There are so many stories of giving birth in Nigeria. From good to not so great. These stories come from people in all classes of the society. While there are thousands of successful deliveries that happen daily across the country, it is often the unsuccessful deliveries that seem to make it faster to the news. And for good reason, because every single life counts. Even though the target of the globally adopted Sustainable Development Goals is to ensure that by 2030, not more than 70 women out of every 100,000 births die from pregnancy related complications, ideally no woman should die at all giving life. No one would want their wife, daughter, sister, or mother to be one of the fatalities.
Discouraging numbers
A lot of investment has gone into improving Nigeria’s worrying maternal health statistics, but it seems that outputs are not commensurate with the inputs. The numbers suggest this. When the National Bureau of Statistics (NBS) and partners released the initial Key Indicators Report of Nigeria’s Demographic and Health Survey (NDHS) 2018, it had some promising findings. The report showed gradual improvement in maternal health indicators over the past 10 years. Since the 2018 figures showed some improvement, the expectation was that the maternal mortality rate would also drop significantly given all the completed and ongoing projects aimed at tackling maternal and child health issues.
They did drop, from 576 in the NDHS 2013 to 556 pregnancy related deaths for every 100,000 women who gave birth in NDHS 2018. These numbers are still too gruesome. The GivingBirthInNigeria tracks reports of women who die giving birth in three wards of one LGA each across six states and Nigeria’s federal capital territory, Abuja. The project is being implemented by a consortium of EpiAFRIC, Africare and Nigeria Health Watch and supported by MSD for Mothers. Community Based Organisations in each of the states collect and enter the data into an online database, reporting where and when women die while pregnant or giving birth, and the reasons women are dying. Just after six months of deployment, data entries from the CBOs showed that over 130 women have died in communities (not health facilities). This is not an estimate but actual reported deaths of women, some of whom the EpiAFRIC team met and interviewed during their baseline assessment. Given these initial numbers, it is little wonder that Nigeria is responsible for 20% of global maternal deaths.
A different approach
Every week in Nigeria, 1,115 women die from pregnancy related issues. This amounts to 58,000 every year. While the numbers are mind-boggling, there are innovative initiatives being implemented to change Nigeria’s maternal health narrative.
Tolu Adeleke-Aire decided to be part of finding a solution to this challenge. Tolu worked in the United Kingdom (UK) for seven years after completing her nursing and midwifery training in 2009. She said the statistics about maternal health in Nigeria were shocking to her because where she worked in the UK, a whole review process would be initiated if a woman lost her life during childbirth. “We would have a massive root-cause analysis meeting, starting from the very beginning when she came for the very first appointment,” she said. They did all this to try and determine at what point the death could have been prevented to ensure it doesn’t happen to another woman. So, for Tolu, hearing these maternal deaths numbers about Nigeria “just didn’t make any sense. It was as if surviving pregnancy was a 50–50 chance.”
Her move to Nigeria in 2016 was heavily influenced by previous trips with her mum for medical missions in Nigeria, encouragement from friends who already relocated and visiting Nigeria every four months. To integrate and get a sense of the healthcare system, she did her National Youth Service in a Primary Health Centre (PHC) located in Ojodu Berger, Ogun State. Working in the facility for the 12-month duration of the service helped her experience first-hand the extent of the maternal health challenges and informed her decision to be a change agent.
“I realised I couldn’t make an impact in clinical practice, but I can make an impact in education,” she said. She narrated an incident where a family opted to have a vaginal delivery for a breeched baby. The head got stuck after the body was delivered and the family was desperate, asking the staff to save the woman. “In those cases, what would I do if I was in clinical?” Adeleke asked. These realities strengthened her resolve to choose the education approach to ensure expectant parents have the knowledge they need to go through the pregnancy, delivery and post-delivery processes.
It all started on Social Media
With bills to pay and still determined to accomplish her mission, Adeleke started working for another organisation but created an Instagram page, Toluthemidwife, where she consistently put out content on maternal health. “This was where I got most of my clients,” she said. Soon she started gaining traction with people reaching out to her privately to seek advice. She started organising classes for expectant parents making sure that the men were part of it because of the important role they can play in improving maternal health. It wasn’t easy convincing them to attend her classes since they already had antenatal classes in their respective hospitals. She faced challenges when it came to funding to start fully, gaining people’s trust since she wasn’t well known in the space and getting people understand the value add from her classes. But social media came to the rescue and she did lots of free classes before she started getting paying clients through referrals, she said.
She educated her audience on what to expect during pregnancy, red flags to be aware of, how to go the extra mile to ensure they have safe pregnancies and taking prompt action when they notice anomalies. The men received practical lessons on umbilical cord care, changing diapers, bathing their babies, and supporting their partners during breastfeeding.
Adeleke said she had “always wanted to organise classes for expectant dads because it’s the usual practice in the UK but when I got back to Nigeria, I realised that most men are not involved at all. The society just makes it looks like it’s not their business. They just need to provide funds”. She partnered with the Post-Partum Support Network (PSN) to teach both the men and women about post-partum depression (PPD). This helped them understand that PPD can be experienced by dads and mums.
Even though she has made significant progress since she started, Adeleke said she still struggled with properly structuring her organisation as a self-sustaining business.
Training Champions
“Some of the pregnant women in my class are affluent and have good hospitals. But they still lack such basic information such as the need to take medications to prevent malaria in pregnancy. They don’t know they should count their baby’s kicks often, carry around an antenatal note and ensure their baby’s growth is measured regularly,” says Adeleke. The reaction is usually that of surprise when she informs them. She empowers the women with knowledge to ask for services they previously wouldn’t ask for during a regular hospital visit. She shared the story of a woman who persistently asked that her baby be measured. When done finally, they discovered the baby wasn’t growing as expected and rushed her to the theatre for an emergency caesarean section. Such stories have helped Adeleke and her team show the uniqueness of their classes. She now has mums she refers to as “champions and cheerleaders” because they spread the message about her antenatal classes.
For the dads, the impact is noteworthy.
Mr Taiwo Sherriff Ayoola attended the classes before his wife’s delivery. While he described the classes as “very helpful”, he said it gave him the courage to do what he always dreamt of — “to be there when my wife delivered my baby”. The classes prepared him for what to expect from his wife including unexplained mood swings and demands. He learned that pregnancy isn’t the same for every woman and to support, encourage and give positive affirmations when he feels his wife isn’t herself. He gained practical skills like baby bathing, properly changing diapers and cleaning the baby’s umbilical cord. He did this regularly and shared the tasks with his wife because he knew when and how to help. It also helped him bond better with his child and wife, making him a “better father and husband,” he says.
“The fact that I wasn’t alone also helped as other expectant dads were present and we talked about our fears — financial, emotional and mental commitments, being present during delivery, birth defects, and being a good father,” Ayoola said. For him, it was like a support system because they were at different levels. Some were expecting in a month, three, five or six months. Another expectant dad said, “As men, we find it difficult to open up when we have challenges because the society expects us to be strong,” adding that the classes helped them to speak more about the pregnancy and his experience supporting his wife.
Adeleke plans to partner with other organisations to scale her classes to rural communities so that more women and men in poor underserved communities can benefit too.
Different Strokes
There isn’t a one size fits all approach to solving maternal health issues. Every idea, intervention or product contributes to the overall effort, because every life matters.
There is evidence that emotional, physical, and informational support positively impacts women’s mental and physical health during pregnancy. So beyond clinical interventions, there is need to be proactive with providing useful information and support to expecting parents without waiting for the woman to have pregnancy complications first. This will contribute significantly to reduce the first delay in pregnancy related mortality. The above research also stated that mothers who have the support of a companion during labor and delivery experience fewer childbirth complications and less postpartum depression. Also, their postpartum mental health is related to both the emotional support and practical help such as housework and child care activities they get from the husband and others.
Amref Health African Global CEO and Co-Chair of UHC2030, Dr. Githinji Gitahi captured this clearly when he advocated for services to be taken to the people instead of waiting for them to fall sick first. He called it a people-centred, people-responsive health system.
With dads like Ayoola who are knowledgeable about practical ways to support their pregnant wives and who understand the danger signs in pregnancy, and better informed expectant mothers who know when to seek proper care for themselves and their babies, Tolu Adeleke-Aire, popularly known as Tolu The Midwife, is a change agent, making pregnancy and childbirth in Nigeria safe for both mums, and dads.
Do you know anyone working towards making giving birth in Nigeria safer and healthier? Give them a shout out on Twitter, using #NHWEngage and tag us @nighealthwatch.