted.

However,referrals remain difficult, often requiring Chaw to walk to a nearby village for a taxi. Fortunately, supportive local drivers and villagers frequently assist with emergency transport free of charge. The VDC also organises educational forums on proper nutrition and encourages husbands to ease their wives’ household workloads.

Measurable changes on the ground

The Gambia has seen a significant drop in home deliveries, with rates plunging from 36.18% in 2013 to 14.39% in the latest Demographic and Health Survey.

The Gambia’s Health Ministry is building on this momentum through the National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy, thereby reinforcing mortality monitoring at the central, regional, facility, and community levels. Each of these levels has its own unique structure and specific responsibilities.

In Jigawa State, Nigeria, the impact is equally commendable. According to Dr Sambo, who leads the JSPHCDA, the transport scheme safely transports over 3,000 women annually, and participating facilities have recorded zero maternal mortality linked to transport delays since its inception.

This collaboration has transformed clinic attendance. Ahmad Yakubu Kwaimawa, Officer in Charge at the Jaudi PHC, noted a sharp increase in facility utilisation. “We used to have between 20 and 30 deliveries in a month,” Kwaimawa explained. “Now, we record up to 100 deliveries in a month.”

Khadijat Umar, a resident of Jigawa, noted that, “With the way women suffer from complications associated with home deliveries, I now believe in giving birth in the hospital. Travelling to PHCs is now easier and safer.”

Limitations and institutional gaps

Despite these inspiring achievements, significant challenges remain. Institutional gaps still threaten the long-term sustainability of these models.

Fahad Hazaru, Head of Programmes at the Youth Impact Foundation in Jigawa State, noted that some TBAs occasionally delay referrals, and the occasional nonchalant attitude of Skilled Birth Assistants at clinics can alienate patients.

Furthermore, facility-level constraints persist. Dr Sambo points out that some PHCs suffer from severe staff shortages, operating with a single midwife when the National Primary Health Care Development Agency (NPHCDA) guidelines require four, alongside drug stockouts and infrastructural challenges, such as stolen electricity and water installations.

In the past, similar government-led transport programmes in the state, such as the Haiyuwa Lafiya (safe motherhood) programme, hit a sustainability wall when vehicles broke down, maintenance funds dried up, and drivers began demanding out-of-pocket fuel support from low-income families.

Solutions for scalability and future impact

To solidify these gains and make the model fully replicable across borders, such as in similar rural setups in The Gambia, Fahad Hazaru recommends involving community-based organisations to ensure independent monitoring, accountability, and real-time feedback on driver stipends and drug availability.

“There should be regular, joint training sessions between TBAs and skilled clinic staff to build mutual respect, reduce friction, and ensure seamless patient handoffs,” he added.

Hazaru also recommended maintaining consistent stipend disbursements for both drivers and retrained TBAs to prevent burnout and eliminate the temptation to levy hidden costs on struggling rural families.

Geographical isolation also ceases to be a barrier when tradition meets modern science. A maternal health advocate in Nigeria, Ken Nnaji, noted that “sustainable health reform requires more than building hospitals. It demands cultural alignment where TBAs become trusted allies. By respecting local wisdom and funding reliable transport, rural mothers receive safe care.”